Clinical education of ethicists: the role of a clinical ethics fellowship.
(9/42)
BACKGROUND: Although clinical ethicists are becoming more prevalent in healthcare settings, their required training and education have not been clearly delineated. Most agree that training and education are important, but their nature and delivery remain topics of debate. One option is through completion of a clinical ethics fellowship. METHOD: In this paper, the first four fellows to complete a newly developed fellowship program discuss their experiences. They describe the goals, structure, participants and activities of the fellowship. They identify key elements for succeeding as a clinical ethicist and sustaining a clinical ethics program. They critically reflect upon the challenges faced in the program. RESULTS: The one-year fellowship provided real-time clinical opportunities that helped them to develop the necessary knowledge and skills, gain insight into the role and scope of practice of clinical ethicists and hone valuable character traits. CONCLUSION: The fellowship enabled each of the fellows to assume confidently and competently a position as a clinical ethicist upon completion. (+info)
Terri Schiavo, Son Hudson, and 'nonbeneficial' medical treatments.
(10/42)
Two disputed cases about withholding life support (Terri Schiavo and Son Hudson) call for greater public discussion. Confusion arises from intermixing three kinds of cases: those (1) in which demanded treatment is physiologically futile, (2) involving competition for scarce resources, and (3) in which the treatment would likely achieve the patient's goals although the clinician perceives those goals to be valueless. This Perspective argues that clinicians should unilaterally refuse the first but do not have legitimate roles in blocking access to the second and third. Absent scarcity, patients should have access to effective life-prolonging treatments even if clinicians see no value in them. (+info)
Project examining effectiveness in clinical ethics (PEECE): phase 1-- descriptive analysis of nine clinical ethics services.
(11/42)
OBJECTIVE: The field of clinical ethics is relatively new and expanding. Best practices in clinical ethics against which one can benchmark performance have not been clearly articulated. The first step in developing benchmarks of clinical ethics services is to identify and understand current practices. DESIGN AND SETTING: Using a retrospective case study approach, the structure, activities, and resources of nine clinical ethics services in a large metropolitan centre are described, compared, and contrasted. RESULTS: The data yielded a unique and detailed account of the nature and scope of clinical ethics services across a spectrum of facilities. General themes emerged in four areas-variability, visibility, accountability, and complexity. There was a high degree of variability in the structures, activities, and resources across the clinical ethics services. Increasing visibility was identified as a significant challenge within organisations and externally. Although each service had a formal system for maintaining accountability and measuring performance, differences in the type, frequency, and content of reporting impacted service delivery. One of the most salient findings was the complexity inherent in the provision of clinical ethics services, which requires of clinical ethicists a broad and varied skill set and knowledge base. Benchmarks including the average number of consults/ethicist per year and the hospital beds/ethicist ratio are presented. CONCLUSION: The findings will be of interest to clinical ethicists locally, nationally, and internationally as they provide a preliminary framework from which further benchmarking measures and best practices in clinical ethics can be identified, developed, and evaluated. (+info)
Paying research participants: a study of current practices in Australia.
(12/42)
OBJECTIVE: To examine current research payment practices and to inform development of clearer guidelines for researchers and ethics committees. DESIGN: Exploratory email based questionnaire study of current research participant reimbursement practices. A diverse sample of organisations and individuals were targeted. SETTING: Australia. PARTICIPANTS: Contacts in 84 key research organisations and select electronic listservers across Australia. A total of 100 completed questionnaires were received with representations from a variety of research areas (for example, market, alcohol and drug, medical, pharmaceutical and social research). MAIN MEASUREMENTS: Open-ended and fixed alternative questions about type of research agency; type of research; type of population under study; whether payment is standard; amounts and mechanisms of payment; factors taken into account when deciding on payment practices; and whether payment policies exist. RESULTS: Reimbursement practice is highly variable. Where it occurs (most commonly for drug dependent rather than health professional or general population samples) it is largely monetary and is for time and out-of-pocket expenses. Ethics committees were reported to be often involved in decision making around reimbursement. CONCLUSIONS: Research subject payment practices vary in Australia. Researchers who do provide payments to research participants generally do so without written policy and procedures. Ethics committees have an important role in developing guidelines in this area. Specific guidelines are needed considering existing local policies and procedures; payment models and their application in diverse settings; case study examples of types and levels of reimbursement; applied definitions of incentive and inducement; and the rationale for diverse payment practices in different settings. (+info)
Controversial choice of a control intervention in a trial of ventilator therapy in ARDS: standard of care arguments in a randomised controlled trial.
