This paper examines the association of the sociodemographic characteristics of women and the unobserved hospital factors with maternal mortality in Kenya using multilevel logistic regression. The data analysed comprise hospital records for 58,151 obstetric admissions in sixteen public hospitals, consisting of 182 maternal deaths. The results show that the probability of maternal mortality depends on both observed factors that are associated with a particular woman and unobserved factors peculiar to the admitting hospital. The individual characteristics observed to have (...) a significant association with maternal mortality include maternal age, antenatal clinic attendance and educational attainment. The hospital variation is observed to be stronger for women with least favourable sociodemographic characteristics. For example, the risk of maternal death at high-risk hospitals for women aged 35 years and above, who had low levels of education, and did not attend antenatal care is about 280 deaths per 1000 admissions. The risk for similar women at low-risk hospitals is about 4 deaths per 1000. To complement results from the analysis of individual patient records, the paper includes findings from hospital staff reports regarding the maternal mortality situation at the hospitals. (shrink)

The Hospital Standardised Mortality Ratio (HSMR) is a commonly used measure of hospital mortality that is standardised for age, comorbidities and other factors. By tradition, this statistic has always excluded patients classified as ‘palliative’. The HSMR has never been validated as a reliable measure of quality of care, and it can be very hard to interpret, partly due to difficulties with defining and applying the term ‘palliative’. In this paper, we review the Canadian experience with the palliative status (...) flag, and explain why it is so difficult to define and apply consistently. We also highlight some potential concerns about clinicians labelling inpatients as ‘palliative’ during their admission. Finally, we propose an organisational ethics framework, and six specific suggestions for hospitals to use when publishing statistics such as the HSMR. (shrink)

This study assessed the attitudes and needs of physicians and health professional staff at a tertiary care hospital in Canada regarding the introduction of physician assisted dying (PAD) during 2015–16. This research aimed to develop an understanding of the wishes, concerns and hopes of stakeholders related to handling requests for PAD; to determine what supports/structures/resources health care professionals (HCP) require in order to ensure high quality and compassionate care for patients requesting PAD, and a supportive environment for all healthcare providers (...) across the moral spectrum. This study constituted a mixed methods design with a qualitative descriptive approach for the study’s qualitative component. A total of 303 HCPs working in a tertiary care hospital completed an online survey and 64 HCPs working in hospital units with high mortality rates participated in 8 focus group discussions. Both focus group and survey data coalesced around several themes to support the implementation of PAD following the decriminalization of this practice: the importance of high quality care; honoring moral diversity; supporting values (such as autonomy, privacy, beneficence); and developing resources, including collaboration with palliative care, education, policies and a specialized team. This study provided the foundational evidence to support the development of the PAD program described in other papers in this collection, and can be a model for gathering evidence from stakeholders to inform the implementation of PAD in any healthcare organization. (shrink)

Objectives: The objective of this study is to investigate the relationship between a physician’s subjective mortality prediction and the level of confidence with which that mortality prediction is made.Design and participants: The study is a prospective cohort of patients less than 18 years of age admitted to a tertiary Paediatric Intensive Care Unit at a University Children’s Hospital with a minimum length of ICU stay of 10 h. Paediatric ICU attending physicians and fellows provided mortality risk predictions (...) and the level of confidence associated with these predictions on consecutive patients at the time of multidisciplinary rounds within 24 hours of admission to the paediatric ICU. Median confidence levels were compared across different ranges of mortality risk predictions.Results: Data were collected on 642 of 713 eligible patients . Mortality predictions greater than 5% and less than 95% were made with significantly less confidence than those predictions 95%. Experience was associated with greater confidence in prognostication.Conclusions: We conclude that a physician’s subjective mortality prediction may be dependent on the level of confidence in the prognosis; that is, a physician less confident in his or her prognosis is more likely to state an intermediate survival prediction. Measuring the level of confidence associated with mortality risk predictions may therefore be important because different levels of confidence may translate into differences in a physician’s therapeutic plans and their assessment of the patient’s future. (shrink)

