Mitigating ethical conflict and moral distress in the care of patients on ECMO: impact of an automatic ethics consultation protocol.

AIMS: This study evaluates a protocol for early, routine ethics consultation (EC) for patients on extracorporeal membrane oxygenation (ECMO) to support decision-making in the context of clinical uncertainty with the aim of mitigating ethical conflict and moral distress. METHODS: We conducted a single-site qualitative analysis of EC documentation for all patients receiving ECMO support from 15 August 2018 to 15 May 2019 (n=68). Detailed analysis of 20 ethically complex cases with protracted ethics involvement identifies four key ethical domains: limits of prognostication, bridge to nowhere, burden of treatment and system-level concerns. There are three subthemes: relevant contextual factors, the role of EC and observed outcomes. Content analysis of transcripts from interviews with 20 members of the multidisciplinary ECMO team yields supplemental data on providers' perceptions of the impact of the early intervention protocol. RESULTS: Limited outcome data for ECMO, unclear indications for withdrawal, adverse effects of treatment and an obligation to attend to programme metrics present significant ethical challenges in the care of this patient population. Upstream EC mitigates ethical conflict by setting clear expectations about ECMO as a time limited trial, promoting consistent messaging among multiple services and supporting surrogate decision-makers. When ECMO becomes a 'bridge to nowhere', EC facilitates decision-making that respects patient values yet successfully sets limits on non-beneficial use of this novel therapy. CONCLUSION: Data from this study support the conclusion that ECMO poses unique ethical challenges that necessitate a standardised protocol for early, routine EC-at least while this medical technology is in its nascent stages.

Use and Meaning of "Goals of Care" in the Healthcare Literature: a Systematic Review and Qualitative Discourse Analysis.

BACKGROUND: The specific phrase "goals of care" (GOC) is pervasive in the discourse about serious illness care. Yet, the meaning of this phrase is ambiguous. We sought to characterize the use and meaning of the phrase GOC within the healthcare literature to improve communication among patients, families, clinicians, and researchers. METHODS: A systematic review of the English language healthcare literature indexed in MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus was performed in October of 2018. We searched for all publications with the exact phrase "goals of care" within the title or abstract; no limitations on publication date or format were applied; conference abstracts were excluded. We used qualitative, discourse analysis to identify key themes and generate an operational definition and conceptual model of GOC. RESULTS: A total of 214 texts were included in the final analysis. Use of GOC increased over time with 87% of included texts published in the last decade (2009-2018). An operational definition emerged from consensus within the published literature: the overarching aims of medical care for a patient that are informed by patients' underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions. Application of the GOC concept was described as important to the care of patients with serious illness, in order to (1) promote patient autonomy and patient-centered care, (2) avoid unwanted care and identify valued care, and (3) provide psychological and emotional support for patients and their families. DISCUSSION: The use of the phrase "goals of care" within the healthcare literature is increasingly common. We identified a consensus, operational definition that can facilitate communication about serious illness among patients, families, and clinicians and provide a framework for researchers developing interventions to improve goal-concordant care.

A Framework for Tracking Former Patients in the Electronic Health Record Using an Educational Registry.

One challenge of contemporary medical education is that shorter lengths of stay and time-limited clerkships often interrupt a student's relationship with a patient before a diagnosis is made or treatment is completed, limiting the learning experience. Medical students sometimes use electronic health records (EHRs) to overcome these limitations. EHRs provide access to patients' future medical records, enabling students to track former patients across care venues to audit their diagnostic impressions and observe outcomes. While this activity has potential to improve clinical training, there is a risk of unintended harm to patients through loss of privacy. Students need guidance on how to perform this activity appropriately. This article describes an ethical framework for tracking using an "educational registry," a list of former patients housed within the EHR that one follows longitudinally for educational purposes. Guiding principles include obtaining permission from patients, having legitimate educational intent, and restricting review of records to those essential for training. This framework could serve as a foundation for institutions seeking to develop a policy on tracking former patients, and may facilitate research on the use of EHRs to improve medical education, such as reducing diagnostic error and promoting self-directed learning.

Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents.

