Evaluating clinical ethics support services has been hailed as important research task. At the same time, there is considerable debate about how to evaluate CESS appropriately. The criticism, which has been aired, refers to normative as well as empirical aspects of evaluating CESS. In this paper, we argue that a first necessary step for progress is to better understand the intervention in CESS. Tools of complex intervention research methodology may provide relevant means in this respect. In a first step, we (...) introduce principles of “complex intervention research” and show how CESS fulfil the criteria of “complex interventions”. In a second step, we develop a generic “conceptual framework” for “ethics consultation on request” as standard for many forms of ethics consultation in clinical ethics practice. We apply this conceptual framework to the model of “bioethics mediation” to make explicit the specific structural and procedural elements of this form of ethics consultation on request. In a final step we conduct a comparative analysis of two different types of CESS, which have been subject to evaluation research: “proactive ethics consultation” and “moral case deliberation” and discuss implications for evaluating both types of CESS. To make explicit different premises of implemented CESS interventions by means of conceptual frameworks can inform the search for sound empirical evaluation of CESS. In addition, such work provides a starting point for further reflection about what it means to offer “good” CESS. (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)

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)

BackgroundClinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital.MethodsSemi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. (...) All documents were analysed by two researchers independently.ResultsTwenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43–96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1–65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases.ConclusionsTo the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes. (shrink)

Zusammenfassung Hintergrund Advance Care Planning (ACP) wird auch in Deutschland zunehmend praktiziert. Aus klinisch-ethischer Perspektive bietet ACP eine Möglichkeit, Vorausverfügungen zu konkretisieren und auf diese Weise die Entscheidungsfindung bei fehlender Selbstbestimmungsfähigkeit von Patient:innen zu unterstützen. Während es für Gesprächsangebote im Sinne des ACP in Pflegeeinrichtungen und Einrichtungen der Eingliederungshilfe seit 2015 Finanzierungsmöglichkeiten gibt und erste Studien zu Angeboten veröffentlich wurden, fehlt es in Deutschland bisher an publizierten Evaluationsstudien zu ACP-Angeboten im Krankenhaus. Intervention und Methoden Im vorliegenden Beitrag erfolgt die strukturierte (...) Darstellung von ACP als ein Element des klinisch-ethischen Unterstützungsangebotes am Universitätsklinikum Halle (Saale) (UKH). Es erfolgte eine quantitative Inhaltsanalyse der schriftlichen Dokumentation von durchgeführten ACP-Gesprächsprozessen für den Zeitraum der Pilotphase von 01/2020 bis 08/2021 (20 Monate). Ergebnisse Im Zeitraum wurden 93 ACP-Gespräche angefragt. Mit 79 Patient:innen konnten 110 Gespräche geführt werden. 46 % der Anfragen kamen von Palliative Care betreuten Patient:innen. Im Durchschnitt dauerten die Beratungen 45 min. Der Gesprächsprozess zur Erstellung einer Patientenverfügung benötigte durchschnittlich 122 min und 2,5 Gespräche. Bei 23 % der Patient:innen endete der ACP-Prozess nach dem Erstgespräch. Die Inhalte der ACP-Prozesse tangierten verschiedene Bereiche anderer Professionen im Krankenhaus, insbesondere die Entscheidungsfindung über aktuelle Diagnostik und Therapie zwischen Ärzt:innen und Patient:innen. Diskussion Die Einführung eines ACP-Angebotes im Krankenhaus zeigt neben einer Vielzahl an Chancen auch Herausforderungen auf, welche es im gemeinsamen Diskurs zu bewältigen gilt. Bei der Einbettung eines ACP-Angebots im Krankenhaus müssen die Besonderheiten der Klinik und insbesondere die Abgrenzung von ACP zu anderen Arbeitsfeldern der Ethikberatung, wie beispielsweise die Ethikfallberatung, bedacht werden. (shrink)

In their national follow-up study on ethics consultation in the U.S., Fox et al. report the worrying finding of a decline in efforts to evaluate ECs. Compared to the findings of Fox et...