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A review of clinical ethics consultations in a regional healthcare system over a two-year timeframe. 对一个地区医疗系统两年来的临床伦理咨询进行回顾。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-11-09 DOI: 10.1186/s12910-024-01129-6
Graham Anderson, Jacob Hodge, Dean Fox, Stacey Jutila, Catherine McCarty

Background: Clinical Ethics Consultations (CECs) are used by healthcare systems to offer healthcare practitioners a structured level of support to approach ethical questions. The objective of this study was to detail the elements of surveyed CECs and offer guidance in the approach to future ethics consultations at a regional healthcare system.

Methods: This cohort study has a qualitative and quantitative retrospective approach, surveying ethics consultations through the dates of 4/27/22 to 4/26/24. A documentary sheet was created, and information was entered via online data-gathering forms. The cases are from a range of specialties within a regional healthcare system servicing Minnesota, Wisconsin, and North Dakota.

Results: 103 CECs were performed within the study period across the regional healthcare system. Consultations were identified through retrospective review of the internal CEC database, and patient information was collected through the medical record. Decision-making was often performed by a substitute decision-maker (N = 54), occurring in 70.1% of cases with known decision makers. CECs were documented in an ethics-specific note in the patient medical record in 37 of 82 (45.1%) documented patient cases. It was common for physicians to mention the ethics consultation in their patient notes, occuring in 51 of 82 (62.2%) of documented patient cases. Age was recorded in 92.0% (N = 91) of unique patient cases; the median age was 62 years. Ethical questions concerning end-of-life care were the most common cause for consultation (N = 35, 34%), and CECs were most commonly requested in general medicine or hospitalist departments (N = 38, 45.2%). Most consultations resulted in resolution at time of initial consultation with the ethics call team.

Conclusions: Recommendations for increased frequency and timing of policy review are given based on the results of the data presented. Using interpretation of the CECs in this study, we offer recommendations towards the use and documentation of ethics consultations in the era of open notes, open the door towards areas of future research, and ultimately promote use of CECs for more favorable patient outcomes.

背景:医疗保健系统采用临床伦理咨询(CEC)为医疗保健从业人员提供结构化支持,帮助他们解决伦理问题。本研究的目的是详细介绍已调查的 CEC 的要素,并为一个地区医疗保健系统今后的伦理咨询方法提供指导:这项队列研究采用了定性和定量的回顾性方法,调查了 4/27/22 至 4/26/24 期间的伦理咨询情况。研究人员制作了记录表,并通过在线数据收集表输入信息。这些病例来自明尼苏达州、威斯康星州和北达科他州地区医疗保健系统的各个专科:在研究期间,该地区医疗系统共进行了 103 次 CEC。通过对内部 CEC 数据库的回顾性审查确定了会诊情况,并通过病历收集了患者信息。决策通常由替代决策者做出(N = 54),在已知决策者的病例中占 70.1%。在 82 例记录在案的患者病历中,有 37 例(45.1%)在伦理专用说明中记录了 CEC。医生在病历中提及伦理会诊的情况很常见,82 例记录在案的患者中有 51 例(62.2%)提及了伦理会诊。92.0%(N=91)的独特病例记录了患者的年龄;年龄中位数为 62 岁。有关临终关怀的伦理问题是最常见的会诊原因(N = 35,34%),而 CEC 最常见于普通内科或住院医师科室(N = 38,45.2%)。大多数会诊在与伦理呼叫小组初次会诊时就得到了解决:结论:根据所提供的数据结果,对增加政策审查的频率和时机提出了建议。通过对本研究中的 CECs 进行解释,我们对开放式笔记时代伦理咨询的使用和记录提出了建议,为未来的研究领域打开了大门,并最终促进了 CECs 的使用,为患者带来了更有利的结果。
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引用次数: 0
Public perceptions of the Hippocratic Oath in the U.K. 2023. 2023 年英国公众对希波克拉底誓言的看法。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-11-04 DOI: 10.1186/s12910-024-01127-8
Ben Green

This paper explores public perceptions of the Hippocratic Oath (Physician's Oath) in the U.K. Results of a questionnaire administered online to 106 adults indicated that the majority were of the opinion that their primary and secondary health care doctors had taken the Oath (88% and 86% respectively). A majority thought that nurses, paramedics, psychotherapists and graduate scientists and researchers should also take some form of professional oath. Elements of the Oath which were deemed most important included that it is a sworn oath, that doctors should not harm patients, act in the best interests of patients, abide by the principles of autonomy and informed consent and maintain patient confidentiality. A significant proportion - about 20% - of the UK public felt that doctors had forgotten their Hippocratic Oath during COVID-19 lockdowns and associated vaccination programme, suggesting that recent history may have damaged the public faith in the medical profession.

