Preventing moral conflicts in patient care: Insights from a mixed-methods study with clinical experts

Background and aim Healthcare professionals are regularly exposed to moral challenges in patient care potentially compromising quality of care and safety of patients. Preventive clinical ethics support aims to identify and address moral problems in patient care at an early stage of their development. This study investigates the occurrence, risk factors, early indicators, decision parameters, consequences and preventive measures of moral problems. Method Semi-structured expert interviews were conducted with 20 interprofessional healthcare professionals from 2 university hospitals in Basel, Switzerland. A Likert scale questionnaire was completed by the interviewees and analysed using descriptive and inferential statistics. Results Healthcare professionals are frequently exposed to a variety of moral problems, such as end-of-life decisions, resource allocation and assessing the patient's will or decisional capacity. Thirty-four different risk factors for moral problems are identified, e.g. patient vulnerability, divergent values or world views, inadequate resources or poor ethical climate. Twenty-one early indicators are recognised such as disagreement between healthcare professionals, patients and relatives, emotional disturbances, gut feeling or conflict of conscience. A variety of preventive measures are suggested and presented in a preventive clinical ethics support process model. The most helpful measures are early ethical conversations with colleagues, early team-internal ethical case discussions and an ethics-trained contact person on the ward. Ethics training, kerbside consultations, proactive ethics consultations, ethics screening and rounds are also considered helpful. Conclusions Clinical ethics support services should not only offer reactive and complex, but also proactive and low-threshold support for healthcare professionals, patients and relatives.

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Managing ethical issues in patient care and the need for clinical ethics support

Australian Health Review ◽

10.1071/ah14034 ◽

2015 ◽

Vol 39 (1) ◽

pp. 44 ◽

Cited By ~ 3

Author(s):

Evan Doran ◽

Jennifer Fleming ◽

Christopher Jordens ◽

Cameron L Stewart ◽

Julie Letts ◽

...

Keyword(s):

Patient Care ◽

Clinical Ethics ◽

Ethical Issues ◽

Public Hospitals ◽

Cross Sectional Survey ◽

Convenience Sample ◽

Clinical Ethics Support ◽

Ethical Environment ◽

Ethics Support ◽

A Priority

Objective To investigate the range, frequency and management of ethical issues encountered by clinicians working in hospitals in New South Wales (NSW), Australia. Methods A cross-sectional survey was conducted of a convenience sample of 104 medical, nursing and allied health professionals in two NSW hospitals. Results Some respondents did not provide data for some questions, therefore the denominator is less than 105 for some items. Sixty-two (62/104; 60%) respondents reported occasionally to often having ethical concerns. Forty-six (46/105; 44%) reported often to occasionally having legal concerns. The three most common responses to concerns were: talking to colleagues (96/105; 91%); raising the issue in a group forum (68/105; 65%); and consulting a relevant guideline (64/105; 61%). Most respondents were highly (65/99; 66%) or moderately (33/99; 33%) satisfied with the ethical environment of the hospital. Twenty-two (22/98; 22%) were highly satisfied with the ethical environment of their department and 74 (74/98; 76%) were moderately satisfied. Most (72/105; 69%) respondents indicated that additional support in dealing with ethical issues would be helpful. Conclusion Clinicians reported frequently experiencing ethical and legal uncertainty and concern. They usually managed this by talking with colleagues. Although this approach was considered adequate, and the ethics of their hospital was reported to be satisfactory, most respondents indicated that additional assistance with ethical and legal concerns would be helpful. Clinical ethics support should be a priority of public hospitals in NSW and elsewhere in Australia. What is known about the topic? Clinicians working in hospitals in the US, Canada and UK have access to ethics expertise to help them manage ethical issues that arise in patient care. How Australian clinicians currently manage the ethical issues they face has not been investigated. What does this paper add? This paper describes the types of ethical issues faced by Australian clinicians, how they manage these issues and whether they think ethics support would be helpful. What are the implications for practitioners? Clinicians frequently encounter ethically and legally difficult decisions and want additional ethics support. Helping clinicians to provide ethically sound patient care should be a priority of public hospitals in NSW and elsewhere in Australia.

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Moral Competence, Moral Teamwork, Moral Action – Outcomes of Moral Case Deliberation in the Euro-MCD 2.0 For Evaluating Clinical Ethics Support

Studia Universitatis Babeş-Bolyai Bioethica ◽

10.24193/subbbioethica.2021.spiss.38 ◽

2021 ◽

Vol 66 (Special Issue) ◽

pp. 67-67

Author(s):

Janine de Snoo-Trimp ◽

◽

Keyword(s):

Clinical Ethics ◽

Healthcare Professionals ◽

Moral Action ◽

Moral Case Deliberation ◽

Moral Competence ◽

Revision Process ◽

Clinical Ethics Support ◽

Ethics Support ◽

Moral Case ◽

Difficult Situations

"Background: For Moral Case Deliberation (MCD), like any form of Clinical ethics support (CES), it is important to know whether it reaches its presumed goal of supporting healthcare professionals in their ethical challenges. Evaluation is needed to gain insight in the value of MCD. Therefore, the Euro-MCD instrument was developed to assess outcomes of MCD, and has now been revised. The aim of this presentation is to present the revised Instrument: the Euro-MCD 2.0. Methods: The revision process was an iterative dialogue in which field study findings were integrated with theoretical reflections and expert-input. Results: The Euro-MCD 2.0 has three domains: 1) Moral Competence, 2) Moral Teamwork and 3) Moral Action. Moral Competence includes items on moral sensitivity, analytical skills and a virtuous attitude, like ‘I speak up in ethically difficult situations’. Moral Teamwork refers to open dialogue and supportive relationships, for example ‘We feel secure to share emotions in ethically difficult situations’. Moral Action includes items about moral decision-making and responsible care, like ‘We are able to explain and justify our care towards patients and their families’. Discussion: The Euro-MCD 2.0 is shorter and more strongly substantiated by empirical data and theoretical reflections. At the conference, we will reflect on the revision process and the underlying foundations of the domains. The revised instrument helps to get insight in the MCD related outcomes for healthcare professionals in their daily practice. Our research can further improve implementation of MCD and contribute to the research field of evaluation of CES in general. "

