Business conversion. Catholic Healthcare West ends formal ties to church and hopes as Dignity Health that it can more easily add non-Catholic hospitals

Catholic Healthcare West is now rechristened Dignity Health. Freed from its formal ties with the Roman Catholic Church, it's seeking to expand east by more easily adding hospitals that may have previously been apprehensive about adopting Catholic ethical directives. "I would say our vision has not changed and neither has our mission as being a voice for the voiceless," says Lloyd Dean, left, the system's president and CEO.     

Preventive Ethics Through Expanding Education

Healthcare institutions have been making increasing efforts to standardize consultation methodology and to accredit both bioethics training programs and the consultants accordingly. The focus has traditionally been on the ethics consultation as the relevant unit of ethics intervention. Outcome measures are studied in relation to consultations, and the hidden assumption is that consultations are the preferred or best way to address day-to-day ethical dilemmas. Reflecting on the data from an internal quality improvement survey and the literature, we argue that having general ethics education as a key function of ethics services may be more important in meeting the contemporaneous needs of acute care settings. An expanded and varied ethics education, with attention to the time constraints of healthcare workers’ schedules, was a key recommendation brought forward by survey respondents. Promoting ethical reflection and creating a culture of ethics may serve to prevent ethical dilemmas or mitigate their effects.     

Ricoeur’s “Petite éthique”: An Ethical Epistemological Perspective for Clinician–Bioethicists

The passage from a posture of clinician to that of clinician–bioethicist poses significant challenges for health professionals, most notably with regards to theoretical or epistemological views of complex ethical impasses encountered in clinical settings. Apprehending these situations from the only clinical perspective of the nurse or the doctor, for example, can be very unproductive to help solve this kind of situation and certainly poses great limits to the role of the clinician–bioethicist. Drawing on my own experience as a former nurse who, following graduate studies in bioethics has begun providing ethics consultation services, I argue that clinicians must undergo an epistemological transformation in order to become clinician–bioethicists. A source of inspiration or framework for would-be clinician–bioethicists is, I suggest, the “Petite éthique” developed by the contemporary French philosopher Paul Ricoeur. Specifically, clinician–bioethicists should develop specific core ethical competencies (in line with the conclusions of the American Society for Bioethics and Humanities (Core competencies for health care ethics consultation, 1998); namely: savoir or knowing, savoir faire or knowing how to do, and savoir être or knowing how to be.     

Research on clinical ethics and consultation. Introduction to the theme

Clinical ethics consultation has developed from local pioneer projects into a field of growing interest among both clinicians and ethicists. What is needed are more systematic studies on the ethical challenges faced in clinical practice and problem solving through ethics consultation from interdisciplinary perspectives. The Thematic Issue covers a range of topics and includes five recent studies from various European countries and the USA, focusing on issues such as the ethical difficulties of end of life decisions, experiences with newly developed or well established ethics consultation services, and the expectations of physicians in various clinical fields who are still unfamiliar with clinical ethics consultation. The papers included illustrate the interface between different socio-cultural contexts and their ways of dealing with clinical ethics consultation. They deepen the dialogue on clinical ethics consultation that has emerged at the European and International level.     

What Ethical Issues Really Arise in Practice at an Academic Medical Center? A Quantitative and Qualitative Analysis of Clinical Ethics Consultations from 2008 to 2013

As the field of clinical ethics consultation sets standards and moves forward with the Quality Attestation process, questions should be raised about what ethical issues really do arise in practice. There is limited data on the type and number of ethics consultations conducted across different settings. At Loyola University Medical Center, we conducted a retrospective review of our ethics consultations from 2008 through 2013. One hundred fifty-six cases met the eligibility criteria. We analyzed demographic data on these patients and conducted a content analysis of the ethics consultation write-ups coding both the frequency of ethical issues and most significant, or key, ethical issue per case. Patients for whom ethics consultation was requested were typically male (55.8 %), white (57.1 %), between 50 and 69 years old (38.5 %), of non-Hispanic origin (85.9 %), and of Roman Catholic faith (43.6 %). Nearly half (47.4 %) were in the intensive care unit and 44.2 % died in the hospital. The most frequent broad ethical categories were decision-making (93.6 %), goals of care/treatment (80.8 %), and end-of-life (73.1 %). More specifically, capacity (57.1 %), patient’s wishes/autonomy (54.5 %), and surrogate decision maker (51.3 %) were the most frequent particular ethical issues. The most common key ethical issues were withdrawing/withholding treatment (12.8 %), patient wishes/autonomy (12.2 %), and capacity (11.5 %). Our findings provide additional data to inform the training of clinical ethics consultants regarding the ethical issues that arise in practice. A wider research agenda should be formed to collect and compare data across institutions to improve education and training in our field.     