(13/42)
When evaluating an innovative intervention in a randomised controlled trial (RCT), choosing an appropriate control intervention is necessary for a clinically meaningful result. An RCT reported in 2000 addressed the relative merits of two tidal volume ventilatory strategies, 6 ml/kg (innovative) and 12 ml/kg (control), in patients with acute respiratory distress syndrome. Critics claim that the 12 ml/kg volume did not represent the clinical practice standard at that time, and that lower tidal volumes had been used in some patients prior to randomisation. The trialists responded that current practice involved the use of a broad range of tidal volumes, including 12 ml/kg. Appropriate control interventions for RCTs can be ensured by: a systematic review of the relevant literature; a formal survey of expert clinicians; and publication of the proposed research protocol to solicit critical appraisal. A global survey of experts during the RCT's design stage would have been of probative value in determining the appropriate control tidal volume. Hypothetical, but plausible, results of such a survey are presented and examined to demonstrate the value of this method. (+info)
The costs of nonbeneficial treatment in the intensive care setting.
(14/42)
Ethics consultations have been shown to reduce the use of "nonbeneficial treatments," defined as life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, when treatment conflicts occurred in the adult intensive care unit (ICU). In this paper we estimated the costs of nonbeneficial treatment using the results from a randomized trial of ethics consultations. We found that ethics consultations were associated with reductions in hospital days and treatment costs among patients who did not survive to hospital discharge. We conclude that consultations resolved conflicts that would have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU instead of focusing on more appropriate comfort care. (+info)
On the difficulty of neurosurgical end of life decisions.
(15/42)
OBJECTIVE: To analyse the process of end of life decisions in a neurosurgical environment. METHODS: All 113 neurosurgical patients, who were subject to so called end of life decisions within a one year period were prospectively enrolled in a computerised data bank. Decision pathways according to patient and physician related parameters were assessed. RESULTS: Leading primary diagnoses of the patients were traumatic brain injury and intracranial haemorrhage. Forty-five patients had undergone an emergency neurosurgical operation prior to end of life decision, N = 69 were conservatively treated, which included intracranial pressure recording, or they were not offered neurosurgical care because of futile prognosis. N = 111 died after a median of two (zero to nine) days. Two, in whom the end of life decisions were revised, survived. Clear decisions to terminate further treatment were made by a senior staff member on call being informed by the senior resident on call (27.4%), difficult decisions on the basis of extensive round discussions (71.7%), and very difficult decision by an interdisciplinary ethical consult (0.9%). Decisions were further substantiated by electrophysiological examinations in N = 59. CONCLUSION: End of life decisions are to be considered standard situations for neurosurgeons. These decisions may reach a high rate of "positive" prediction, if substantiated by electrophysiological examinations as well as on the grounds of clinical experience and respect for the assumed will of the patient. The fact that patients may survive following revision of an end of life decision underlines the necessity for repeated reassessment of these decisions. Ethical training for neurosurgeons is to be encouraged. (+info)
Why doctors use or do not use ethics consultation.
(16/42)
BACKGROUND: Ethics consultation is used regularly by some doctors, whereas others are reluctant to use these services. AIM: To determine factors that may influence doctors to request or not request ethics consultation. METHODS: A survey questionnaire was distributed to doctors on staff at the University Community Hospital in Tampa, Florida, USA. The responses to the questions on the survey were arranged in a Likert Scale, from strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree to strongly agree. Data were analysed with the Wilcoxon test for group comparisons, the chi2 test to compare proportions and a logistic regression analysis. RESULTS: Of the 186 surveys distributed, 121 were returned, giving a 65% response rate. Demographic data were similar between the groups saying yes (I do/would use ethics consultation when indicated) and no (I do not/would not use ethics consultation when indicated). No statistically significant differences were observed between the user and non-user groups in terms of opinions about ethics consultants having extensive training in ethics or participating in ethics educational opportunities. On the issue "Ethics committee members or consultants cannot grasp the full picture from the outside", the non-users were neutral, whereas the users somewhat disagreed (p=0.012). Even more significant was the difference between surgeons and non-surgeons, where, by logistic regression analysis, surgeons who believed that ethics consultants could not grasp the full picture from the outside were highly likely to not use (p=0.0004). Non-users of ethics consultations thought that it was their responsibility to resolve issues with the patient or family (72.2% agree, p<0.05). Users of ethics consultation believed in shared decision making or the importance of alternate points of view (90.8% agree, p<0.05). IMPLICATIONS: Ethics consultations are used by doctors who believe in shared decision making. Doctors who did not use ethics consultation tended to think that it was their responsibility to resolve issues with patients and families and that they were already proficient in ethics. (+info)