Emerging Ethical Challenges in Critical Care for the 21st Century: A Case-Based Discussion.

Ethical challenges for doctors and other health care professionals have existed since the practice of medicine began. Many of the oldest challenges live on to this day, such as who has more authority to make key decisions (autonomy vs. paternalism) and what are the boundaries of life at the beginning and at the end. Two powerful driving forces are new technologies and an ever-changing culture and society. The practice of medicine in intensive care units (ICUs) has been the source of many ethical challenges. Once firmly fixed concepts, such as death or "brain death" are now coming under increasing debate. In other areas, the concept of patient autonomy has been used to request life-prolonging therapies, once thought "futile." New technologies for procreation have necessitated new ethical challenges as well. In this paper, we will use a series of cases, based on experiences from our hospital ethics committee, that occurred over the course of several years and illustrate ethical challenges which are either new to us or not new but growing in frequency due to technological or societal changes. Each one of these topics is complex and worthy of its own large review but for this overview, we will briefly discuss the key points of each dilemma.

Knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses from a resource poor setting, Nepal.

BACKGROUND: Healthcare ethics is neglected in clinical practice in LMICs (Low and Middle Income Countries) such as Nepal. The main objective of this study was to assess the current status of knowledge, attitude and practice of healthcare ethics among resident doctors and ward nurses in a tertiary teaching hospital in Nepal. METHODS: This was a cross sectional study conducted among resident doctors (n = 118) and ward nurses (n = 86) in the largest tertiary care teaching hospital of Nepal during January- February 2016 with a self-administered questionnaire. A Cramer's V value was assessed to ascertain the strength of the differences in the variables between doctors and nurses. Association of variables were determined by Chi square and statistical significance was considered if p value was less than 0.05. RESULTS: Our study demonstrated that a significant proportion of the doctors and nurses were unaware of major documents of healthcare ethics: Hippocratic Oath (33 % of doctors and 51 % of nurses were unaware), Nuremberg code (90 % of both groups were unaware) and Helsinki Declaration (85 % of doctors and 88 % of nurses were unaware). A high percentage of respondents said that their major source of information on healthcare ethics were lectures (67.5 % doctors versus 56.6 % nurses), books (62.4 % doctors versus 89.2 % nurses), and journals (59 % doctors versus 89.2 % nurses). Attitude of doctors and nurses were significantly different (p < 0.05) in 9 out of 22 questions pertaining to different aspects of healthcare ethics. More nurses had agreement than doctors on the tested statements pertaining to different aspects of healthcare ethics except for need of integration of medical ethics in ungraduate curricula (97.4 % doctors versus 81.3 % nurses),paternalistic attitude of doctor was disagreed more by doctors (20.3 % doctors versus 9.3 % nurses). Notably, only few (9.3 % doctors versus 14.0 % nurses) doctors stood in support of physician-assisted dying. CONCLUSIONS: Significant proportion of doctors and nurses were unaware of three major documents on healthcare ethics which are the core principles in clinical practice. Provided that a high percentage of respondents had motivation for learning medical ethics and asked for inclusion of medical ethics in the curriculum, it is imperative to avail information on medical ethics through subscription of journals and books on ethics in medical libraries in addition to lectures and training at workplace on medical ethics which can significantly improve the current paucity of knowledge on medical ethics.

Continuing education in ethical decision making using case studies from medical social work.

Medical social workers have needs for training in ethics that is specific to dilemmas that arise while providing service to patients who are very ill, mentally compromised, or in a terminal condition. A social work department developed a continuing education training to educate social workers in bioethics related to determining decisional capacity and understanding standards of ethical decision making. Case studies are used to illustrate ethical conflicts and the role of social workers in resolving them. The benefits of case study training are discussed.

Research ethics in accessing hospital staff and securing informed consent.

Qualitative researchers cannot rely on research ethics to be a static practice. In this article we discuss how observation of guidelines for inquiry and international agreements on the dignity of health care research are not sufficient on their own to ensure that the challenges inherent in the everyday management of a project are regulated. We focus in particular on ethics in accessing participants and the construction of informed consent. During our study, important contrasts emerged between the ideal presented for the standard ethics review process and practical ethics. As a result, we focused on building open communication with the participants through rigorous project management. We analyzed the data and wrote this article collaboratively to represent the empirical reality of a team of researchers aiming to take ethical challenges seriously while collecting data in three National Health Service Trusts in the United Kingdom.

Organizational ethics: a literature review.