Reinforcing medical authority: clinical ethics consultation and the resolution of conflicts in treatment decisions

Despite substantial efforts in the past 15 years to professionalise the field of clinical ethics consultation, sociologists have not re-examined past hypotheses about the role of such services in medical decision-making and their effect on physician authority. In relation to those hypotheses, we explore two questions: (i) What kinds of issues does ethics consultation resolve? and (ii) what is the nature of the resolution afforded by these consults? We examined ethics consultation records created between 2011 and mid-2015 at a large tertiary care US hospital and found that in most cases, the problems addressed are not novel ethical dilemmas as classically conceived, but are instead disagreements between clinicians and patients or their surrogates about treatment. The resolution offered by a typical ethics consultation involves strategies to improve communication rather than the parsing of ethical obligations. In cases where disagreements persist, the proposed solution is most often based on technical clinical judgements, reinforcing the role of physician authority in patient care and the ethical decisions made about that care.     

Special treatment. The CHA says it's leading the fight for all not-for-profit hospitals to receive fair compensation for being nation's healthcare safety net

Some observers may say the timing was preordained. Against the backdrop of Tenet Healthcare Corp.'s mounting woes, the Catholic Health Association, headed by the Rev. Michael Place (left), is expected this week to release a report arguing that Roman Catholic hospitals deserve special and distinct financial concessions from the federal government because of the role they play.     

Transplant Ethics: Let’s Begin the Conversation Anew

Standardizing consultation processes is increasingly important as clinical ethics consultation (CEC) becomes more utilized in and vital to medical practice. Solid organ transplant represents a relatively nascent field replete with complex ethical issues that, while explored, have not been systematically classified. In this paper, we offer a proposed taxonomy that divides issues of resource allocation from viable solutions to the issue of organ shortage in transplant and then further distinguishes between policy and bedside level issues. We then identify all transplant related ethics consults performed at the Cleveland Clinic (CC) between 2008 and 2013 in order to identify how consultants conceptually framed their consultations by the domains they ascribe to the case. We code the CC domains to those in the Core Competencies for Healthcare Consultation Ethics in order to initiate a broader conversation regarding best practices in these highly complex cases. A discussion of the ethical issues underlying living donor and recipient related consults ensues. Finally, we suggest that the ethical domains prescribed in the Core Competencies provide a strong starting ground for a common intra-disciplinary language in the realm of formal CEC.     

Physicians’ Access to Ethics Support Services in Four European Countries

Clinical ethics support services are developing in Europe. They will be most useful if they are designed to match the ethical concerns of clinicians. We conducted a cross-sectional mailed survey on random samples of general physicians in Norway, Switzerland, Italy, and the UK, to assess their access to different types of ethics support services, and to describe what makes them more likely to have used available ethics support. Respondents reported access to formal ethics support services such as clinical ethics committees (23%), consultation in individual cases (17.6%), and individual ethicists (8.8%), but also to other kinds of less formal ethics support (23.6%). Access to formal ethics support services was associated with work in urban hospitals. Informal ethics resources were more evenly distributed. Although most respondents (81%) reported that they would find help useful in facing ethical difficulties, they reported having used the available services infrequently (14%). Physicians with greater confidence in their knowledge of ethics (P = 0.001), or who had had ethics courses in medical school (P = 0.006), were more likely to have used available services. Access to help in facing ethical difficulties among general physicians in the surveyed countries is provided by a mix of official ethics support services and other resources. Developing ethics support services may benefit from integration of informal services. Development of ethics education in medical school curricula could lead to improved physicians sensititity to ethical difficulties and greater use of ethics support services. Such support services may also need to be more proactive in making their help available.     