本文探讨了英国公众对希波克拉底誓言(医生誓言)的看法。对 106 名成年人进行在线问卷调查的结果表明,大多数人认为他们的初级和二级医疗保健医生已经宣誓(分别为 88% 和 86%)。大多数人认为,护士、辅助医务人员、心理治疗师以及研究生科学家和研究人员也应进行某种形式的职业宣誓。誓言中被认为最重要的内容包括:誓言是宣过誓的,医生不得伤害病人,以病人的最佳利益为重,遵守自主和知情同意的原则,并为病人保密。有相当一部分(约 20%)英国公众认为,在 COVID-19 封锁和相关疫苗接种计划期间,医生忘记了他们的希波克拉底誓言,这表明近期的历史可能损害了公众对医疗行业的信心。
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引用次数: 0
Ethical challenges in organ transplantation for Syrian refugees in Türkiye. 土耳其叙利亚难民器官移植的伦理挑战。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-11-02 DOI: 10.1186/s12910-024-01124-x
Deniz Birtan, Aslıhan Akpınar

Background: There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants.

Methods: From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method.

Results: The findings elucidate two principal themes related to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye's commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees.

Conclusions: This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees.

背景:有关难民和寻求庇护者进行活体器官移植时遇到的伦理问题的信息十分有限。本研究调查了在土耳其接受临时保护的叙利亚难民进行活体器官移植时所面临的伦理挑战:这项研究于 2022 年 4 月至 7 月在伊斯坦布尔进行,采用了定性设计,对包括器官捐献者和接受者在内的 27 名参与者进行了半结构化深入访谈。分析采用了主题分析法:研究结果阐明了与伦理问题相关的两大主题:公正和自主。在 "公正 "主题下,出现了几个次主题,突出了叙利亚难民在获得医疗服务方面面临的多方面挑战。这些挑战包括移民和语言障碍,极大地妨碍了他们理解医疗程序和权利的能力。经济困难和在国内行动受限使他们获得必要的医疗服务变得更加复杂。尽管存在这些障碍,难民仍可免费获得器官移植服务和药物,这一政策凸显了土耳其对受保护人群医疗平等的承诺。自主性主题涉及捐献者同意和动机的伦理处理。研究结果表明,叙利亚难民在移植过程中没有受到胁迫,器官移植伦理委员会的严格监督确保了防止捐赠者被滥用。然而,尽管采取了这些保护措施,知情同意过程中的挑战依然存在,主要原因是语言障碍阻碍了医护人员与患者之间的有效沟通。虽然医疗保健专业人员的协助努力被认为缓解了一些困难,但获得全面医疗服务的更广泛问题仍然是一个重大问题。这些障碍表明,有必要加强语言和财政支持,以改善难民获得医疗保健服务的机会:本研究认为,土耳其为受临时保护的叙利亚人提供的医疗保健框架可作为国际人权和社会正义的典范。然而,本研究也强调了解决长期存在的限制寻求庇护者获得医疗服务的障碍的重要性。关于加强政策的建议侧重于改善语言服务、增加财政支持和扩大综合保健服务的可及性,以确保难民获得公平的保健成果。
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引用次数: 0
What ethical conflicts do internists in Spain, México and Argentina encounter? An international cross-sectional observational study based on a self-administrated survey. 西班牙、墨西哥和阿根廷的内科医生会遇到哪些伦理冲突?一项基于自我调查的国际横断面观察研究。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-11-02 DOI: 10.1186/s12910-024-01123-y
Antonio Blanco Portillo, Rebeca García-Caballero, Diego Real de Asúa, Karmele Olaciregui Dague, Octavio Márquez Mendoza, Pascual Valdez, Benjamín Herreros

Background: The differences in clinical bioethics between the Mediterranean and Latin American cultures have not been analyzed. The objective of the study is to compare the ethical conflicts that internists in Spain, Mexico and Argentina have.

Methods: Cross-sectional observational study through a survey directed at internists from Spain, Argentina and Mexico. The survey was administered to affiliated members of the National Societies of Internal Medicine across three countries via an online platform.

Results: 762 internists participated, 261 from Spain, 154 from Argentina and 347 from Mexico. The main ethical conflicts that internists in Spain, Argentina and Mexico have are related (in order) to the end of life, to the clinical relationship and to the patient's autonomy. Withholding and withdrawing life-sustaining treatment is the most frequent conflict in Spain and Argentina and the second in Mexico.

Conclusions: Internists from Spain and Argentina identify very similar ethical conflicts. Furthermore, they consider them more frequent and difficult than in Mexico. In Argentina they are less satisfied with the way they are resolved. To explain these differences, socio-cultural factors are postulated, among others: paternalism, individualism, masculinity, organization of the health system, formal training in bioethics and assessment of death.