Objectives To conduct an independent evaluation of the first phase of the Health Foundation’s Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design Mixed method evaluation involving five substudies, before and after design. Setting NHS hospitals in the United Kingdom. Participants Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention The SPI1 (...) was a compound (multi-component) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration—monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items)—there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for “difference in difference” 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from 17% (63) to 13% (49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening. (shrink)

BackgroundAlthough the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP.MethodsThis multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively (...) from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan–Meier curve analyses for survival were performed.ResultsOf 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63–81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan–Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001).ConclusionsAfter the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed. (shrink)

Background Recent publications reveal shortcomings in evidence review and summarization methods for patient decision aids. In the large-scale "Share to Care (S2C)" Shared Decision Making (SDM) project at the University Hospital Kiel, Germany, one of 4 SDM interventions was to develop up to 80 decision aids for patients. Best available evidence on the treatments' impact on patient-relevant outcomes was systematically appraised to feed this information into the decision aids. Aims of this paper were to (1) describe how PtDAs are developed (...) and how S2C evidence reviews for each PtDA are conducted, (2) appraise the quality of the best available evidence identified and (3) identify challenges associated with identified evidence. Methods The quality of the identified evidence was assessed based on GRADE quality criteria and categorized into high-, moderate-, low-, very low-quality evidence. Evidence appraisal was conducted across all outcomes assessed in an evidence review and for specific groups of outcomes, namely mortality, morbidity, quality of life, and treatment harms. Challenges in evidence interpretation and summarization resulting from the characteristics of decision aids and the type and quality of evidence are identified and discussed. Conclusions Evidence reviews in this project were carefully conducted and summarized. However, the evidence identified for our decision aids was indeed a "scattered landscape" and often poor quality. Facing a high prevalence of low-quality, non-directly comparative evidence for treatment alternatives doesn't mean it is not necessary to choose an evidence-based approach to inform patients. While there is an urgent need for high quality comparative trials, best available evidence nevertheless has to be appraised and transparently communicated to patients. (shrink)

In 2020, COVID-19 patients overwhelmed hospital beds in several Spanish cities, producing an increase in mortality derived from a lack of resources. The provision of new spaces to be reconfigured as healthcare centers for COVID patients was one of the measures implemented. In Madrid, two of these COVID centers drew enormous media and political repercussions due to their high cost and the controversy surrounding the quality of the care they offered. In this scenario of misinformation, several doctors and patients (...) rejected to be transferred to such medical centers, but they were nonetheless compelled to make the move. This manuscript underscores how this lack of transparency affects health workers, patients, and the relationship between them, and brings out the question of how many essential bioethical principles can be individually violated by a matter of public health. New guidelines for the transfer of patients should be designed from an ethical perspective and updated, as the epidemic continues, to improve the modern understanding of human factors in times of uncertainty. The lesson that these centers provide us is that we must rethink crisis resource management from a new perspective that prioritizes access to quality information. In its absence, the principle of autonomy must prevail. (shrink)

As physicians, we have seen patients with substance use disorders leave the hospital against medical advice, slipping through the cracks of our health care system. In fact, despite a high burden of life‐threatening illnesses, patients with SUDs are at a nearly threefold increased risk of leaving the hospital against medical advice. Leaving against medical advice is associated with an increased thirty‐day mortality rate as well as an increased rate of hospital readmission. When a patient leaves in this way, the (...) health care system loses the opportunity to engage with someone who is struggling with an SUD and whose health is at imminent risk. Fortunately, there are ways to address some of these challenges within existing organizational frameworks. Addiction consult teams and supervised injection facilities are two interventions that have proven successful. (shrink)

The power of care: the Women’s Hospital 1884–1914The effectiveness of late‐nineteenth‐century nursing care should not be underestimated. The archive of patient records at Melbourne’s Women’s Hospital reveals a commitment to patient care that more often than not made the difference between life and death in the recovery from major surgery or post‐partum infection. These records suggest the need to reassess the role of medical care in the mortality transition after 1850.