The aim of the study was to report the results of a systematically conducted literature review of empirical studies about healthcare organizations' ethics and management or leadership issues. Electronic databases MEDLINE and CINAHL yielded 909 citations. After a two stage application of the inclusion and exclusion criteria 56 full-text articles were included in the review. No large research programs were identified. Most of the studies were in acute hospital settings from the 1990s onwards. The studies focused on ethical challenges, dilemmas in practice, employee moral distress and ethical climates or environments. Study samples typically consisted of healthcare practitioners, operational, executive and strategic managers. Data collection was mainly by questionnaires or interviews and most of the studies were descriptive, correlational and cross-sectional. There is need to develop conceptual clarity and a theoretical framework around the subject of organizational ethics and the breadth of the contexts and scope of the research needs to be increased.

From ethics to palliative care: a community hospital experience.

One of the most vulnerable and voiceless groups of patients within American hospitals and institutions today are those who are dying. Health care institutions struggle with the challenge of providing excellent palliative and end-of-life care to patients while providing curative therapies at the same time. This article describes the efforts and accomplishments of the ethics committee of a community hospital system to provide for the palliative and end-of-life needs of its patients.

How Competitive Orientation Influences Unethical Decision-making in Clinical Practices?

PURPOSE: This study aims to investigate how competitive orientation influences unethical decision-making (UDM) through relationship conflict and the moderating effect of hostile attribution bias. METHODS: This study was conducted using a self-report questionnaire. Data were collected from 727 employees in Chinese hospitals. For each variable, measures were adopted or adapted from existing literature. Data were analyzed using descriptive statistics, correlation analysis, confirmatory factor analysis, and hierarchical regression analysis. Common method variance was established using Harman's single-factor test. RESULTS: Competitive orientation is significantly and positively associated with relationship conflict (ß = .36, p < .001) and UDM (ß = .35, p < .001). Relationship conflict is significantly and positively associated with UDM (ß = .51, p < .001). Relationship conflict partially mediates the relationship between competitive orientation and UDM. In addition, hostile attribution bias strengthens the positive relationship between competitive orientation and UDM through relationship conflict. CONCLUSION: This study provides some implications for hospital employees to deal with ethical dilemmas in decision-making. Hospital employees including nurses, physicians, and other health-care professionals should raise awareness of competitive orientation and adopt a cooperative approach to human relations. Effective training programs should be utilized to direct all hospital employees to depress hostile attribution bias whenever possible to everything in clinical practice.

Pandemic influenza preparedness: an ethical framework to guide decision-making.

BACKGROUND: Planning for the next pandemic influenza outbreak is underway in hospitals across the world. The global SARS experience has taught us that ethical frameworks to guide decision-making may help to reduce collateral damage and increase trust and solidarity within and between health care organisations. Good pandemic planning requires reflection on values because science alone cannot tell us how to prepare for a public health crisis. DISCUSSION: In this paper, we present an ethical framework for pandemic influenza planning. The ethical framework was developed with expertise from clinical, organisational and public health ethics and validated through a stakeholder engagement process. The ethical framework includes both substantive and procedural elements for ethical pandemic influenza planning. The incorporation of ethics into pandemic planning can be helped by senior hospital administrators sponsoring its use, by having stakeholders vet the framework, and by designing or identifying decision review processes. We discuss the merits and limits of an applied ethical framework for hospital decision-making, as well as the robustness of the framework. SUMMARY: The need for reflection on the ethical issues raised by the spectre of a pandemic influenza outbreak is great. Our efforts to address the normative aspects of pandemic planning in hospitals have generated interest from other hospitals and from the governmental sector. The framework will require re-evaluation and refinement and we hope that this paper will generate feedback on how to make it even more robust.

Hiring for "organizational fit". A St. Louis system has developed tools for assessing candidates' compatibility with the organization.

To a great extent, the continued success of Catholic health care organizations is dependent on the selection of co-workers and leaders who are committed to carrying on the organization's mission. The Sisters of Mercy Health System, St. Louis, uses three tools to help leaders be more consistent and objective in assessing employment candidates for organizational fit. The first tool involves behavioral-based interviewing, which looks at a candidate's potential for future behaviors based on his or her past behaviors. The second tool assesses a candidate's values in such a way that accounts for and reduces the interviewer's own subjectivity. And the third tool-values-based interviewing-helps reveal a candidate's natural aptitude for, interest in, and personal agreement with the organization's charism, religious heritage, and values.

Machiavellian tendencies of nonprofit health care employees.