背景:地中海和拉丁美洲文化在临床生物伦理方面的差异尚未得到分析。本研究旨在比较西班牙、墨西哥和阿根廷内科医生的伦理冲突:方法:通过一项针对西班牙、阿根廷和墨西哥内科医生的调查进行横断面观察研究。调查通过在线平台对三个国家的国家内科医学会附属成员进行:共有 762 名内科医生参与了调查,其中 261 人来自西班牙,154 人来自阿根廷,347 人来自墨西哥。西班牙、阿根廷和墨西哥的内科医生面临的主要伦理冲突(依次)与生命终结、临床关系和患者自主权有关。在西班牙和阿根廷,拒绝和撤销维持生命的治疗是最常见的冲突,在墨西哥则是第二常见的冲突:西班牙和阿根廷的内科医生发现了非常相似的伦理冲突。结论:西班牙和阿根廷的内科医生发现了非常相似的伦理冲突,而且他们认为这些冲突比墨西哥更频繁、更困难。在阿根廷,他们对解决冲突的方式不太满意。为了解释这些差异,提出了一些社会文化因素,其中包括:家长制、个人主义、男性气质、卫生系统的组织、生物伦理和死亡评估方面的正规培训。
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引用次数: 0
Medical futility at the end of life: the first qualitative study of ethical decision-making methods among Turkish doctors. 生命末期的医疗无用论:土耳其医生伦理决策方法的首次定性研究。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-11-01 DOI: 10.1186/s12910-024-01120-1
Esra Aksoy, Ilhan Ilkilic

Background: The swift advancement of intensive care medicine, coupled with technological possibilities, has prompted numerous ethical inquiries regarding decision-making processes concerning the withholding or withdrawal of treatment due to medical futility. This study seeks to delineate the decision-making approaches employed by intensive care physicians in Türkiye when faced with medical futility at the end of life, along with an ethical evaluation of these practices.

Methods: Grounded theory, a qualitative analysis method was employed, conducting semi-structured, in-depth interviews with eleven intensive care physicians in Türkiye. The subsequent text analysis was carried out using MAXQDA software.

Results: Participants assert that the decisions made by Turkish physicians determine whether treatment is futile, rely on medical consensus, and lack a standardized decision-making process. The decisions are influenced by legal and social pressures, resource constraints, and occasional conflicts of interest. The significance of professional hierarchy is notable, with limited consideration given to the opinions of nurses and other staff. The unstructured medical consensus processes are shaped by normative concepts such as benefit, age, justice, and conscience. Furthermore, it was observed that the conscientious opinions of physicians carry more weight than adherence to ethical principles and guidelines.

Conclusion: To create optimal conditions for doctors to make ethically justifiable decisions, the dynamics within the treatment team should be improved, emphasizing the minimization of hierarchy, and ensuring the active participation of all team members in the decision-making process. Additionally, efforts should be directed toward narrowing the gap between the conscience of the individual doctor and established ethical principles. A potential solution lies in the nationwide implementation of clinical ethics committees and the establishing of clinical ethics guidelines, aiming to address, and overcome the identified challenges.

