Clinical ethics consultations: a scoping review of reported outcomes

Abstract

Background Clinical ethics consultations (CEC) can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council (MRC) proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. Objective The primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization. Methods We searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. Results Forty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality (n = 31), process factors (n = 23), and clinical factors (n = 19). The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes. Conclusions This scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC.

Formal Ethics Consultation in Extracorporeal Membrane Oxygenation Patients: A Single-Center Retrospective Cohort of a Quaternary Pediatric Hospital

“…There is conflicting evidence regarding impacts of CES on quality experienced by providers, resource and cost utilization, clinical outcomes, and communication (38). Nonetheless, there is emerging evidence for alleviating provider moral distress through enhanced ethical literacy (36). Our cohort had a very high rate of moral distress identified as an ethical theme in EC.…”

“…Our cohort had a very high rate of moral distress identified as an ethical theme in EC. Moral distress has been linked to poor ethical climate with adverse impacts on staff well-being, performance, retention and burnout, so targeted interventions may have multifaceted benefits (26, 35, 36). Earlier identification of simmering ethical issues and utilization EC services, may help to prevent and/or mitigate moral distress (39).…”

“…Earlier identification of simmering ethical issues and utilization EC services, may help to prevent and/or mitigate moral distress (39). As is unfortunately common in the literature addressing outcomes of EC, our analysis does not address the parental or patient experience, who likely experience distress not captured by our methods (36). The ability to identify and effectively address ethical issues that present with complex life-sustaining support is an important step toward robust decision-making, provision of quality care to patients and their families, as well as adequate support for healthcare providers in a challenging environment fraught with difficult decisions.…”

“…CES is increasingly being studied as an intervention to improve quality of care, either examining objective outcome measures such as LOS or invasive interventions at end of life, or through more qualitative measures such as provider and family satisfaction (35,36). Due to heterogeneity of CES and lack of standardization, there continue to be gaps in evidence for effectiveness (35), and substantial challenges in defining consensus-based outcome measures for EC (36,37). There is conflicting evidence regarding impacts of CES on quality experienced by providers, resource and cost utilization, clinical outcomes, and communication (38).…”

Ethics consultation in patients with behavioral and psychological symptoms of dementia

“…There have been attempts to establish core competency guidelines for ECS in the United States, most notably by the American Society for Bioethics and Humanities (ASBH), 18 though additional guidelines have been influential, such as those by the Catholic Health Association and Ascension Health, 19 and by the US Department of Veterans Affairs, 20 Another confounder in the variability of ECS roles and expectations is that there has been little adoption of these guidelines among US hospitals as hospitals continue to vary widely in ethics practice. 21 The study of ECS nationally is further limited by the lack of consensus about appropriate ECS outcome measures to research, 22,23 though notably, some positive outcomes have been reported. 24,25 What is the role of hospital ethics consultation in dementia?…”