Federal and state regulators have heightened scrutiny of nonprofit hospital operations, particularly in billing collections. The move for hospitals to adopt more compassionate methods within their business functions drives the need to examine the ethical reasoning of their employees. The purpose of this study is to assess the existence of Machiavellian propensities among health care employees. People defined as Machiavellian are impersonal, rational, and strategy-oriented rather than person-oriented. Results indicate employee participants exhibit these propensities, and tend to agree with questionable scenarios. Knowledge of the ethical propensities of employees may serve as a crucial factor to the success of any plan in establishing an ethical work environment.

Living with conflicts-ethical dilemmas and moral distress in the health care system.

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as "moral distress". The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.

RCN announces innovative plan to tackle discrimination against staff.

Black and minority ethnic (BME) nurses have been trained to sit on staff disciplinary panels at three NHS trusts in Birmingham to challenge discrimination, as part of a groundbreaking RCN project.

Do-not-resuscitate decisions in a large tertiary hospital: differences between wards and results of a hospital-wide intervention.

BACKGROUND: Despite the advent of palliative care, the quality of dying in the hospital remains poor. Differences in quality of end-of-life practice between hospital wards are well known in clinical practice but rarely have been investigated. METHODS: A prospective observation of do-not-resuscitate (DNR) decisions was conducted in patients dying in a Belgian university hospital before (115 patients) and after (113 patients) a hospital-wide intervention consisting in informing hospital staff on the law on Patient's Rights and the introduction of a new DNR form.The new DNR form puts more emphasis on the motivation of the DNR decision and on the description of the participants in the decision-making process. RESULTS: The completion of DNR forms improved after the intervention: physicians better documented who participated in DNR decisions (for participation of family: 63% after the intervention vs. 44% before the intervention, p = 0.022, for nurses: 27% vs. 14%, p = 0.047) and the motivation for these decisions (59% vs. 32%, p = 0.001). However, there was no difference in referral to the intensive care unit (ICU) at the end of life (in 40% of patients after and 37% before the intervention). Furthermore, the number of patients dying without DNR form on the wards was similar (13% and 8%). Surgical patients and patients with non-malignant diseases were more often referred to ICU at the end of life (71% in surgical vs. 35% in medical patients, p < 0.001 and 49% in patients with non-malignant diseases vs. 23% in patients with malignancy, p < 0.001). Moreover, surgical patients less frequently received a DNR order (56% in surgical vs. 92% in medical patients, p = 0.007). CONCLUSIONS: The introduction of a new DNR form and informing hospital staff on patients' right to information did not improve physicians' end-of-life practice.Transition from life-prolonging treatment to a more palliative approach was less anticipated in surgical patients and patients with non-malignant diseases.

Ethical behaviours in clinical practice among Mexican health care workers.

The objective of this study was to describe the cultural domain of ethical behaviours in clinical practice as defined by health care providers in Mexico. Structured interviews were carried out with 500 health professionals employed at the Mexican Institute of Social Security in Mexico City. The Smith Salience Index was used to evaluate the relevance of concepts gathered from the free listings of the interviewees. Cluster analysis and factor analysis facilitated construction of the conceptual categories, which the authors refer to as ;dimensions of ethical practice'. Six dimensions emerged from the analysis to define the qualities that comprise ethical clinical practice for Mexican health care providers: overall quality of clinical performance; working conditions that favour quality of care; use of ethical considerations as prerequisites for any health care intervention; values favouring teamwork in the health professional-patient relationship; patient satisfaction scores; and communication between health care providers and patients. The findings suggest that improved working conditions and management practices that promote the values identified by the study's participants would help to improve quality of care.

Privacy and equality in diagnostic genetic testing.

This study aimed to determine the extent to which the principles of privacy and equality were observed during diagnostic genetic testing according to views held by patients or child patients' parents (n = 106) and by staff (n = 162) from three Finnish university hospitals. The data were collected through a structured questionnaire and analysed using the SAS 8.1 statistical software. In general, the two principles were observed relatively satisfactorily in clinical practice. According to patients/parents, equality in the post-analytic phase and, according to staff, privacy in the pre-analytic phase, involved the greatest ethical problems. The two groups differed in their views concerning pre-analytic privacy. Although there were no major problems regarding the two principles, the differences between the testing phases require further clarification. To enhance privacy protection and equality, professionals need to be given more genetics/ethics training, and patients individual counselling by genetics units staff, giving more consideration to patients' world-view, the purpose of the test and the test result.