Pandemic flu preparedness: ethical issues and recommendations to the Indiana State Department of Health

Four Recommendations are proposed: 1. the State must identify all healthcare workers who are deemed to be critically necessary during the pandemic; 2. the State and healthcare organizations should adopt a “high expectations, no punishment” approach to absenteeism; 3. the State should set and communicate expectations that healthcare institutions have adequate medical supplies and that these institutions ensure these supplies be made available to all personnel expected to interact with patients; and 4. the State should encourage healthcare institutions to establish clear policies for determining sanctions for noncompliance with expected responsibilities that are both fair and responsive to exceptional circumstances.The Indiana State Department of Healt

Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates

Background Hospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions. Objectives To determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards. Design Semi-structured interview study of the experience and process of decision making. Setting A public safety-net hospital and a tertiary referral hospital in a large city in the Midwest. Participants Thirty-five surrogates with a recent decision making experience for an inpatient age 65 and older. Measurements Key factors surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis. Results Surrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: 1) respecting the patient’s input, (2) using past knowledge of patient to infer the patient’s wishes, and (3) considering what is in the patient’s best interests. Some surrogates expressed a desire for more information about the patient’s prior wishes. Surrogate-centered factors included 1) Surrogate’s wishes as a guide, (2) The surrogate’s religious beliefs and/or spirituality, (3) The surrogate’s interests, (4) Family consensus and (5) Obligation and guilt. Conclusion These data show that surrogate decision making is more complex than the standard ethical models, which are limited to patient autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates’ desire for more information about patient preferences suggests a need for greater advance care planning

Doctor, What Would You Do?: An ANSWER for patients requesting advice about value-laden decisions

This article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients

CEASE: A guide for clinicians on how to stop resuscitation efforts

Resuscitation programs such as Advanced Cardiac Life Support, Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program offer inadequate guidance to physicians who must ultimately decide when to stop resuscitation efforts. These decisions involve clinical and ethical judgments and are complicated by communication challenges, group dynamics, and family considerations. This article presents a framework, summarized in a mnemonic (CEASE: Clinical Features, Effectiveness, Ask, Stop, Explain), for how to stop resuscitation efforts and communicate that decision to clinicians and ultimately the patient’s family. Rather than a decision rule, this mnemonic represents a framework based on best evidence for when physicians are considering stopping resuscitation efforts and provides guidance on how to communicate that decision

A Conceptual Model of the Role of Communication in Surrogate Decision Making for Hospitalized Adults

OBJECTIVE: To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics. METHODS: We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model. RESULTS: The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes. CONCLUSION: Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model. PRACTICE IMPLICATIONS: Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate

Communicating with Clinicians: The Experiences of Surrogate Decision‐Makers for Hospitalized Older Adults

OBJECTIVES: To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult. DESIGN: Semistructured interviews about a recent hospitalization. SETTING: Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital. PARTICIPANTS: Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died). MEASUREMENTS: Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory. RESULTS: Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences. CONCLUSION: In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support

Oncology Nurses’ Experiences with Prognosis Related Communication

poster abstractBackground: Oncology nurses have opportunities to engage in prognosis related communication with advanced cancer patients but often encounter barriers that impede patient prognosis understanding. Deficits in prognosis understanding have been associated with delays in transitions to end of life care, overly aggressive and potentially non-beneficial cancer treatments, and poor quality of life. Purpose: The purpose of this study was to describe nurses' experiences with prognosis related communication with advanced cancer patients. Methods: A framework of realism was used in this qualitative, descriptive design. A thematic analysis of audio-recorded interviews with oncology nurses (n=27) recruited from a Midwestern urban academic health center and 3 affiliated institutions was performed. Interviews were transcribed verbatim and accuracy checked. Data were coded by 3 experienced researchers. After coding, themes were identified, and a thematic map was developed. Methods to ensure trustworthiness of the findings were used. Results: Six themes were identified: Being in the middle, assessing the situation, barriers to prognosis communication, nurse actions, benefits of prognosis understanding, and negative outcomes. Nurses managed barriers through facilitation, collaboration, or independent actions to assist patients and/or families with prognosis understanding. Conclusions: Shortcomings in prognosis related communication with advanced cancer patients may contribute to negative outcomes for patients and nurses. Interventions to advance nurses’ abilities to facilitate and engage in prognosis communications are needed. Inter-professional communication skills education may also be beneficial

Disclosing Medical Mistakes: A Communication Management Plan for Physicians

Introduction: There is a growing consensus that disclosure of medical mistakes is ethically and legally appropriate, but such disclosures are made difficult by medical traditions of concern about medical malpractice suits and by physicians’ own emotional reactions. Because the physician may have compelling reasons both to keep the information private and to disclose it to the patient or family, these situations can be conceptualized as privacy dilemmas. These dilemmas may create barriers to effectively addressing the mistake and its consequences. Although a number of interventions exist to address privacy dilemmas that physicians face, current evidence suggests that physicians tend to be slow to adopt the practice of disclosing medical mistakes. Methods: This discussion proposes a theoretically based, streamlined, two-step plan that physicians can use as an initial guide for conversations with patients about medical mistakes. The mistake disclosure management plan uses the communication privacy management theory. Results: The steps are 1) physician preparation, such as talking about the physician’s emotions and seeking information about the mistake, and 2) use of mistake disclosure strategies that protect the physician-patient relationship. These include the optimal timing, context of disclosure delivery, content of mistake messages, sequencing, and apology. A case study highlighted the disclosure process. Conclusion: This Mistake Disclosure Management Plan may help physicians in the early stages after mistake discovery to prepare for the initial disclosure of a medical mistakes. The next step is testing implementation of the procedures suggested

Timing of Do‐Not‐Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision‐Maker

OBJECTIVES: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions. DESIGN: Retrospective cohort study. SETTING: Large, urban, public hospital. PARTICIPANTS: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004–12/31/2006) with a DNR order during their hospital stay. MEASUREMENTS: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders

Spiritual Experiences of Adults with Advanced Cancer in Outpatient Clinical Settings

Context Adults who have advanced cancer experience distress, and many use religion and spirituality to cope. Research on the spiritual experiences of advanced cancer patients will help guide the provision of high-quality spiritual care. Objectives To qualitatively describe advanced cancer patients’ spiritual experiences of illness. Methods We conducted semi-structured qualitative interviews at a single cancer center with 21 patients with stage IV solid malignancies who had a prognosis of less than 12 months, as estimated by each patient’s medical oncologist. Five investigators conducted a thematic analysis of the transcribed interviews. Results We found 31 patients who were eligible for enrollment, and 21 (67.7%) participated in interviews to thematic saturation. Using a thematic-analysis approach, five major themes emerged. Relationships with family and friends was the most important theme among all 21 patients irrespective of their religious or spiritual identity. Relationship with God and faith community was frequently identified by those who considered themselves spiritually religious. Cancer often led to reflection about the meaning of life and the nature of existential suffering Patients addressed the extent to which identity was changed or maintained through the cancer experience, and some expressed acceptance as a way of coping with illness. Conclusions Spiritual care for dying cancer patients should always include the exploration of relationships with family and friends, as well as God and faith community for some patients. Relationships with family, friends, and God can be a source of strength for many. Making meaning, addressing identity concerns, supporting acceptance as a resource for coping with illness, and acknowledging existential suffering will often arise for these patients