In den USA haben sich im Wesentlichen drei verschiedene Organisationsformen klinischer Ethikberatung entwickelt: der einzelne Berater, das große Komitee und das Beratungsteam teilweise mit Rückbindung an ein größeres Komitee. Bislang gibt es jedoch weder empirische Daten noch ein Ergebnis der anfänglichen theoretischen Diskussion, ob es ein favorisiertes Modell für die klinische Ethikberatung geben sollte und welches dieses sei. Dieser Artikel argumentiert, dass die Vorzüge, Nachteile und die Erfolgsfaktoren der verschiedenen Organisationsformen in Abhängigkeit von der Zielsetzung klinischer Ethikdienste (KED) bewertet werden (...) müssen. Diese Zielsetzung kann auf einem Spektrum vom „Patientenanwalt“ bis zum „Gewissen der Institution“ angesiedelt sein. Die Zielsetzung bestimmt dabei Aufgabenschwerpunkte, Zusammensetzung, die favorisierte Organisationsform und wünschenswerte Standards. Die Untersuchung stützt sich zum einen auf die Analyse von Interviews mit fünf Vorsitzenden klinischer Ethikkomitees von Harvard Lehrkrankenhäusern in Boston, die jeweils etwa 20 Jahre Erfahrung in klinischer Ethikberatung mit den drei unterschiedlichen Modellen gemacht haben. Zum anderen basiert sie auf der Rezeption der Literatur und empirischen Studien zu KEDs in den USA und Deutschland. Insgesamt scheint das Konsilteam mit Rückbindung an ein Komitee am besten geeignet, die Behandlung einzelner Patienten und das ethische Bewusstsein einer ganzen Organisation zu verbessern. Es vereint die Vorteile der anderen beiden Modelle auf sich, ohne unter deren Schwächen zu leiden. (shrink)

Background Few studies have been conducted to assess the quality of orientation practices for ethics advisory committees that conduct ethics consultation. This survey study focused on several Harvard teaching hospitals, exploring orientation quality and committee members’ self-evaluation in the American Society of Bioethics and Humanities ethics consultation competencies. Methods We conducted a survey study that involved 116 members and 16 chairs of ethics advisory committees, respectively. Predictor variables included professional demographics, duration on committees and level of training. Outcome variables included (...) familiarity with and preparedness in the ASBH competencies and satisfaction with orientations. We hypothesised that responses would be associated with both the aforementioned predictors and whether or not participants had encountered the ASBH competencies in training. Results A majority of respondents found their orientation curricula to be helpful, although a significant portion of respondents did not receive any orientation or were unsatisfied with their orientation. Familiarity with ASBH competencies was a statistically significant predictor of respondents’ self-evaluation in particular categories. Standard educational materials were reported as offered during orientation, such as readings and case studies ; different medium resources were less evidenced such as videos on ethics consultation. Conclusions Institutions should re-evaluate orientation practices for ethics committee members that perform ethics consultation. Integrating ASBH competencies and useful methods into a resourceful pedagogy will help improve both member satisfaction with orientation and preparation in consultation. (shrink)

In den USA haben sich im Wesentlichen drei verschiedene Organisationsformen klinischer Ethikberatung entwickelt: der einzelne Berater, das große Komitee und das Beratungsteam teilweise mit Rückbindung an ein größeres Komitee. Bislang gibt es jedoch weder empirische Daten noch ein Ergebnis der anfänglichen theoretischen Diskussion, ob es ein favorisiertes Modell für die klinische Ethikberatung geben sollte und welches dieses sei. Dieser Artikel argumentiert, dass die Vorzüge, Nachteile und die Erfolgsfaktoren der verschiedenen Organisationsformen in Abhängigkeit von der Zielsetzung klinischer Ethikdienste (KED) bewertet werden (...) müssen. Diese Zielsetzung kann auf einem Spektrum vom „Patientenanwalt“ bis zum „Gewissen der Institution“ angesiedelt sein. Die Zielsetzung bestimmt dabei Aufgabenschwerpunkte, Zusammensetzung, die favorisierte Organisationsform und wünschenswerte Standards. Die Untersuchung stützt sich zum einen auf die Analyse von Interviews mit fünf Vorsitzenden klinischer Ethikkomitees von Harvard Lehrkrankenhäusern in Boston, die jeweils etwa 20 Jahre Erfahrung in klinischer Ethikberatung mit den drei unterschiedlichen Modellen gemacht haben. Zum anderen basiert sie auf der Rezeption der Literatur und empirischen Studien zu KEDs in den USA und Deutschland. Insgesamt scheint das Konsilteam mit Rückbindung an ein Komitee am besten geeignet, die Behandlung einzelner Patienten und das ethische Bewusstsein einer ganzen Organisation zu verbessern. Es vereint die Vorteile der anderen beiden Modelle auf sich, ohne unter deren Schwächen zu leiden. (shrink)