A descriptive study of healthcare ethics consultants in Canada: Results of a national survey

As part of a project to examine health care ethics consultation in Canada, we surveyed individuals who were considered by themselves or others to play a significant role in health care ethics consultation. Since one goal of the project was to examine the education and abilities necessary for consultants, we sought to determine the qualifications and skills currently possessed by persons considered to be ethics consultants. For the purposes of the questionnaire, 'health care ethics consultation' was defined broadly to include consultation on ethical issues in clinical care or in clinical research, ethics consultation to Clinical Ethics Committees, Research Ethics Committees, and policy formulation committees in health care institutions; 'clinical ethics work' was defined more broadly still to include, in addition to the above, ethics education, administration, research and writing on bioethics other than the above, and public speaking. Three hundred and fifty questionnaires were sent to individuals and institutions across Canada that were thought to have some involvement in health care ethics consultation. Two hundred and fifty-three questionnaires were returned for a response rate of 72%. This report presents initial findings of the study and attempts to provide a comprehensive overview of the current state of ethics consultation within Canada. The survey examines demographics, educational background, time spent on ethics, institutional affiliations, approaches to the role of consultation, research related issues, and attitudes toward certification. Of the 253 questionnaires returned, 162 were completed by individuals who indicated that they provided some kind of ethics consultation. Of these, 43 indicated that they spent 30% or more of their time in clinical ethics work. These individuals are quite heterogeneous in background, training and activities, and while the great majority of them are based in an academic setting (university or teaching hospital), many act as resources to community hospitals, long-term care facilities and other organizations. Finally, the survey found that respondents' views on the advisability of certification for those offering ethics consultation were split evenly between those in favour of and those against certification. This report serves, then, as a reference point for studying the roles, responsibilities, training and accreditation of ethics consultants in health care.     

Expected Ethical Competencies of Public Health Professionals and Graduate Curricula in Accredited Schools of Public Health in North America

Objectives. We assessed expected ethics competencies of public health professionals in codes and competencies, reviewed ethics instruction at schools of public health, and recommended ways to bridge the gap between them.Methods. We reviewed the code of ethics and 3 sets of competencies, separating ethics-related competencies into 3 domains: professional, research, and public health. We reviewed ethics course requirements in 2010–2011 on the Internet sites of 46 graduate schools of public health and categorized courses as required, not required, or undetermined.Results. Half of schools (n = 23) required an ethics course for graduation (master’s or doctoral level), 21 did not, and 2 had no information. Sixteen of 23 required courses were 3-credit courses. Course content varied from 1 ethics topic to many topics addressing multiple ethics domains.Conclusions. Consistent ethics education and competency evaluation can be accomplished through a combination of a required course addressing the 3 domains, integration of ethics topics in other courses, and “booster” trainings. Enhancing ethics competence of public health professionals is important to address the ethical questions that arise in public health research, surveillance, practice, and policy.Public health as a profession has a long history of expecting ethical behavior by its providers, scientists, and decision-makers. With early influences from medicine and nursing, laboratory science, and epidemiology, to more contemporary disciplines (e.g., behavioral science and engineering), public health consists of diverse professions,1 each of which contributes unique training, expectations of professional behavior, and discipline-specific codes of ethics. The common link that brings these disparate professionals together is the need for collective effort to improve health through a population focus.2Public health’s population focus presents unique ethics considerations that differ from those reflected in biomedicine and clinical care. Interactions between health care providers and patients emphasize the clinician’s obligation to the patient and the patient’s autonomy. Emphasis on the individual presents a challenge to public health professionals whose “patient” is the community or population. Since the early 2000s, at least a dozen public health ethics frameworks offered by scholars and practitioners have discussed the tensions that occur between autonomy and community responsibility.3 Public health professionals, many of whom are trained in medicine and allied health, understand that ethical challenges arise in the population setting, in public health practice, and public health research. The purpose of this assessment was to assess the expected ethical competencies of public health professionals as reflected in published codes and competencies, review current ethics instruction at schools of public health (SPH), and recommend ways to bridge the gap between what is expected and what is currently taught in graduate level courses.     