背景:随着重症监护医学的迅速发展以及技术的进步,人们对因医疗无效而暂停或撤消治疗的决策过程提出了许多伦理问题。本研究旨在探讨土耳其重症监护医生在生命末期面对医疗无效时所采用的决策方法,并对这些做法进行伦理评估:研究采用了基础理论这一定性分析方法,对 11 名土耳其重症监护医生进行了半结构化的深度访谈。随后使用 MAXQDA 软件进行文本分析:结果:参与者认为,土耳其医生在决定治疗是否无效时,依赖于医学共识,缺乏标准化的决策过程。这些决定受到法律和社会压力、资源限制以及偶尔出现的利益冲突的影响。专业等级制度的重要性显而易见,对护士和其他工作人员的意见考虑有限。利益、年龄、公正和良知等规范性概念决定了非结构化的医学共识过程。此外,据观察,医生的良心意见比遵守伦理原则和指导方针更有份量:结论:为了给医生做出符合伦理的决定创造最佳条件,应改善治疗团队内部的动态关系,强调尽量减少等级制度,并确保团队所有成员积极参与决策过程。此外,还应努力缩小医生个人良知与既定伦理原则之间的差距。一个潜在的解决方案是在全国范围内建立临床伦理委员会,并制定临床伦理指南,以应对和克服所发现的挑战。
{"title":"Medical futility at the end of life: the first qualitative study of ethical decision-making methods among Turkish doctors.","authors":"Esra Aksoy, Ilhan Ilkilic","doi":"10.1186/s12910-024-01120-1","DOIUrl":"10.1186/s12910-024-01120-1","url":null,"abstract":"<p><strong>Background: </strong>The swift advancement of intensive care medicine, coupled with technological possibilities, has prompted numerous ethical inquiries regarding decision-making processes concerning the withholding or withdrawal of treatment due to medical futility. This study seeks to delineate the decision-making approaches employed by intensive care physicians in Türkiye when faced with medical futility at the end of life, along with an ethical evaluation of these practices.</p><p><strong>Methods: </strong>Grounded theory, a qualitative analysis method was employed, conducting semi-structured, in-depth interviews with eleven intensive care physicians in Türkiye. The subsequent text analysis was carried out using MAXQDA software.</p><p><strong>Results: </strong>Participants assert that the decisions made by Turkish physicians determine whether treatment is futile, rely on medical consensus, and lack a standardized decision-making process. The decisions are influenced by legal and social pressures, resource constraints, and occasional conflicts of interest. The significance of professional hierarchy is notable, with limited consideration given to the opinions of nurses and other staff. The unstructured medical consensus processes are shaped by normative concepts such as benefit, age, justice, and conscience. Furthermore, it was observed that the conscientious opinions of physicians carry more weight than adherence to ethical principles and guidelines.</p><p><strong>Conclusion: </strong>To create optimal conditions for doctors to make ethically justifiable decisions, the dynamics within the treatment team should be improved, emphasizing the minimization of hierarchy, and ensuring the active participation of all team members in the decision-making process. Additionally, efforts should be directed toward narrowing the gap between the conscience of the individual doctor and established ethical principles. A potential solution lies in the nationwide implementation of clinical ethics committees and the establishing of clinical ethics guidelines, aiming to address, and overcome the identified challenges.</p>","PeriodicalId":55348,"journal":{"name":"BMC Medical Ethics","volume":"25 1","pages":"122"},"PeriodicalIF":3.0,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11529328/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142559541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"哲学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Financial conflicts of interest among authors of clinical practice guideline for headache disorders in Japan. 日本头痛疾病临床实践指南作者的经济利益冲突。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-10-29 DOI: 10.1186/s12910-024-01126-9
Anju Murayama, Yuki Senoo

Background: Financial relationships between clinical guideline authors and pharmaceutical companies introduce conflicts of interest (COI), potentially biasing guideline recommendations. Thus, proper management of COI is paramount for clinical guideline authors. Nevertheless, little is known about COI among neurology clinical guideline authors. This study aimed to evaluate the financial relationships between pharmaceutical companies and authors of Clinical Practice Guideline for Headache Disorders (CPGHD) in Japan.

Methods: This is a retrospective analysis of 2016-2020 personal payments data disclosed by all pharmaceutical companies affiliated with the Japan Pharmaceutical Manufacturers Association. We examined amounts and fraction of personal payments to all 57 CPGHD authors and all neurologists board-certified by the Japanese Society of Neurology. Payment data was descriptively analyzed at individual author level.

Results: Among 57 CPGHD authors, 56 (98.3%) received personal payments totaling $2.7 million from pharmaceutical companies between 2016 and 2020. Median five-year payments were $89,955 for CPGHD authors, while $521 for board-certified neurologists. The CPGHD chairperson and vice chairperson received substantial payments during the guideline development period. Nevertheless, because of less rigorous and transparent COI policy compared to international standard policies, only 10 authors disclosed their financial relationships with the pharmaceutical companies in the guideline.

Conclusions: More than 98% of CPGHD authors received much higher personal payments from pharmaceutical companies than those to board-certified neurologists during the guideline development period in Japan.