Every July, when new resident physicians arrive at our teaching hospital, a colleague reminds them that “You now work in the train station of the gods. People coming and going all the time. You’ll need to ask spiritual questions.” He can offer this counsel annually because—whether it arrives early, as expected, or in error—every one of us is awaiting her departing train. Every few years, an experienced physician-writer offers counsel on what it means to work in these train stations, to (...) tend to people as they die in contemporary hospitals. The physician-writer often describes the equivalent of train wrecks—harried and heedless deaths—and sounds a call for reform. The call is answered, in part, by... (shrink)

Previous research has suggested that individuals who identify as being more religious request more aggressive medical treatment at end of life. These requests may generate disagreement over life-sustaining treatment (LST). Outside of anecdotal observation, however, the actual role of religion in conflict over LST has been underexplored. Because ethics committees are often consulted to help mediate these conflicts, the ethics consultation experience provides a unique context in which to investigate this question. The purpose of this paper was to examine the (...) ways religion was present in cases involving conflict around LST. Using medical records from ethics consultation cases for conflict over LST in one large academic medical centre, we found that religion can be central to conflict over LST but was also present in two additional ways through (1) religious coping, including a belief in miracles and support from a higher power, and (2) chaplaincy visits. In-hospital mortality was not different between patients with religiously versus non-religiously centred conflict. In our retrospective cohort study, religion played a variety of roles and did not lead to increased treatment intensity or prolong time to death. Ethics consultants and healthcare professionals involved in these cases should be cognisant of the complex ways that religion can manifest in conflict over LST. (shrink)

Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics (...) consult outcomes were analyzed. In 42 of the 116 cases, the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying. The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants’ recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients. (shrink)

This paper describes the application of eight statistical and machine-learning methods to derive computer models for predicting mortality of hospital patients with pneumonia from their findings at initial presentation. The eight models were each constructed based on 9847 patient cases and they were each evaluated on 4352 additional cases. The primary evaluation metric was the error in predicted survival as a function of the fraction of patients predicted to survive. This metric is useful in assessing a model’s potential to (...) assist a clinician in deciding whether to treat a given patient in the hospital or at home. We examined the error rates of the models when predicting that a given fraction of patients will survive. We examined survival fractions between 0.1 and 0.6. Over this range, each model’s predictive error rate was within 1% of the error rate of every other model. When predicting that approximately 30°K of the patients will survive, all the models have an error rate of less than 1.5%. The models are distinguished more by the number of variables and parameters that they contain than by their error rates; these differences suggest which models may be the most amenable to future implementation as paper-based guidelines. (shrink)

In response to the COVID‐19 pandemic philosophers and governments have proposed scarce resource allocation guidelines. Their purpose is to advise healthcare professionals on how to ethically allocate scarce medical resources. One challenging feature of the pandemic has been the large numbers of patients needing mechanical ventilatory support. Guidelines have paradigmatically focused on the question of what doctors should do if they have fewer ventilators than patients who need respiratory support: which patient should get the ventilator? There is, however, an important (...) higher level allocation problem. Namely, how are we to ethically distribute newly obtained ventilators across hospitals: which hospital should get the ventilator(s)? In this paper, we identify a set of principles for allocating newly obtained ventilators across hospitals. We focus particularly on low and middle income countries, who frequently have limited pre‐existing intensive care capacity, and have needed to source additional ventilators. We first provide some background. Second, we argue that the main population healthcare aim during the COVID‐19 pandemic should be to save the most lives. Next, we assess a series of potential heuristics or principles that could be used to guide allocation: allocation to the most densely populated cities, random allocation, allocation based on the ratio of patients to ICU personnel, prioritisation in terms of intrahospital mortality, prioritisation of younger populations, and prioritisation in terms of population mortality. We conclude by providing a plausible ranking of the principles, while noting a number of epistemological challenges, in terms of how they best further the aim of increasing the probability of saving the most lives. (shrink)