In den USA haben sich im Wesentlichen drei verschiedene Organisationsformen klinischer Ethikberatung entwickelt: der einzelne Berater, das große Komitee und das Beratungsteam teilweise mit Rückbindung an ein größeres Komitee. Bislang gibt es jedoch weder empirische Daten noch ein Ergebnis der anfänglichen theoretischen Diskussion, ob es ein favorisiertes Modell für die klinische Ethikberatung geben sollte und welches dieses sei. Dieser Artikel argumentiert, dass die Vorzüge, Nachteile und die Erfolgsfaktoren der verschiedenen Organisationsformen in Abhängigkeit von der Zielsetzung klinischer Ethikdienste (KED) bewertet werden (...) müssen. Diese Zielsetzung kann auf einem Spektrum vom „Patientenanwalt“ bis zum „Gewissen der Institution“ angesiedelt sein. Die Zielsetzung bestimmt dabei Aufgabenschwerpunkte, Zusammensetzung, die favorisierte Organisationsform und wünschenswerte Standards. Die Untersuchung stützt sich zum einen auf die Analyse von Interviews mit fünf Vorsitzenden klinischer Ethikkomitees von Harvard Lehrkrankenhäusern in Boston, die jeweils etwa 20 Jahre Erfahrung in klinischer Ethikberatung mit den drei unterschiedlichen Modellen gemacht haben. Zum anderen basiert sie auf der Rezeption der Literatur und empirischen Studien zu KEDs in den USA und Deutschland. Insgesamt scheint das Konsilteam mit Rückbindung an ein Komitee am besten geeignet, die Behandlung einzelner Patienten und das ethische Bewusstsein einer ganzen Organisation zu verbessern. Es vereint die Vorteile der anderen beiden Modelle auf sich, ohne unter deren Schwächen zu leiden. (shrink)

Ethics consultation is a familiar concept to clinicians, and there are site-specific guidelines detailing procedures for both obtaining and performing these consults. Evaluative data about clinician experiences with ethics consults are becoming more extensive but information about family experiences, especially parent perceptions, of the same is lacking. Without a better understanding of those family experiences, an evidence base for ethics consultations cannot be built. This manuscript describes the reasons for obtaining this necessary information, details prior research designed to obtain knowledge (...) about family experiences with pediatric ethics consultations, and suggests mechanisms for acquiring it. (shrink)

Objective: To evaluate one ethics rounds model by describing nurses’ and doctors’ experiences of the rounds. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis. Findings: The goal of the rounds was partly (...) fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses’ expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous. Conclusion: When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented. (shrink)

Background:Clinical ethics committees have been broadly implemented in university hospitals, general hospitals and nursing homes. To ensure the quality of ethics consultations, evaluation should be...

Evaluation of clinical ethics support services (CESS) has attracted considerable interest in recent decades. However, few evaluation studies are explicit about normative presuppositions which underlie the goals and the research design of CESS evaluation. In this paper, we provide an account of normative premises of different approaches to CESS evaluation and argue that normativity should be a focus of considerations when designing and conducting evaluation research of CESS. In a first step, we present three different approaches to CESS evaluation from (...) published literature. Next to a brief sketch of the well-established approaches of ‘descriptive evaluation’ and ‘evaluation of outcomes’, we will give a more detailed description of a third approach to evaluation—‘reconstructing quality norms of CESS’—which is explicit about the normative presuppositions of its research (design). In the subsequent section, we will analyse the normative premises of each of the three approaches to CESS evaluation. We will conclude with a brief argument for more sensitivity towards the normativity of CESS and its evaluation research. (shrink)

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, (...) existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals. (shrink)