背景:临床指南作者与制药公司之间的财务关系会带来利益冲突(COI),从而可能使指南建议产生偏差。因此,临床指南作者必须妥善处理 COI。然而,人们对神经病学临床指南作者的利益冲突知之甚少。本研究旨在评估制药公司与日本《头痛疾病临床实践指南》(CPGHD)作者之间的财务关系:本研究对日本制药工业协会下属所有制药公司披露的 2016-2020 年个人支付数据进行了回顾性分析。我们研究了所有 57 名 CPGHD 作者和所有获得日本神经病学学会认证的神经病学家的个人支付金额和比例。我们对作者个人的付款数据进行了描述性分析:在 57 位 CPGHD 作者中,有 56 位(98.3%)在 2016 年至 2020 年期间从制药公司获得了总计 270 万美元的个人报酬。CPGHD作者的五年报酬中位数为89955美元,而获得医学会认证的神经学家的五年报酬中位数为521美元。CPGHD 主席和副主席在指南制定期间收到了大笔酬金。然而,由于COI政策与国际标准政策相比不够严格和透明,只有10位作者在指南中披露了他们与制药公司的财务关系:结论:在日本,98% 以上的 CPGHD 作者在指南制定期间从制药公司获得的个人报酬远高于获得董事会认证的神经科医生。
{"title":"Financial conflicts of interest among authors of clinical practice guideline for headache disorders in Japan.","authors":"Anju Murayama, Yuki Senoo","doi":"10.1186/s12910-024-01126-9","DOIUrl":"10.1186/s12910-024-01126-9","url":null,"abstract":"<p><strong>Background: </strong>Financial relationships between clinical guideline authors and pharmaceutical companies introduce conflicts of interest (COI), potentially biasing guideline recommendations. Thus, proper management of COI is paramount for clinical guideline authors. Nevertheless, little is known about COI among neurology clinical guideline authors. This study aimed to evaluate the financial relationships between pharmaceutical companies and authors of Clinical Practice Guideline for Headache Disorders (CPGHD) in Japan.</p><p><strong>Methods: </strong>This is a retrospective analysis of 2016-2020 personal payments data disclosed by all pharmaceutical companies affiliated with the Japan Pharmaceutical Manufacturers Association. We examined amounts and fraction of personal payments to all 57 CPGHD authors and all neurologists board-certified by the Japanese Society of Neurology. Payment data was descriptively analyzed at individual author level.</p><p><strong>Results: </strong>Among 57 CPGHD authors, 56 (98.3%) received personal payments totaling $2.7 million from pharmaceutical companies between 2016 and 2020. Median five-year payments were $89,955 for CPGHD authors, while $521 for board-certified neurologists. The CPGHD chairperson and vice chairperson received substantial payments during the guideline development period. Nevertheless, because of less rigorous and transparent COI policy compared to international standard policies, only 10 authors disclosed their financial relationships with the pharmaceutical companies in the guideline.</p><p><strong>Conclusions: </strong>More than 98% of CPGHD authors received much higher personal payments from pharmaceutical companies than those to board-certified neurologists during the guideline development period in Japan.</p>","PeriodicalId":55348,"journal":{"name":"BMC Medical Ethics","volume":"25 1","pages":"121"},"PeriodicalIF":3.0,"publicationDate":"2024-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11520797/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142549074","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"哲学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Differing needs for Advance Care Planning in the Veterans Health Administration: use of latent class analysis to identify subgroups to enhance Advance Care Planning via Group Visits for veterans. 退伍军人健康管理局中对预先护理规划的不同需求:使用潜类分析法确定子群体,通过集体探访加强退伍军人的预先护理规划。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-10-28 DOI: 10.1186/s12910-024-01117-w
Monica M Matthieu, Songthip T Ounpraseuth, J Silas Williams, Bo Hu, David A Adkins, Ciara M Oliver, Laura D Taylor, Jane Ann McCullough, Mary J Mallory, Ian D Smith, Jack H Suarez, Kimberly K Garner

Background: Advance Care Planning via Group Visits (ACP-GV) is a patient-centered intervention facilitated by a clinician using a group modality to promote healthcare decision-making among veterans. Participants in the group document a "Next Step" to use in planning for their future care needs. The next step may include documentation of preferences in an advance directive, discussing plans with family, or anything else to fulfill their ACP needs. This evaluation seeks to determine whether there are identifiable subgroups of group participants with differing needs prior to delivery of the ACP-GV program and, if so, to use information about the subgroups to enhance the program offered to veterans in United States Department of Veterans Affairs (VA) healthcare settings.

Methods: We conducted a secondary analysis of national data from a quality improvement evaluation. Patient- and provider-level data from administrative healthcare records for VA users in all 50 states, territories, and the District of Columbia provides data on veterans attending ACP-GV during federal fiscal years 2018-2022 (N = 26,857). Latent class analysis seeks to identify the various subgroups of veterans based on their level of ACP self-efficacy before attending ACP-GV and any demographic differences across the resulting subgroups of veterans attending ACP-GV. ACP self-efficacy is derived from seven items obtained from a participant worksheet used during the group.

Results: Analysis revealed two distinct groups of veterans, distinguishable by their pre-ACP-GV levels of one aspect of ACP self-efficacy: prior knowledge of ACP. Veterans with higher prior knowledge of ACP are associated with an identified next step focused on checking their current AD status and updating it, and veterans with lower ACP prior knowledge are associated with identifying a next step to discuss ACP more fully with family. Differences in age, sex, race, ethnicity, and marital status exist across subgroups of veterans.

Conclusion: Greater attention must be paid to ACP and veterans' prior knowledge of ACP to consistently encourage annual review and status updates.