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Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care

BMC Medical Ethics ◽

10.1186/s12910-021-00597-4 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Charlotte Weiner ◽

Pernilla Pergert ◽

Bert Molewijk ◽

Anders Castor ◽

Cecilia Bartholdson

Keyword(s):

Quality Of Care ◽

Childhood Cancer ◽

Clinical Ethics ◽

Cancer Care ◽

Healthcare Professionals ◽

Well Being ◽

Clinical Ethics Support ◽

Ethics Support ◽

Moral Case

Abstract Background In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for clinical ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that healthcare professionals in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden. Methods This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content validated European MCD Outcomes Instrument, before participating in regular MCDs. Answers to the main open-ended question, included in the questionnaire, was analysed according to systematic text condensation. Results Data was collected from 161 responses from the healthcare professionals. The responses included healthcare professionals’ perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care for the child and the family on a care level. Conclusions Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then create relevant working conditions for clinical ethics support.

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Provide Access to Information on Assisted Suicide for a Patient with a Diagnosis of Depression?

GeroPsych ◽

10.1024/1662-9647/a000259 ◽

2021 ◽

pp. 1-6

Author(s):

Laura Winkler ◽

Charlotte Wetterauer

Keyword(s):

Clinical Ethics ◽

Assisted Suicide ◽

Healthcare Professionals ◽

Psychiatric Patients ◽

Ethics Consultation ◽

Daily Practice ◽

Clinical Ethics Support ◽

Moral Uncertainty ◽

Ethics Support ◽

Clinical Ethics Consultants

Abstract. Assisted suicide (AS) is one of the most controversially discussed topics, both in bioethical academia and in clinical practice. This is especially true for psychiatric patients. In Switzerland, the organization of AS and patient accompaniment in the dying process is practiced by lay right-to-die societies (RTDS). Despite this demedicalization, healthcare professionals are increasingly encountering AS requests in their institutions and experiencing moral uncertainty. This led to a physician’s request for clinical ethics support when confronted with an elderly patient with depression asking for information on AS: When does “assistance” start and what am I supposed and willing to do? The following clinical case report discusses these ethical questions from the perspective of the clinical ethics consultants involved. By recounting and discussing this clinical ethics case, this article aims to illustrate the difficulties that arise in daily practice, the importance of guidance and support in view of controversy, the possibilities of finding pragmatic, acceptable solutions for all parties involved, and what clinical ethics consultation can contribute.

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48. Clinical ethics support services in veterinary practice

Professionals in food chains ◽

10.3920/978-90-8686-869-8_48 ◽

2018 ◽

Author(s):

S. Springer ◽

U. Auer ◽

F. Jenner ◽

H. Grimm

Keyword(s):

Support Services ◽

Clinical Ethics ◽

Clinical Ethics Support ◽

Veterinary Practice ◽

Ethics Support

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Ethics of fertility preservation for prepubertal children: should clinicians offer procedures where efficacy is largely unproven?

Journal of Medical Ethics ◽

10.1136/medethics-2016-104042 ◽

2017 ◽

Vol 44 (1) ◽

pp. 27-31 ◽

Cited By ~ 14

Author(s):

Rosalind J McDougall ◽

Lynn Gillam ◽

Clare Delany ◽

Yasmin Jayasinghe

Keyword(s):

Fertility Preservation ◽

Clinical Ethics ◽

Reproductive Potential ◽

Clinical Ethics Support ◽

Prepubertal Children ◽

Ethics Support ◽

Future Fertility ◽

Difference Of Opinion ◽

Proven Efficacy ◽

Pathway Of Care

Young children with cancer are treated with interventions that can have a high risk of compromising their reproductive potential. ‘Fertility preservation’ for children who have not yet reached puberty involves surgically removing and cryopreserving reproductive tissue prior to treatment in the expectation that strategies for the use of this tissue will be developed in the future. Fertility preservation for prepubertal children is ethically complex because the techniques largely lack proven efficacy for this age group. There is professional difference of opinion about whether it is ethical to offer such ‘experimental’ procedures. The question addressed in this paper is: when, if ever, is it ethically justifiable to offer fertility preservation surgery to prepubertal children? We present the ethical concerns about prepubertal fertility preservation, drawing both on existing literature and our experience discussing this issue with clinicians in clinical ethics case consultations. We argue that offering the procedure is ethically justifiable in certain circumstances. For many children, the balance of benefits and burdens is such that the procedure is ethically permissible but not ethically required; when the procedure is medically safe, it is the parents’ decision to make, with appropriate information and guidance from the treating clinicians. We suggest that clinical ethics support processes are necessary to assist clinicians to engage with the ethical complexity of prepubertal fertility preservation and describe the framework that has been integrated into the pathway of care for patients and families attending the Royal Children’s Hospital in Melbourne, Australia.

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