Institutional Ethics Resources: Creating Moral Spaces

Since 1992, institutions accredited by The Joint Commission have been required to have a process in place that allows staff members, patients, and families to address ethical issues or issues prone to conflict. While the commission's expectations clearly have made ethics committees more common, simply having a committee in no way demonstrates its effectiveness in terms of the availability of the service to key constituents, the quality of the processes used, or the outcomes achieved. Beyond meeting baseline accreditation standards, effective ethics resources are requisite for quality care for another reason. The provision of care to the sick is a practice with profound moral dimensions. Clinicians need what Margaret Urban Walker has called “moral spaces,” reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of care. Walker proposed that ethicists needed to be concerned with the design and maintenance of these moral spaces. Clearly, that concern needs to extend beyond ethicists to institutional leaders. This essay uses Walker's idea of moral space to describe individuals and groups who are actual and potential ethics resources in health care institutions. We focus on four requisite characteristics of effective resources and the challenges to achieving them, and we identify strategies to build them. In our view, such moral spaces are particularly important for nurses and their colleagues on interprofessional teams and need to be expanded and strengthened in most settings

Team-based learning and ethics education in Nursing

This report describes the use of team-based learning concepts in an undergraduate nursing applied ethics course using established reporting guidelines. Team-based learning relies on actively engaging students in the learning process through small-group activities that facilitate the development of skills, including concept analysis, critical thinking, and problem solving. Students are divided into teams of five to seven members who collaborate throughout the semester to work through activities that build on ethics concepts introduced through reading and lectures. Nurse educators are challenged to develop educational approaches that will engage students and help them to apply what they learn from the study of ethics to the lived experience of clinical practice. The ultimate goal is to help students to develop into morally sensitive and competent professionals. Team-based learning represents a novel way to teach these skills to undergraduate nursing students

A code of ethics for health care ethics consultants: Journey to the present and implications for the field

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here

Values, quality, and evaluation in ethics consultation

Background: The American Society for Bioethics and Humanities has recommended regular evaluation of the quality of health care ethics consultation. This article discusses the impact of ethics consultation on clinicians' perceptions of a patient's plan of care and on the personal values of clinicians who participated in an ethics consultation. Methods: Following institutional review board (IRB) approval, select data points were abstracted from case file report forms for ethics consultations over a 12-month period. Clinicians involved in the care of a patient who was the focus of an ethics consultation were invited to participate in an anonymous online survey. Clinicians who initiated an ethics consultation, were interviewed during the course of an ethics consultation, or were present at a patient care conference attended by an ethics consultant were invited to participate. A purposive sampling approach was used to invite clinicians to participate in an in-person interview. Results: The survey response rate was 44.4% (123 respondents from 277 invited). More than 60% of participants felt the consultation helped clarify the values of the patient and/or patient's family and helped them clarify their own values. Only 32% of participants indicated the patient's plan of care changed as a result of the ethics consultation, yet 75% indicated their confidence in the plan of care increased as a result of the ethics consultation. Preliminary findings from the qualitative interviews support the overall positive assessments reported by survey respondents. Conclusions: Ethics consultation can help clinicians clarify their own values and helps them clarify the values of patients and patients' families. Ethics consultation offers meaningful support when clinicians face ethically challenging cases, provides an opportunity to address moral distress, and is viewed favorably by those who experience the resource

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

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

"Doctor, what would you do?": physicians' responses to patient inquiries about periviable delivery

OBJECTIVE: To qualitatively assess obstetricians' and neonatologists' responses to standardized patients (SPs) asking "What would you do?" during periviable counseling encounters. METHODS: An exploratory single-center simulation study. SPs, portraying a pregnant woman presenting with ruptured membranes at 23 weeks, were instructed to ask, "What would you do?" if presented options regarding delivery management or resuscitation. Responses were independently reviewed and classified. RESULTS: We identified five response patterns: 'Disclose' (9/28), 'Don't Know' (11/28), 'Deflect' (23/28), 'Decline' (2/28), and 'Ignore' (2/28). Most physicians utilized more than one response pattern (22/28). Physicians 'deflected' the question by: restating or offering additional medical information; answering with a question; evoking a hypothetical patient; or redirecting the SP to other sources of support. When compared with neonatologists, obstetricians (40% vs. 15%) made personal or professional disclosures more often. Though both specialties readily acknowledged the importance of values in making a decision, only one physician attempted to elicit the patient's values. CONCLUSION: "What would you do?" represented a missed opportunity for values elicitation. Interventions are needed to facilitate values elicitation and shared decision-making in periviable care. PRACTICE IMPLICATIONS: If physicians fail to address patients' values and goals, they lack the information needed to develop patient-centered plans of care