We examined nurses’ perceptions of the ethical climate of their workplace and the relationships among the perceptions, medical error experience and intent to leave through a cross-sectional survey of 1826 nurses in 33 Korean public hospitals. Ethical climate was measured using the Hospital Ethical Climate Survey. Although the sampled nurses perceived their workplace ethical climate positively, 19% reported making at least one medical error during the previous year, and 25% intended to leave their jobs in the near future. Controlling for (...) individual and organizational characteristics, we found that nurses with a more positive perception of the ‘patient’ dimension of ethical climate were less likely to have made medical errors. Nurses with a more positive perception of the ‘patient’, ‘manager’, ‘hospital’ and ‘physician’ dimensions of ethical climate were less likely to leave their current job. Enhancing workplace ethical climate could reduce medical errors and improve nurses’ retention in public hospitals. (shrink)

Inquiries into organisational scandals repeatedly attribute wrongdoing to the normalisation of deviance. From this perspective, the cause of harm lies not in the actions of any individual but rather in the institutionalised practices of organisations or sectors. Although an important corrective to dramatic tales of bad apples, the normalisation thesis underplays the role of management in the emergence of deviance. Drawing on literatures exploring ideas of amoral (Carroll in Bus Horiz 30(2):7–15, 1987) or ethically neutral leadership (Treviño et al. in (...) Calif Manag Rev 42(4):128–142, 2000) we seek to bring management back into the explanation of organisational wrongdoing. Amoral theorists point to management’s ethical silence, but they also describe the way in which that silence is sustained by a series of organisational characteristics. We build on this work in arguing that it is management’s deliberate focus on bottom line performance, the diffusion of responsibility and high levels of organisational identification that explain the emergence of wrongdoing. We apply these ideas to the case of the UK’s Stafford hospital which hit the headlines in 2009 when it was reported that poor standards of care had led to a mortality rate markedly above that expected for a hospital of its type. We conclude with a discussion of the circumstances which translate amoral management into unethical outcomes. (shrink)

Disparities in maternal morbidity and mortality for Latinx populations are a paradigmatic example of the now widely acknowledged structural racism in U.S. health care that predisposed minorities to...

Objectives To characterize the prevalence and content of pediatric triage policies.Methods We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators.Results Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children’s hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions shared (...) their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions.Conclusions While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities. (shrink)

I read Dr Cherniack’s article regarding do not resuscitate orders with interest.1 One of the problems with DNR orders is the patients’ assumption that if there is no DNR order they will survive resuscitative efforts. This of course is far from the truth. In my hospital these orders have been modified to “do not attempt to resuscitate” orders. One cannot be truly autonomous without being informed. Long term survival, as measured only by being alive, following inhouse cardiac arrest, is about (...) 15% over all age groups.2 In sick elderly patients over 70 years of age who survive a cardiac arrest, the subsequent hospital mortality approaches 100%. This fact, and concerns about harm, influence physicians’ attitudes, …. (shrink)

This paper describes a practice innovation: the addition of formal weekly discussions of patients with prolonged PICU stay to reduce healthcare providers’ moral distress and decrease length of stay for patients with life-threatening illnesses. We evaluated the innovation using a pre/post intervention design measuring provider moral distress and comparing patient outcomes using retrospective historical controls. Physicians and nurses on staff in our pediatric intensive care unit in a quaternary care children's hospital participated in the evaluation. There were 60 patients in (...) the interventional group and 66 patients in the historical control group. We evaluated the impact of weekly meetings to establish goals of care for patients with longer than 10 days length of stay in the ICU for a year. Moral distress was measured intermittently and reported moral distress thermometer scores fluctuated. "Clinical situations" represented the most frequent contributing factor to moral distress. Post intervention, overall moral distress scores, measured on the moral distress scale revised, were lower for respondents in all categories, and on three specific items. Patient outcomes before and after PEACE intervention showed a statistically significant decrease in PRISM indexed LOS, a statistically significant increase in both code status changes DNR, and in-hospital death, with no change in patient 30 or 365 day mortality. The addition of a clinical ethicist and senior intensivist to weekly inter-professional team meetings facilitated difficult conversations regarding realistic goals of care. The study demonstrated that the PEACE intervention had a positive impact on some factors that contribute to moral distress and can shorten PICU length of stay for some patients. (shrink)