The Pitfalls of Proceduralism: An Exploration of the Goods Internal to the Practice of Clinical Ethics Consultation

In an age of professionalization and specialization, the practice of clinical ethics is facing an identity crisis. Are clinical ethicists moral experts, ethics experts, or merely quasi-lawyers giving legal advice? Are they extensions of the hospital, always working to advance the hospital’s interests? Or is there another option? Since 1998, when the American Society for Bioethics and Humanities (ASBH) first issued its Core Competencies for Healthcare Ethics Consultation, there has been debate about the role of standardization and proceduralism in clinical ethics consultation. Now, as ASBH continues to move forward with its credentialing program, proceduralism in clinical ethics must be critically examined. In this paper, I argue that the proceduralist approach to clinical ethics consultation, as espoused by the ASBH’s call for credentialing, creates a demeaning experience for all parties involved and precludes goods internal to the practice of clinical ethics consultation from being actualized. As a practice embedded in medicine and in institutions such as the hospital, clinical ethics consultation must define and examine its own goods in order to bring about more than a sterile, law-like solution to difficult moral quandaries, as these sterile solutions leave patients, families, and providers unsatisfied, abandoned, and disappointed. Thus, in an effort to push back against this proceduralism in clinical ethics consultation, I will offer a preliminary exploration of what these goods might be.     

Ethics Consultation in Surgical Specialties

HEC Forum - Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of...     

TEACHING ETHICS IN THE ERA OF AIDS

AIDS has focused attention on deficiencies in medical education and in particular the teaching of ethics in medicine. The relative impotence of doctors to treat HIV/AIDS has served to remind them and other health workers that the ethics of care and prevention is ultimately about power-sharing with people. A holistic approach to ethics in medicine requires proper attention to be given to developing both professional competence and interpersonal competencies . These need to be developed at the Micro (Clinical), Macho (Interprofessional), Meso (Service Management) and Macro (Health Policy) levels. Like medicine, ethics is a practical discipline, requiring knowledge of general principles and skills in problem-solving . Both need to be learned in actual clinical settings, in interprofessional team-work, applied management of health services, and through participation in the development of ethical health policy (albeit for the local health centre, clinic or hospital). In ethics, as with general medical education, AIDS has shown that there needs to be more scope for person-centred and experiential learning, to build the kind of competencies that enable young doctors to deal with sensitive issues around sexuality, substance abuse, death and bereavement (particularly affecting people of their own age group). Instead of reinforcing the tendency towards the privatization of ethics, medical schools should follow the example of some leading business corporations in conducting institutional ethical reviews of systems and procedures, in developing corporate ethical policies , which will nourish the development of ethical competence in all staff and place ethics teaching in the context of total quality management .     

Safeguarding patients' dignity. The revised directives discuss spiritual and professional considerations

The Catholic health ministry recognizes that caring for the spiritual nature of a person is a high priority. The rights of patients and residents in their relationship with care givers are also important. These topics are treated in Parts 2 and 3, respectively, of the Ethical and Religious Directives for Catholic Health Services. This article focuses on those directives. Directive 10 says pastoral care should be available to all persons in a Catholic healthcare facility, no matter their religious affiliation. Directives 12 to 20 are concerned with the reception of the sacraments of baptism, penance, anointing, and communion by Catholics. Directive 21 discusses the appointment of priests and deacons to the pastoral care staff. Directive 23 reminds care givers that respect for human dignity must inform all Catholic healthcare. Directives 24 and 25 discuss norms for responding to advance directives and the responsibilities of surrogates. Directives 26 to 28 are concerned with free and informed consent on the part of patients and surrogates. Directives 29 to 30 say care givers have a moral obligation to preserve a patient's anatomical and functional integrity. Directive 31 discusses the ethical limits on medical research, and Directive 33 discusses therapeutic procedures likely to harm the patient. Directive 34 says care givers must protect patients' privacy. Directive 36 discusses the care of women who have been raped, including treatment that would prevent ovulation as a result of the rape. Directive 37 says ethical consultation should be available to all Catholic facilities, usually through an ethics committee.     