背景:通过小组探访进行预先护理规划(ACP-GV)是一种以患者为中心的干预措施,由临床医生通过小组方式促进退伍军人做出医疗决策。小组参与者记录 "下一步",用于规划未来的护理需求。下一步 "可能包括在预先指示中记录偏好、与家人讨论计划或满足其 ACP 需求的任何其他事项。本评估旨在确定在实施 ACP-GV 计划之前,是否存在可识别的具有不同需求的小组参与者亚群,如果存在,则利用有关亚群的信息来改进在美国退伍军人事务部 (VA) 医疗机构中为退伍军人提供的计划:我们对一项质量改进评估的全国数据进行了二次分析。来自所有 50 个州、地区和哥伦比亚特区退伍军人事务部用户的行政医疗保健记录的患者和提供者级别数据提供了 2018-2022 联邦财政年度期间参加 ACP-GV 的退伍军人的数据(N = 26857)。潜类分析旨在根据退伍军人在参加 ACP-GV 前的 ACP 自我效能水平,以及由此产生的参加 ACP-GV 的退伍军人亚群之间的任何人口统计学差异,确定各种退伍军人亚群。ACP 自我效能感来自小组活动期间使用的参与者工作表中的七个项目:分析结果显示,退伍军人分为两个不同的群体,他们在参加 ACP-GV 前的 ACP 自我效能水平有一个方面的差异:对 ACP 的先前了解。对 ACP 预先了解较多的退伍军人会确定下一步行动,重点是检查他们目前的 AD 状态并进行更新,而对 ACP 预先了解较少的退伍军人会确定下一步行动,与家人更充分地讨论 ACP。不同亚群的退伍军人在年龄、性别、种族、民族和婚姻状况方面存在差异:结论:必须更加关注 ACP 和退伍军人对 ACP 的预先了解,以持续鼓励进行年度审查和状态更新。
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引用次数: 0
A qualitative focus group study on legal experts' views regarding euthanasia requests based on an advance euthanasia directive. 关于法律专家对基于预先安乐死指令的安乐死请求的看法的焦点小组定性研究。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-10-24 DOI: 10.1186/s12910-024-01111-2
D O Coers, S H Scholten, M E de Boer, E M Sizoo, M A J M Buijsen, B J M Frederiks, C J W Leget, C M P M Hertogh

Background: The Dutch Euthanasia law permits euthanasia in patients with advanced dementia lacking decisional capacity based on advance euthanasia directives. Nevertheless, physicians encounter difficulties assessing the criteria for due care in such cases. This study explores the perspectives of legal experts on the fulfillment of these criteria and the potential for additional legal guidance to support physicians' decision-making processes.

Methods: A qualitative study was conducted with legal experts. Two focus group sessions were conducted. The data analysis was conducted iteratively, with the data being interpreted using thematic content analysis and the framework method.

Results: Participants emphasize the importance of considering the patient's current wishes and informing them about the limitations of advance euthanasia directives. While representatives and healthcare professionals can assist in interpreting wishes, the final decision regarding euthanasia rests with the physician. The participants also discuss the challenges posed by pre-recorded wishes due to changing preferences. Furthermore, they present different views on the value of life wishes of patients with advanced dementia. While some participants prioritize life wishes over advance euthanasia directives, others question whether such expressions still reflect their will. Participants find it essential to assess unbearable suffering in the context of the current situation. Participants acknowledge the necessity to interpret advance euthanasia directives but also current expressions and they entrust this interpretation to physicians, viewing them as the primary authority, despite consulting multiple sources.

Conclusions: The Dutch Euthanasia law's due care criteria are open norms -which are open in substance and require further elaboration, mostly determined on a case-by-case basis to the field standards of the profession-, placing the responsibility on physicians to interpret advance euthanasia directives and patient expressions. Despite potential support from various sources of information, there is limited additional legal guidance available to assist physicians in making decisions.