Maternal morbidity and mortality are high in the Indian context, but the majority of maternal deaths could be avoided by prompt and effective access to intrapartum care (WHO, 1999). Understanding the care seeking responses to intrapartum morbidities is crucial if maternal health is to be effectively improved, and maternal mortality reduced. This paper presents the results of a prospective study of 388 women followed through delivery and traditional postpartum in rural Karnataka in southern India. In this setting, few (...) women use the existing health facilities and most deliveries occur at home. The analysis uses quantitative data, collected via questionnaires administered to women both during pregnancy and immediately after delivery. By virtue of its prospective design, the study gives a unique insight into intentions for intrapartum care during pregnancy as well as events following morbidities during labour. Routine care in the intrapartum period, both within institutions and at home, and impediments to appropriate care are also examined. The study was designed to collect information about health seeking decisions made by women and their families as pregnancies unfolded, rather than trying to capture women’s experience from a retrospective instrument. The data set is therefore a rich source of quantitative information, which incorporates details of event sequences and health service utilization not previously collected in a Safe Motherhood study. Additional qualitative information was also available from concurrent in-depth interviews with pregnant women, their families, health care providers and other key informants in the area. The level of unplanned institutional care seeking during the intrapartum period within the study area was very high, increasing from 11% planning deliveries at a facility to an eventual 35% actually delivering in hospitals. In addition there was a significant move away from planned deliveries with the auxiliary nurse midwive (ANM), to births with a lay attendant or dai. The proportion of women who planned for an ANM to assist was 49%, as compared with the actual occurrence, which was less than half of this proportion. Perceived quality of care was found to be an important factor in health seeking behaviour, as was wealth, caste, education and experience of previous problems in pregnancy. Actual care given by a range of practitioners was found to contain both beneficial and undesirable elements. As a response to serious morbidities experienced within the study period, many women were able to seek care although sometimes after a long delay. Those women who experienced inadequate progression of labour pains were most likely to proceed unexpectedly to a hospital delivery. (shrink)

Lower respiratory tract infections are a leading cause of paediatric morbidity and mortality worldwide. Children in low-income countries are disproportionately affected. This is in large part due to limitations in healthcare resources and medical technologies. Mechanical ventilation can be a life-saving therapy for many children with acute respiratory failure. The scarcity of functioning ventilators in low-income countries results in countless preventable deaths. Some hospitals have attempted to adapt to this scarcity by using hand-bag ventilation, as either a bridge to (...) a mechanical ventilator, or until clinical improvement occurs rendering mechanical ventilation no longer necessary. In instances of hand-bag ventilation, an endotracheal tube is first placed. Family members are then asked to play the role of a ventilator, manually compressing a bag repeatedly to inflate the child’s lungs. This approach is fraught with numerous ethical challenges. A careful examination of the data and a nuanced approach to the ethical considerations are imperative. Ethical arguments in support of and in opposition to allowing parental hand-bag ventilation are explored, including the best interests of the child, the child’s right to an open future, beneficence and parental protection, legitimising substandard care, and finally, contextual concerns. An algorithmic, potentially ethically permissible approach to parental participation in manual ventilation is proposed. (shrink)

