While consensus exists among many practitioners of ethics consultation about the need for and identification of core competencies and standards, there has been virtually no attempt to determine how these competencies and standards are best taught and assessed. We believe that clinical ethics consultation has reached a state of sufficient maturity that expert practitioners can evaluate those who are new to the field. We will outline several steps that can facilitate the creation of a certification process for clinical ethics consultants, (...) assuring the competency and quality of consultation for the patients, families, and healthcare professionals who utilize ECSs. (shrink)

We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients’ ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS’s advice and recommendations generally promoted “reasonable accommodation” of the requests, balancing compassion for grieving families with other ethical and (...) moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finitegoal accommodation, a “reasonable accommodation” strategy proved effective in balancing stakeholders’ interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the “reasonable accommodation” approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases. (shrink)

Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of the checklist at a large academic medical system (Cleveland Clinic). The specific aims of this project are as follows: (1) to improve the quality of ethics consultations (...) by providing reminders to ethics consultants about process steps that are important for most patient-centered ethics consultations, (2) to create consistency in the ethics consultation process across the medical system, and (3) to establish an effective educational tool for trainers and trainees in clinical ethics consultation. The checklist was developed after a thorough literature review and an iterative process of revising and testing by a group of experienced ethics consultants. To pilot test the checklist, it was distributed to 46 ethics consultants. After a six-month pilot period in which ethics professionals used the checklist during their clinical activities, a survey was distributed to all of those who used the checklist. The 10-item survey examined consultants’ perceptions regarding the three aims listed above. Of the 25 survey respondents, 11 self-reported as experts in ethics consultation, nine perceived themselves to have mid-level expertise, and five self-reported as novices. The majority (68 percent) of all respondents, regardless of expertise, believed that the checklist could be a “helpful” or “very helpful” tool in the consultation process generally. Novices were more likely than experts to believe that the checklist would be useful in conducting consultations. The limitations of this study include: reduced generalizability given that this project was conducted at one medical system, utilized a small sample size, and used self-reported quality outcome measures. Despite these limitations, to the authors’ knowledge this is the first investigatation of the use of a checklist systematically to improve quality in ethics consultation. Importantly, our findings shed light on ways this checklist can be used to improve ethics consultation, including its use as an educational tool. The authors hope to test the checklist with consultants in other healthcare systems to explore its usefulness in different healthcare environments. (shrink)

We congratulate Fox and her colleagues (2007) for contributing to the published empirical literature on ethics consultation in United States hospitals. Their study demonstrates the continued wide v...

Conflicts of interest. None to report. Despite widespread acceptance in the United States of neurological criteria to determine death, clinicians encounter families who object, often on religious grounds, to the categorization of their loved ones as “brain dead.” The concept of “reasonable accommodation” of objections to brain death, promulgated in both state statutes and the bioethics literature, suggests the possibility of compromise between the family’s deeply held beliefs and the legal, professional and moral values otherwise directing clinicians to withdraw medical (...) interventions. Relying on narrative to convey the experience of a family and clinical caregivers embroiled in this complex dilemma, the case analyzed here explores the practical challenges and moral ambiguities presented by the concept of reasonable accommodation. Clarifying the term’s meaning and boundaries, and identifying guidelines for its clinical implementation, could help to reduce uncertainty for both health care professionals and families and, thereby, the incremental moral distress such uncertainty creates. (shrink)

Mistakes and errors happen in most spheres of human life and activity, including in medicine. A mistake can be as simple and benign as the collection of an extra and unnecessary urine sample. Or a mistake can cause serious but reversible harm, such as an overdose of insulin in a patient with diabetes, resulting in hypoglycemia, seizures, and coma. Or a mistake can result in serious and permanent damage for the patient, such as the failure to consider epiglottitis in an (...) initial differential diagnosis, resulting in a chronic vegetative state for a seven-year-old boy. Or a mistake can be an error in judgment that leads to a patient's death. (shrink)

We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed. To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple consultants with advanced training in bioethics. Several of these ethicists work closely with specialized clinical units and research departments, where they participate in multidisciplinary (...) meetings and provide specialized assistance. This combination of historical experience, large numbers of consultation requests, and specialized clinical ethicists suggests that the experience at the Cleveland Clinic may be helpful to ethicists and others who may be considering how to structure and sustain a vibrant ECS. Our results highlight the diversity of activities performed by a high-volume ECS at a tertiary care facility. Our hope in sharing the inner workings of the ECS at the Cleveland Clinic is to promote dialogue on common practices and approaches across medical institutions that support ethics consultation. (shrink)