Wie muss ein ethischer Beratungsdienst strukturiert sein, damit er in moralischen Konfliktsituationen im klinischen Alltag angefragt wird und die Ratsuchenden ergebnisorientiert unterstützen kann? Nach welchen Kriterien lassen sich die Beratungsgespräche auswerten und bewerten? Zur Beantwortung dieser Fragen werden theoretisch fundierte Konzepte ethischer Fallbesprechung aus Nimwegen, Leuven und Basel herangezogen; dies geschieht vor dem Hintergrund der Erfahrungen mit der über zehnjährigen Entwicklung der ethischen Arbeit im Ev. Krankenhaus Bielefeld (EvKB). Als Resultat stellen wir einen strukturierten, multidisziplinären Ansatz vor, mit dem in (...) den Beratungsgesprächen die ethischen Dimensionen unterschiedlicher Vorstellungen herausgearbeitet und möglichst einvernehmlichen Lösungen zugeführt werden. Am Beispiel des EvKB lässt sich zeigen, dass der ethische Beratungsdienst auch in Zeiten knapper Ressourcen implementiert und praktiziert werden kann und eine Gesprächskultur schafft, die zu neuen Zielvariablen führt; hier spielen der Perspektivenwechsel und die Prozessgerechtigkeit eine zentrale Rolle und liefern zugleich Ansatzpunkte für unsere eigene Evaluationsstrategie. Zum aktuellen Stand der Evaluation klinischer Ethikberatung wird die internationale Literatur kritisch gewürdigt. Erste konzeptionelle Ansätze und Ergebnisse einer eigenen Evaluationsstrategie werden vorgestellt. Durch die Offenlegung hoffen wir, die Auseinandersetzung mit diesen Themen zu intensivieren. (shrink)

Wie muss ein ethischer Beratungsdienst strukturiert sein, damit er in moralischen Konfliktsituationen im klinischen Alltag angefragt wird und die Ratsuchenden ergebnisorientiert unterstützen kann? Nach welchen Kriterien lassen sich die Beratungsgespräche auswerten und bewerten? Zur Beantwortung dieser Fragen werden theoretisch fundierte Konzepte ethischer Fallbesprechung aus Nimwegen, Leuven und Basel herangezogen; dies geschieht vor dem Hintergrund der Erfahrungen mit der über zehnjährigen Entwicklung der ethischen Arbeit im Ev. Krankenhaus Bielefeld (EvKB). Als Resultat stellen wir einen strukturierten, multidisziplinären Ansatz vor, mit dem in (...) den Beratungsgesprächen die ethischen Dimensionen unterschiedlicher Vorstellungen herausgearbeitet und möglichst einvernehmlichen Lösungen zugeführt werden. Am Beispiel des EvKB lässt sich zeigen, dass der ethische Beratungsdienst auch in Zeiten knapper Ressourcen implementiert und praktiziert werden kann und eine Gesprächskultur schafft, die zu neuen Zielvariablen führt; hier spielen der Perspektivenwechsel und die Prozessgerechtigkeit eine zentrale Rolle und liefern zugleich Ansatzpunkte für unsere eigene Evaluationsstrategie. Zum aktuellen Stand der Evaluation klinischer Ethikberatung wird die internationale Literatur kritisch gewürdigt. Erste konzeptionelle Ansätze und Ergebnisse einer eigenen Evaluationsstrategie werden vorgestellt. Durch die Offenlegung hoffen wir, die Auseinandersetzung mit diesen Themen zu intensivieren. (shrink)

This article describes a qualitative study of models of ethics consultation used by ethics consultants in Canada. We found four different models used by Canadian ethics consultants whom we interviewed, and one sub-variant. We describe the lone ethics consultant model, the hub-and-spokes sub-variant of this model; the ethics committee model; the capacity-building model; and the facilitated model. Previous empirical studies of ethics consultation describe only two or three of these models.