Hospitals must have adequate lighting so that medical personnel can do their duties and attend to the requirements of patients and visitors. A comfortable recuperation environment may be created with the aid of good lighting. The relationship between daylighting and artificial lighting and their role in the design process will be mentioned. Specific areas of the hospital will be under adequate lighting analysis. The areas taken into consideration are entrance and waiting areas, circulation areas, operating theatres and clean rooms, wards (...) and bedrooms, ancillary areas, restaurant and kitchen, and exterior lighting. Some of these areas are also analyzed regarding the case study of the Military Hospital (University Trauma Hospital) of Tirana Albania. The purpose of this paper is to compare different lighting standards, the EU standards, and the Albanian ones. Solutions can be provided for lighting systems, starting from luminaries and lamps, to lighting controls and lighting management systems, from the early stage of design. The architect is the enabling partner to develop meaningful lighting solutions for all areas of healthcare facilities. (shrink)

Sharply in focus in the United States right now is the disproportionate COVID‐19 infection, hospitalization, and mortality rates of Black, Indigenous, Hispanic, and Pacific Islanders living in the United States in contrast to White people. These COVID‐19 disparities are but one example of how systemic racism filters into health outcomes for many Black, Indigenous, and other People of Color (BIPOC). With these issues front and center, more attention is being given to the ways that White medical professionals contribute to (...) these disparities, including their socialization to ignore or deny inequities. As such, the present study sought to understand how educating White health‐care pre‐professionals about systemic racism might influence their understanding of and responsibility for disrupting White supremacy. Data were drawn from 49 White‐identified nursing students who participated in a mapping project that uncovered instantiations of systemic racism in the United States. Participant written reflections were analyzed using thematic analysis. Findings revealed that mapping projects can develop White people's knowledge and understanding of systemic racism. We introduce the construct, transformative dissonant encounters, to describe how this project precipitated shifts in world view necessary for White people to confront systemic racism. Implications for nursing educators, psychological researchers, and antiracist activists are discussed. (shrink)

During the mid-nineteenth century the annual tuberculosis mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the (...) disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus. (shrink)

During the mid-nineteenth century the annual tuberculosis mortality in the penitentiaries at Auburn, N.Y., Boston, and Philadelphia exceeded 10 percent of the inmate population. At the beginning of the sanatorium era, 80 percent of the prison deaths were attributed to TB. As the mountain air was “commonly known” to be healthful, the first prison sanatorium was opened in the mountains near Dannemora, N.Y. in 1904. It served to isolate contagious prison inmates until the advent of effective chemotherapy for the (...) disease in the 1950’s. Early antibiotic therapy for TB was such a great success that the public health aspects of TB in prisons remained dormant for the next 40 years.In 1991, a correctional officer from Auburn Correctional Facility in Auburn, New York died as a result of multidrug-resistant TB. He had been posted to care for hospitalized patients, from whom he acquired his disease. This death, and the transmission of TB infection to health care workers in the same hospital, brought the nature and extent of modern inmate medical care into finer focus. (shrink)

Hospitals are places where patients are unwell, where patients and their families may be upset, confused, frustrated, in pain, and vulnerable. The likelihood of these experiences and emotions manifesting in anger and aggressive behaviour is high. In this paper, we describe the involvement of a clinical ethics service responding to a request to discuss family aggression within a rehabilitation department in a large paediatric hospital in Australia. We suggest two key advantages of involving a clinical ethics service in discussions about (...) how to respond to family aggression. First, the process of ethics deliberation provides an opportunity for clinicians to be involved in the solution by articulating their perspectives, tolerance levels, and general concerns about the effects of family aggression towards staff. Second, supporting clinicians to articulate and identify the impact of parental aggression directly counters the disadvantages of the more blunt zero-tolerance policy response, which is necessarily imposed from the top down. (shrink)

The assumption in current U.S. mainstream medicine is that birthing requires hospitalization. In fact, while the American College of Obstetricians and Gynecologists supports the right of every birthing person to make a medically informed decision about their delivery, they do not recommend home birth owing to data indicating greater neonatal morbidity and mortality. In this article, we examine the evidence surrounding home birth in the United States and its current limitations, as well as the ethical considerations around birth setting.