背景:荷兰安乐死法允许根据预先安乐死指令对缺乏决定能力的晚期痴呆症患者实施安乐死。然而,医生在评估此类情况下的适当护理标准时遇到了困难。本研究探讨了法律专家对满足这些标准的看法,以及为支持医生的决策过程提供更多法律指导的可能性:与法律专家进行了一项定性研究。进行了两次焦点小组会议。数据分析是反复进行的,使用主题内容分析法和框架法对数据进行解释:参与者强调了考虑患者当前意愿并告知他们预先安乐死指令局限性的重要性。虽然代理人和医疗保健专业人员可以协助解释患者的意愿,但安乐死的最终决定权在医生手中。与会者还讨论了预先录制的意愿因偏好改变而带来的挑战。此外,他们还对晚期痴呆症患者生命意愿的价值提出了不同的看法。一些参与者认为生命意愿优先于预先安乐死指令,而另一些参与者则质疑这种表达方式是否仍然反映了他们的意愿。与会者认为在当前情况下评估无法忍受的痛苦至关重要。参与者承认有必要解释预先安乐死指令,但也有必要解释当前的表达方式,他们将这一解释权委托给医生,并将医生视为主要权威,尽管他们曾咨询过多种信息来源:荷兰安乐死法的适当护理标准是开放性规范--实质上是开放性的,需要进一步阐述,主要是根据专业领域的标准逐案确定--将解释预先安乐死指令和患者表达的责任赋予了医生。尽管各种信息来源可能提供支持,但可用于协助医生做出决定的其他法律指导却很有限。
{"title":"A qualitative focus group study on legal experts' views regarding euthanasia requests based on an advance euthanasia directive.","authors":"D O Coers, S H Scholten, M E de Boer, E M Sizoo, M A J M Buijsen, B J M Frederiks, C J W Leget, C M P M Hertogh","doi":"10.1186/s12910-024-01111-2","DOIUrl":"10.1186/s12910-024-01111-2","url":null,"abstract":"<p><strong>Background: </strong>The Dutch Euthanasia law permits euthanasia in patients with advanced dementia lacking decisional capacity based on advance euthanasia directives. Nevertheless, physicians encounter difficulties assessing the criteria for due care in such cases. This study explores the perspectives of legal experts on the fulfillment of these criteria and the potential for additional legal guidance to support physicians' decision-making processes.</p><p><strong>Methods: </strong>A qualitative study was conducted with legal experts. Two focus group sessions were conducted. The data analysis was conducted iteratively, with the data being interpreted using thematic content analysis and the framework method.</p><p><strong>Results: </strong>Participants emphasize the importance of considering the patient's current wishes and informing them about the limitations of advance euthanasia directives. While representatives and healthcare professionals can assist in interpreting wishes, the final decision regarding euthanasia rests with the physician. The participants also discuss the challenges posed by pre-recorded wishes due to changing preferences. Furthermore, they present different views on the value of life wishes of patients with advanced dementia. While some participants prioritize life wishes over advance euthanasia directives, others question whether such expressions still reflect their will. Participants find it essential to assess unbearable suffering in the context of the current situation. Participants acknowledge the necessity to interpret advance euthanasia directives but also current expressions and they entrust this interpretation to physicians, viewing them as the primary authority, despite consulting multiple sources.</p><p><strong>Conclusions: </strong>The Dutch Euthanasia law's due care criteria are open norms -which are open in substance and require further elaboration, mostly determined on a case-by-case basis to the field standards of the profession-, placing the responsibility on physicians to interpret advance euthanasia directives and patient expressions. Despite potential support from various sources of information, there is limited additional legal guidance available to assist physicians in making decisions.</p>","PeriodicalId":55348,"journal":{"name":"BMC Medical Ethics","volume":"25 1","pages":"119"},"PeriodicalIF":3.0,"publicationDate":"2024-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11515591/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142513400","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"哲学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Reducing health disparities in providing care services in the intensive care unit: a critical ethnographic study. 在重症监护室提供护理服务时减少健康差异:一项重要的人种学研究。
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-10-23 DOI: 10.1186/s12910-024-01118-9
Sajad Yarahmadi, Mohsen Soleimani, Mohammad Gholami, Ali Fakhr-Movahedi, Seyed Mohsen Saeidi Madani

Objective: The intensive care unit, with its structural complexity and the exposure of critically ill patients to various disparities, presents a significant setting for health disparities. This critical ethnographic study sought to uncover cultural knowledge and ethical practices for reducing health disparities in providing care services within the intensive care unit. The focus was on understanding how ethical considerations and cultural competence can address and mitigate these disparities effectively.

Methods: This critical ethnographic study was conducted in 2022-2023 at intensive care units in western Iran. Three interrelated phases were used to collect and analyze the data. More than 300 h of observation were done during the first phase. A horizon analysis was carried out in the next phase. To further enhance the dataset, 18 informants participated in semi-structured interviews and informal conversations. Following that, the analysis procedure was conducted to identify a culture of health disparities and factors that reduce it, as it had been in the prior stage. Trustworthiness data collection methods were implemented to ensure the validity and reliability of the study.

Findings: Two key themes emerged from the study: (A) Improved cultural competence, which encompassed empathy towards patients and their families, effective communication, prioritization of continuous learning, appropriate knowledge and awareness, sensitivity to cultural and religious beliefs, staff attitude and personality, and the delivery of customized care tailored to each patient's needs. (B) Supporting role and compensating for disparities involved recommendations for upholding ethical standards, compensatory actions, maintaining professional behavior despite external factors, addressing gaps and deficiencies, and actively defending and supporting patients.

Conclusion: The findings indicate that staff with high cultural competence can ethically mitigate health disparities through their supportive roles. Managers and health policymakers should create barriers to health disparity by improving staff cultural competence and knowledge about health disparities.