There is compelling evidence that residents training in primary care need education in palliative care. Evidence for effective curricula is needed. The objective of this study was to test whether a clinical elective improves measures of knowledge and skill. Residents from three categorical training programs in internal medicine were recruited to an elective including clinical experiences in an acute hospital palliative care consultation service, on an acute hospice and palliative care unit, and in-home hospice care. A 25-question pre- and post-test and a videotaped interview with a standardized patient were used to assess communication skills and measure outcomes. Residents demonstrated a 10 percent improvement in knowledge after the four-week elective (p < 0.05). All residents demonstrated basic competency in communication skills at the end of the rotation. These results indicate that clinical rotation shows promise as an educational intervention to improve palliative care knowledge and skills in primary care residents. An important limitation of the study is that it is an elective; further studies with a required rotation and/or a control group are needed to confirm the findings.

Should medical students track former patients in the electronic health record? An emerging ethical conflict.

Medical students are increasingly using electronic health records (EHRs) in clerkships, and medical educators should seek opportunities to use this new technology to improve training. One such opportunity is the ability to "track" former patients in the EHR, defined as following up on patients in the EHR for educational purposes for a defined period of time after they have left one's direct care. This activity offers great promise in clinical training by enabling students to audit their diagnostic impressions and follow the clinical history of illness in a manner not possible in the era of paper charting. However, tracking raises important questions about the ethical use of protected health information, including concerns about compromising patient autonomy, resulting in a conflict between medical education and patient privacy. The authors offer critical analysis of arguments on both sides and discuss strategies to balance the ethical conflict by optimizing outcomes and mitigating harms. They observe that tracking improves training, thus offering long-lasting benefits to society, and is supported by the principle of distributive justice. They conclude that students should be permitted to track for educational purposes, but only with defined limits to safeguard patient autonomy, including obtaining permission from patients, having legitimate educational intent, and self-restricting review of records to those essential for training. Lastly, the authors observe that this conflict will become increasingly important with completion of the planned Nationwide Health Information Network and emphasize the need for national guidelines on tracking patients in an ethically appropriate manner.

Improving residents' code status discussion skills: a randomized trial.

BACKGROUND: Inpatient Code Status Discussions (CSDs) are commonly facilitated by resident physicians, despite inadequate training. We studied the efficacy of a CSD communication skills training intervention for internal medicine residents. METHODS: This was a prospective, randomized controlled trial of a multimodality communication skills educational intervention for postgraduate year (PGY) 1 residents. Intervention group residents completed a 2 hour teaching session with deliberate practice of communication skills, online modules, self-reflection, and a booster training session in addition to assigned clinical rotations. Control group residents completed clinical rotations alone. CSD skills of residents in both groups were assessed 2 months after the intervention using an 18 item behavioral checklist during a standardized patient encounter. Average scores for intervention and control group residents were calculated and between-group differences on the CSD skills assessment were evaluated using two-tailed independent sample t tests. RESULTS: Intervention group residents displayed higher overall scores on the simulated CSD (75.1% versus 53.2%, p<0.0001) than control group residents. The intervention group also displayed a greater number of key CSD communication behaviors and facilitated significantly longer conversations. The training, evaluation, and feedback sessions were rated highly. CONCLUSION: A focused, multimodality curriculum can improve resident performance of simulated CSDs. Skill improvement lasted for at least 2 months after the intervention. Further studies are needed to assess skill retention and to set minimum performance standards.

Using an online forum to encourage reflection about difficult conversations in medicine.

OBJECTIVE: Medical students encounter many challenging communication situations during the clinical clerkships. We created the Difficult Conversations Online Forum (DC Forum) to give students an opportunity to reflect, debrief, and respond to one another about their experiences. METHODS: The DC Forum is a web-based application with structured templates for student posts and responses, along with a mechanism for faculty feedback. It became a required part of the curriculum for third-year medical students in 2003. We content analyzed data collected during the 2003-2004 and 2004-2005 academic years (N=315). All open-ended responses were coded by two members of the research team; the few disagreements were resolved via discussion. RESULTS: While posts addressed a wide range of topics, more than one-third (35.6%) of students addressed delivering bad news. Nearly half (49.4%) of the students reported they had talked with someone about their difficult conversation, most frequently a resident physician; the suggestions they received varied in terms of helpfulness. Only a small percentage of students (4.7%) reported accessing other resources. CONCLUSION: The DC Forum provides a template that encourages reflection and dialogue about challenging communication situations. The online design is feasible, and enables a virtual discussion that can be joined by students regardless of their clerkship schedule or clinical site. PRACTICE IMPLICATIONS: A structured approach for reflection and a simple, safe mechanism for feedback are essential components of the learning process regarding difficult conversations. While the DC Forum was created for medical students, the online approach may prove useful across the continuum of medical education.