COVID-19 severity and mortality risk are greater for older adults whereas economic impact is deeper for younger adults. Using the Health Belief Model as a framework, this study used a web-based survey to examine how perceived COVID-19 susceptibility and severity and perceived efficacy of recommended health behaviors varied by age group and were related to the adoption of health behaviors. Proportional odds logistic regression was used to examine the relationship between age group and perceived COVID-19 susceptibility, severity, impact, and (...) health behavior efficacy and adoption. Structural equation modeling based on HBM constructs examined the relationships between health beliefs and behaviors. Data from 820 participants were analyzed. Middle-aged and older adults reported greater concerns about the personal risk of hospitalization and mortality, economic impact, and social impact of COVID-19 than young adults. Middle-aged adults also reported greatest concern for other age groups. Adoption and perceived efficacy of health behaviors was similar across age groups with few exceptions. Both middle-aged and older-adults were more likely to perceive their own and each other's age groups as responding adequately to COVID-19 compared to young adults. Structural equation modeling indicated perceived benefits of health behaviors were the primary driver of behavior uptake, with socioeconomic factors and perceived severity and susceptibility indirectly associated with uptake through their influence on perceived benefits. Overall, these results suggest adoption of health behaviors is very high with few differences between age groups, despite differences in perceived impact of COVID-19. Public health communications should focus on the benefits of health behaviors to drive adoption. (shrink)

This paper comprises a case study illustrating ethical and practical challenges for a Ugandan hospital-based social worker early in the COVID-19 pandemic, followed by a commentary. The hospital was under-resourced, with staff and patients experiencing lack of information and panic. The social worker, Denis Adia, recounts his responses to new and ethically challenging situations, including persuading Muslim patients to stop fasting for the good of their health; deciding to keep a baby in hospital with parents although this was against the (...) rules; and supporting a stigmatised former patient in the face of intimidation by colleagues. He reflects on the importance of recognising each person’s unique needs and circumstances, seeing this as a vital role for social workers. The case is followed by a commentary from a UK academic (Sarah Banks), who notes the cognitive and emotional effort (‘ethics work’) undertaken by the social worker to: see the ethical aspects of particular situations; take account of patients’ specific needs; ensure they are treated with respect; promote their well-being; and perform as a good social worker. Banks draws attention to the key role of the virtue of courage in pandemic conditions, which involves working with new risks and facing fears with confidence. (shrink)

This study examines factors impacting ethical behavior of 203 hospital employees in Midwestern and Northwestern United States. Ethical behavior of peers had the most significant impact on ethical behavior. Ethical behavior of successful managers, professional education in ethics and sex of the respondents also significantly impacted ethical behavior. Nurses were significantly more ethical than other employees. Race of the respondent did not impact ethical behavior. Overclaiming scales indicated that social desirability bias did not significantly impact the results of our study. (...) Implications of this study for researchers and practitioners are discussed. (shrink)

To address the burden of maternal morbidity and mortality in low‐ and middle‐income countries (LMICs), research with pregnant women in these settings is increasingly common. Pregnant women in LMIC‐context may experience vulnerability related to giving consent to participate in a clinical trial. To recognize possible layers of vulnerability this study aims to identify factors that influence the decision process towards clinical trial participation of pregnant women in an urban middle‐income setting. This qualitative research used participant observation, in‐depth interviews, and (...) focus group discussion with medical staff and pregnant women eligible for trial participation, at a regional hospital in Accra, Ghana. Besides lack of familiarity with modern scientific concepts, specific factors influencing the decision‐making process were identified. These include a wide power difference between health provider and patient, and a different perception of risk through externalization of responsibility of risk management within a religious context as well as a context shaped by authority. Also, therapeutic misconception was observed. The combination of these factors ensued women to rely on the opinion of the medical professional, rather than being guided by their own motivation to participation. Although being a (pregnant) woman per se should not render the label of being vulnerable, this study shows there are factors that influence the decision process of pregnant woman towards trial participation in a LMIC context that can result in vulnerability. The identification of context‐specific factors that can create vulnerability facilitates adaptation of the design and conduct of research in a culturally competent manner. (shrink)