目的:重症监护室结构复杂,重症患者面临各种差异,是造成健康差异的重要场所。这项重要的人种学研究旨在揭示在重症监护病房提供护理服务时,如何通过文化知识和伦理实践来减少健康差异。重点是了解伦理考虑因素和文化能力如何有效地解决和减少这些差异:这项重要的人种学研究于 2022-2023 年在伊朗西部的重症监护病房进行。收集和分析数据分为三个相互关联的阶段。第一阶段进行了 300 多小时的观察。下一阶段进行了视野分析。为了进一步完善数据集,18 名信息提供者参加了半结构化访谈和非正式谈话。随后,与前一阶段一样,进行了分析程序,以确定健康差异文化和减少差异的因素。为确保研究的有效性和可靠性,采用了可信数据收集方法:研究提出了两个关键主题:(A)提高文化能力,包括对病人及其家属的同理心、有效沟通、优先考虑持续学习、适当的知识和意识、对文化和宗教信仰的敏感性、员工的态度和个性,以及根据每个病人的需求提供定制护理。(B) 支持角色和补偿差异涉及以下方面的建议:坚持道德标准、补偿行动、在外部因素影响下保持专业行为、解决差距和不足、积极维护和支持患者:研究结果表明,具有较高文化素养的医务人员可以通过其支持性角色在道德上减少健康差异。管理者和卫生政策制定者应通过提高员工的文化素养和对健康差异的了解,为消除健康差异设置障碍。
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引用次数: 0
Negative performance feedback from algorithms or humans? effect of medical researchers' algorithm aversion on scientific misconduct. 医学研究人员对算法的厌恶对科学不端行为的影响?
IF 3 1区 哲学 Q1 ETHICS Pub Date : 2024-10-23 DOI: 10.1186/s12910-024-01121-0
Ganli Liao, Feiwen Wang, Wenhui Zhu, Qichao Zhang

Institutions are increasingly employing algorithms to provide performance feedback to individuals by tracking productivity, conducting performance appraisals, and developing improvement plans, compared to traditional human managers. However, this shift has provoked considerable debate over the effectiveness and fairness of algorithmic feedback. This study investigates the effects of negative performance feedback (NPF) on the attitudes, cognition and behavior of medical researchers, comparing NPF from algorithms versus humans. Two scenario-based experimental studies were conducted with a total sample of 660 medical researchers (algorithm group: N1 = 411; human group: N2 = 249). Study 1 analyzes the differences in scientific misconduct, moral disengagement, and algorithmic attitudes between the two sources of NPF. The findings reveal that NPF from algorithms shows higher levels of moral disengagement, scientific misconduct, and negative attitudes towards algorithms compared to NPF from humans. Study 2, grounded in trait activation theory, investigates how NPF from algorithms triggers individual's egoism and algorithm aversion, potentially leading to moral disengagement and scientific misconduct. Results indicate that algorithm aversion triggers individuals' egoism, and their interaction enhances moral disengagement, which in turn leads to increased scientific misconduct among researchers. This relationship is also moderated by algorithmic transparency. The study concludes that while algorithms can streamline performance evaluations, they pose significant risks to scientific misconduct of researchers if not properly designed. These findings extend our understanding of NPF by highlighting the emotional and cognitive challenges algorithms face in decision-making processes, while also underscoring the importance of balancing technological efficiency with moral considerations to promote a healthy research environment. Moreover, managerial implications include integrating human oversight in algorithmic NPF processes and enhancing transparency and fairness to mitigate negative impacts on medical researchers' attitudes and behaviors.

与传统的人力管理相比,各机构正越来越多地采用算法向个人提供绩效反馈,包括跟踪生产率、进行绩效评估和制定改进计划。然而,这种转变引发了关于算法反馈的有效性和公平性的大量争论。本研究通过比较算法和人类的负面绩效反馈(NPF),调查了负面绩效反馈对医学研究人员的态度、认知和行为的影响。研究人员对总共 660 名医学研究人员(算法组:N1 = 411;人类组:N2 = 249)进行了两项基于场景的实验研究。研究 1 分析了两种 NPF 来源在科学不端行为、道德脱离和算法态度方面的差异。研究结果显示,与来自人类的 NPF 相比,来自算法的 NPF 表现出更高水平的道德脱离、科学不端行为和对算法的负面态度。研究 2 以特质激活理论为基础,调查了来自算法的 NPF 如何引发个人的利己主义和算法厌恶,从而可能导致道德脱离和科学不端行为。结果表明,算法厌恶会引发个人的利己主义,两者相互作用会加强道德脱离,进而导致研究人员的科学不端行为增加。这种关系还受到算法透明度的调节。研究得出结论,虽然算法可以简化绩效评估,但如果设计不当,会给研究人员的科学不端行为带来巨大风险。这些发现扩展了我们对 NPF 的理解,突出了算法在决策过程中面临的情感和认知挑战,同时也强调了平衡技术效率与道德考量的重要性,以促进健康的研究环境。此外,其管理意义还包括在算法 NPF 过程中纳入人工监督,提高透明度和公平性,以减轻对医学研究人员态度和行为的负面影响。
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引用次数: 0
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BMC Medical Ethics
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