It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients’ medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor. We aim to provide guidance for a variety of persons engaged in clinical ethics consultation: new and seasoned ethics committee members who are new to ethics consultation, students and trainees (...) in clinical ethics, and those who have significant experience with ethics consultation so that they can reflect on their practice. Toward the goal of promoting quality charting practices in ethics consultations, we propose recommendations on a broad array of questions concerning clinical ethics consultation chart notes, including whether and when to write a chart note, and practical considerations for the tenor, purpose, and content of a chart note. Our broader aim is to promote discussion about good charting practices in clinical ethics, with the hope of contributing to clear standards of excellence in clinical ethics consultation. (shrink)

Our hospital’s policy and procedures for “Patients Without Surrogates” provides for gradated safeguards for managing patients’ treatment and care when they lack decision–making capacity, have no advance directives, and no surrogate decision makers are available. The safeguards increase as clinical decisions become more significant and have greater consequences for the patient. The policy also directs social workers to engage in “rigorous efforts” to search for surrogates who can potentially provide substituted judgments for such patients. We describe and illustrate the policy, (...) procedures, and kinds of expected rigorous efforts through our narration of an actual but disguised case for which we provided clinical ethics guidance and social work expertise. Our experience with and reflection on this case resulted in four recommendations we make for health care facilities and organizations that aim to provide quality care for their own patients without surrogates. (shrink)

Families and surrogates sometimes use religious themes to justify their insistence on aggressive end‐of‐life care. Their hope that “God will work a miracle” can halt negotiations with health care professionals and lead to litigation. The possibility of “re‐imagining” religious themes, to broaden their scope and present a wider vision of the Christian tradition, may offer a solution.

The clinical ethicist met with Ms. H to clarify what information she wants and does not want to know. First, she wants to receive any treatment that could prolong her life, regardless of how the treatment affects her ability to engage in activities of daily living. Second, she wants to be included in the decision‐making process as much as possible, as long as clinicians use only “positive” language. Ms. H considers the words “dying,” “chemotherapy,” “radiation,” and “cancer” to be “bad (...) words.” For conversations in which these words cannot be avoided, she wants her clinicians to talk to her son. Her desired engagement includes hearing about risks, benefits, and alternatives to treatments if clinicians use only “positive” language. Finally, she says that she rarely sees doctors and that she is “very scared” of hospitals, despite exhibiting a comfortable demeanor.Should clinicians honor Ms. H's waiver of specified information and, if so, to what degree? (shrink)

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step (...) on the pathway to an eventual certification process for clinical ethics consultants. (shrink)

Standardizing consultation processes is increasingly important as clinical ethics consultation 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 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. (shrink)

Its critics to the contrary, the “gift of life” metaphor is not to be blamed for the indebtedness and guilt that organ recipients often experience. It is certainly misused, however, both by post‐transplant caregivers, who exploit it to manipulate recipients' behavior, and by the organ procurement system, which has failed to understand that the decision to give the gift of life must be approached communally.

While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and potential challenges in (...) implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: train-the-trainer, local capacity-building, circuit-riding, and consolidated accountability. We note each model’s benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations. (shrink)

Mr. F. is a fifty‐year‐old father of two school‐aged daughters. Six years ago, he received a double lung transplant because he was suffering from interstitial lung disease, a fatal illness that causes suffocation by progressive scarring of the lungs. He is now experiencing chronic rejection of the transplant and is being considered to receive another. Without it, he is expected to survive only a year and a half. With it, his prognosis will improve, but the numbers are still not good. (...) Three years after his lung transplant, Mr. F. stopped attending his office visits. For a period of sixteen months he went without the studies and attention essential to posttransplant care. He stopped performing the required daily self‐monitoring of his lung function about eight months after his transplant, but he has maintained a regular exercise regimen. While lost to follow‐up, he continued to take his immunosuppressant medications, but he stopped taking medicine to control his high blood pressure because of its expense. (shrink)