Using a healthcare matrix to assess patient care in terms of aims for improvement and core competencies

BACKGROUND: In 2001, the Institute of Medicine (IOM) recommended six Aims f or Improvement; the dimensions of quality describe a health care system that is safe, timely, effective, efficient, equitable, and patient centered. In 1999, the Accreditation Council of Graduate Medical Education (ACGME) adopted six core competencies that physicians in training must master if they are to provide quality care. A Healthcare Matrix was developed that links the IOM aims for improvement and the six ACGME Core Competencies. The matrix provides a blueprint to help residents to learn the core competencies in patient care, and to help faculty to link mastery of the competencies with improvement in quality of care. HEALTHCARE MATRIX: The Healthcare Matrix is a conceptual framework that projects an episode of care as an interaction between quality outcomes and the skills, knowledge, and attitudes (core competencies) necessary to affect those outcomes. For example, an anesthesiology resident used the Healthcare Matrix for a complex 18-hour episode of care with a life-threatening situation. ONGOING WORK AND RESEARCH AGENDA: Collecting and analyzing a series of matrices provides the foundation for systematic change in patient care and medical education and a rich source of data for operational and improvement research.     

用模拟病人法评价上海一二级医院门诊医疗服务过程质量

目的 通过评价一二级医院门诊医疗服务过程质量,为领导改善门诊质量提供决策依据。方法 采用模拟病人法对上海区一二级医院各２０所门所医疗服务进行调研。结果 通过模拟病人的４８０次调查中,对医德的总体满意率为５８．７５％,门诊医德医疗服务过程质量总体评价服从正态分布,一级医院平均得分６７．３８,平均就诊时间和费用分别为１６．６２分和１３２．０２元;二级医院平均得分６７．４３,平均就诊时间和费用分别为２２     

Exploring the role of the ethics committee psychiatrist

Healthcare ethics committees (HEC) have emerged as institutional forums for addressing bioethical dilemmas. Psychiatrists have important roles to play on these committees. Their skills in group process assessment, mental status examination, and character assessment have diverse applications. Psychiatrists can facilitate communication within the committee and as HEC-based clinical ethics consultants. HECs must be concerned with how they arrive at ethical decisions, guarding against political influence or individual monopolization. Psychiatrists can assist these efforts as organizational consultants to HECs. The perception of psychiatrists as reflective, tolerant of ambiguity, humanizing, and approachable about ethical aspects of health care suggests they would make excellent committee leaders. Psychiatrists also have important committee roles to play as ethics educators and policy makers. More demographic data is needed to investigate psychiatrist participation on HECs. Studies of how they are perceived by their ethics committee colleagues may reveal new roles and potential pitfalls for HEC psychiatrists.     

Artificial Nutrition and Hydration in Catholic Healthcare: Balancing Tradition, Recent Teaching, and Law

Roman Catholics have a long tradition of evaluating medical treatment at the end of life to determine if proposed interventions are proportionate and morally obligatory or disproportionate and morally optional. There has been significant debate within the Catholic community about whether artificially delivered nutrition and hydration can be appreciated as a medical intervention that may be optional in some situations, or if it should be treated as essentially obligatory in all circumstances. Recent statements from the teaching authority of the church have attempted to clarify this issue, especially for those with a condition known as the persistent vegetative state. I argue that these recent teachings constitute a “general norm” whereby artificial nutrition and hydration are considered obligatory for most patients, but that these documents allow for exception in cases of complication from the means used to deliver nutrition and hydration, progressive illness, or clear refusal of such treatment by patients. While the recent clarifications do not constitute a major deviation from traditional understanding and will rarely conflict with advance directives or legal statutes, there may be rare instances in which remaining faithful to church teaching may conflict with legally enshrined patient prerogatives. Using the Texas Advance Directives Act as an example, I propose ways in which ethics committees can remain faithful to their Roman Catholic identity while respecting patient autonomy and state law pertaining to end of life health care.