Of Goals and Goods and Floundering About: A Dissensus Report on Clinical Ethics Consultation Content Type Journal Article Pages 275-291 DOI 10.1007/s10730-009-9101-1 Authors Jeffrey P. Bishop, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Joseph B. Fanning, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Mark J. Bliton, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite (...) 400 Nashville Tennessee 37203 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 3. (shrink)

Background: Clinical ethics support services have been advocated in recent decades. In clinical practice, clinical ethics support services are often requested for difficult decisions near the end of life. However, their contribution to improving healthcare has been questioned and demands for evaluation have been put forward. Research indicates that there are considerable challenges associated with defining adequate outcomes for clinical ethics support services. In this systematic review, we report findings of qualitative studies and surveys, which have been conducted to evaluate (...) clinical ethics support services near the end of life. Methods: Electronic databases and other sources were queried from 1970 to May 2018. Two authors screened studies independently. Methodological quality of studies was assessed. For each arm of the review, an individual synthesis was performed. Prospero ID: CRD42016036241. Ethical Considerations: Ethical approval is not needed as it is a systematic review of published literature. Results: In all, 2088 hits on surveys and 2786 on qualitative studies were found. After screening, nine surveys and four qualitative studies were included. Survey studies report overall positive findings using a very wide and heterogeneous range of outcomes. Negative results were reported only occasionally. However, methodological quality and conceptual justification of used outcomes was often weak and limits generalizability of results. Conclusion: Evidence points to positive outcomes of clinical ethics support services. However, methodological quality needs to be improved. Further qualitative or mixed-method research on evaluating clinical ethics support services may contribute to the development of evaluating outcomes of clinical ethics support services by means of broaden the range of appropriate (process-oriented) outcomes of (different types of) clinical ethics support services. (shrink)

In their recent work, Kok et al propose a theoretical framework for the evaluation of clinical ethical case interventions, in particular moral case deliberation (MCD).1 According to the authors, this framework provides ‘empirically accessible hypothesis that describe the relationship between MCD and care quality at the organisational level’.1 Evaluation of ethical interventions in healthcare is an important topic. As Donabedian has noted, evaluation can be understood as defining reasonable quality expectations and to check by means of empirical research whether and (...) to what extent these expectations have been met.2 If suitable for ethical interventions like MCDs, the carefully compiled framework by Kok et al would surely present a major step towards satisfying the requirements outlined by Donabedian. However, caution is in order whether this holds true. The authors start by observing that most of the recent research regarding the evaluation of MCD tends to follow a paradigm that can be outlined by two premises. First, focusing on quality is justified by the need to provide a rationale for an intervention’s consumption of resources.3 Second, this implies research that is usually centred around the quality …. (shrink)

Evaluation of clinical ethical case consultations has been discussed as an important research task in recent decades. A rigid framework of evaluation is essential to improve quality of consultations and, thus, quality of patient care. Different approaches to evaluate those services appropriately and to determine adequate empirical endpoints have been proposed. A key challenge is to provide an answer to the question as to which empirical endpoints—and for what reasons—should be considered when evaluating the quality of a service. In this (...) paper, we argue for an approach that adopts the role of ethics consultants as its point of departure. In a first step, we describe empirical and ethical characteristics of evaluating clinical ethical case. We show that the mode of action and the explicit normative character of the interventions constitute two characteristics which pose challenges to the selection of appropriate quality criteria and require special attention. In a second step, we outline the way in which an analysis of the role of ethics consultants in the context of a clinical ethical case consultation services can account for the existing challenges by linking empirically measurable endpoints with normative theory. Finally, we discuss practical implications of our model for evaluation research. (shrink)

Context: Although ethics consultation is commonplace in United States hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the “best informant” within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services were found in 81% of all general hospitals in the U.S., and in 100% (...) of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians, nurses, social workers, or chaplains. Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Clinical ethicist and professor Mark Aulisio argues that good ethics consultation is not simply a manner of meaning well. He writes: [t]he path to ethics consultation is not paved only with good in...

Clinical ethics committees aim to resolve conflict, facilitate communication and ease moral distress in health care. Dialogue in committee discussions is complex and involves a balance between implicitly and explicitly expressed values of patients, families and professionals. Evaluating effectiveness and concrete outcomes is challenging and most studies focus on broad benefits such as quality of care and reduction of unnecessary or unwanted treatments. In this paper we propose ‘physician satisfaction’ as a valuable outcome. We refer to the clinical ethics approach (...) followed at one large paediatric hospital in Australia, propose reasons for the often-expressed feeling of satisfaction and discuss why this feeling matters. We conclude that physician satisfaction is a valid measure of an effective ethics consultation because it implies the person has been listened to and respected by others, and has perhaps developed greater understanding of and insights into their own work and values, and those of others. (shrink)