While outcomes for children with T-cell acute lymphoblastic leukemia have improved dramatically, survival rates for patients with relapsed/refractory disease remain dismal. Prior studies indicate that glucocorticoid resistance is more common than resistance to other chemotherapies at relapse. In addition, failure to clear peripheral blasts during a prednisone prophase correlates with an elevated risk of relapse in newly diagnosed patients. Here we show that intrinsic GC resistance is present at diagnosis in early thymic precursor T-ALLs as well as in a subset (...) of non-ETP T-ALLs. GC-resistant non-ETP T-ALLs are characterized by strong induction of JAK/STAT signaling in response to interleukin-7 stimulation. Removing IL7 or inhibiting JAK/STAT signaling sensitizes these T-ALLs, and a subset of ETP T-ALLs, to GCs. The combination of the GC dexamethasone and the JAK1/2 inhibitor ruxolitinib altered the balance between pro- and anti-apoptotic factors in samples with IL7-dependent GC resistance, but not in samples with IL7-independent GC resistance. Together, these data suggest that the addition of ruxolitinib or other inhibitors of IL7 receptor/JAK/STAT signaling may enhance the efficacy of GCs in a biologically defined subset of T-ALL.Leukemia advance online publication, 30 May 2017; doi:10.1038/leu.2017.136. (shrink)

1 Evidence-based policy requires researchers to provide the answers to ecological questions that are of interest to policy makers. To find out what those questions are in the UK, representatives from 28 organizations involved in policy, together with scientists from 10 academic institutions, were asked to generate a list of questions from their organizations. 2 During a 2-day workshop the initial list of 1003 questions generated from consulting at least 654 policy makers and academics was used as a basis for (...) generating a short list of 100 questions of significant policy relevance. Short-listing was decided on the basis of the preferences of the representatives from the policy-led organizations. 3 The areas covered included most major issues of environmental concern in the UK, including agriculture, marine fisheries, climate change, ecosystem function and land management. 4 The most striking outcome was the preference for general questions rather than narrow ones. The reason is that policy is driven by broad issues rather than specific ones. In contrast, scientists are frequently best equipped to answer specific questions. This means that it may be necessary to extract the underpinning specific question before researchers can proceed. 5 Synthesis and applications. Greater communication between policy makers and scientists is required in order to ensure that applied ecologists are dealing with issues in a way that can feed into policy. It is particularly important that applied ecologists emphasize the generic value of their work wherever possible. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Intensifying Phronesis:Heidegger, Aristotle, and Rhetorical CultureDaniel L. SmithAll too well versed in the commonness of what is multiple and entangled, we are no longer capable of experiencing the strangeness that carries with it all that is simple.—Martin Heidegger, Aristotle's Metaphysics θ 1-3IntroductionIn Norms of Rhetorical Culture Thomas Farrell returns to the thought of Aristotle to develop a contemporary conception of rhetoric as a mode of practical philosophy, one (...) that foregrounds the importance of phronesis. Returning to Aristotle's work to forge contemporary conceptions of rhetoric as practical philosophy is nothing new. What is novel about Farrell's approach, however, are his thoughts on Aristotle's conception of "phainomena," or appearances. "Appearances," Farrell states, "come to us as configurations, as ensembles of objects, habitats, paths, tools, tasks, icons, and more or less recognizable characters that engage and reassure us with their... familiarity" (1993, 27). Phainomena and their stability, therefore, constitute the milieux of human life. But coupled with the stability of phainomena that lends continuity and predictability to our lives is their dynamic element of mutability, contingency, and unpredictability. Therefore phainomena can also be "ambiguous or even equivocal and incomplete," according to Farrell (27). This stable-mutable aspect of phainomena, and thus human life itself, demands that we have ways of inhabiting and responding to the worlds these phainomena constitute.Farrell cites a comment by Merleau-Ponty on Cezanne as an "apt characterization" of Aristotle's thought: Cezanne, writes Merleau-Ponty, "did not want to separate the stable things which we see and the shifting way in which they appear..." (quoted in Farrell, 27). For Farrell, Merleau-Ponty's observation concisely expresses a fundamental aspect of Aristotle's [End Page 77] thought, namely, a focus on the relation between the being of things and their dynamic modes of appearing, which are distinct but inextricably connected. Aristotle's conception of phainomena, Farrell's work suggests, offers possibilities for thinking about rhetoric as practical philosophy, a rhetoric that would be "an art of real life" (274), one that, because of the stability-contingency of real life, features the concept of phronesis.It is interesting to note that the issue of being-appearing that Farrell attributes to Aristotle sounds like a problematic of twentieth-century European phenomenology. Given Merleau-Ponty's status as one of the preeminent phenomenologists of the twentieth century, it is surprising that Farrell makes no mention of Merleau-Ponty's—or phenomenology's—interest in the dynamics of phainomena; nor does he make any explicit connections between Aristotle, rhetoric, and phenomenology. In fact, Farrell's thoughts on the connections between rhetoric and the being-appearing of phainomena are virtually eclipsed in his book when he turns to Jürgen Habermas. Farrell claims "that Habermas's project on discourse ethics, together with his practical placement of the public sphere, offers a basis for synthesizing the normative component of practical wisdom and a rhetoric goaded by emancipatory reason" (188). Farrell's interest in theorizing the enactment of "emancipatory reason" in the public sphere, through norm-governed rhetorical practices (of argumentation, deliberation, and so forth), takes precedence over theorizing the rhetoric-phainomena connection (or at the very least, does not facilitate a phenomenological consideration of rhetorical cultures and norms). This is not a criticism of Farrell, but rather the citing of an absence that opens a possibility. More specifically, because Farrell does not see, or perhaps is not interested in, the connection between his understanding of Aristotle and the problematic of phenomenology, he is not prompted to explore the possibilities that lie in bringing rhetorical studies into an encounter with phenomenology. Furthermore, given the connection Farrell makes between Aristotle and phainomena, Farrell's work suggests that it might be interesting to see what possibilities for rhetoric might exist in readings of Aristotle by phenomenologists.This essay will attempt to look into possibilities unexamined by Farrell. My aim in assuming this task, however, is not to theorize and facilitate the enactment of "emancipatory reason" in the public sphere through discourse governed by normative standards or ideals. Rather, my goal is to highlight the ways that phenomenology and phenomenological readings of Aristotle can help rhetorical scholars to examine... (shrink)

Phenomenology and philosophy of mind can be defined either as disciplines or as historical traditions—they are both. As disciplines: phenomenology is the study of conscious experience as lived, as experienced from the first-person point of view, while philosophy of mind is the study of mind—states of belief, perception, action, etc.—focusing especially on the mind–body problem, how mental activities are related to brain activities. As traditions or literatures: phenomenology features the writings of Edmund Husserl, Martin Heidegger, Jean-Paul Sartre, Maurice Merleau-Ponty, (...) Roman Ingarden, Aron Gurwitsch, and many others, while philosophy of mind includes the writings of Gilbert Ryle, David Armstrong, Hilary Putnam, Jerry Fodor, Daniel Dennett, John Searle, Paul Churchland and Patricia Smith Churchland, and many others. Historically, philosophy of mind has been considered part of the wider tradition called analytic philosophy, while phenomenology has been considered part of the wider tradition called continental philosophy. But all that is changing as we write, and the present volume is designed to express the change. (shrink)

Rhetoric, Composition, Life is written for teacher-scholars of rhetoric and composition who grapple with the following question: Can my teaching not only make a positive difference in the lives of my students but also, in so doing, contribute to making the world a better place? This dissertation argues that in order to be able to answer this question in the affirmative with a greater sense of possibility for the future, that a re-understanding of how the world and its populations or (...) multiplicities of "actors" co-exist is necessary. Such conceptual work is needed because, under the influence of critical pedagogy, teacher-scholars in rhetoric and composition have placed too much emphasis on consciousness and its role in the dynamics of subjectivity, agency, and social transformation. In an effort to open a new space for thought and pedagogy in rhetoric and composition, Rhetoric, Composition, Life engages in a protracted performance of encounter and response with the work of Martin Heidegger. The dissertation argues that Heidegger's thought not only invites us to think of the aforementioned issues in more ecological and existential-affective terms, but does so in a way that is rooted in and extends a concept at the heart of Aristotle's ethics and politics: phronesis. What emerges from the project is an ethos of pedagogy and politics rooted in the phronetic dynamics of "question-ability" and "response-ability," one that attends to and works with-in dynamics and rhythms of power, life, temporality, agency, and social change from a non-representational, ecological, and existential-affective perspective. (shrink)