Five-year experience of clinical ethics consultations in a pediatric teaching hospital

Abstract

Our retrospective study presents and evaluates clinical ethics consultations (CECs) in pediatrics as a structure for implementing hospital-wide ethics. We performed a descriptive and statistical analysis of clinical ethics decision making and its implementation in pediatric CECs at Zurich University Children's Hospital. Ninety-five CECs were held over 5 years for 80 patients. The care team reached a consensus treatment recommendation after one session in 75 consultations (89 %) and on 82 of 84 ethical issues (98 %) after two or more sessions (11 repeats). Fifty-seven CECs recommended limited treatment and 23 maximal treatment. Team recommendations were agreed outright by parents and/or patient in 59 of 73 consultations (81 %). Initial dissensus yielded to explanatory discussion or repeat CEC in seven consultations (10 %). In a further seven families (10 %), no solution was found within the CEC framework: five (7 %) required involvement of the child protection service, and in two families, the parents took their child elsewhere. Eventual team-parent/patient consensus was reached in 66 of 73 families (90 %) with documented parental/patient decisions (missing data, n = 11). Patient preference was assessable in ten CECs. Patient autonomy was part of the ethical dilemma in only three CECs. The Zurich clinical ethics structure produced a 98 % intra-team consensus rate in 95 CECs and reduced initial team-parent dissensus from 21 to 10 %. Success depends closely on a standardized CEC protocol and an underlying institutional clinical ethics framework embodying a comprehensive set of transparently articulated values and opinions, with regular evaluation of decisions and their consequences for care teams and families.

What kinds of cases do paediatricians refer to clinical ethics? Insights from 184 case referrals at an Australian paediatric hospital

“…Similarly, when Kesselheim and colleagues surveyed 33 US paediatric clinical ethicists, 46% reported that their services conducted 6–10 formal ethics consultations in the previous 12 months and a further 24% reported a figure of 1–5 consultations 3. However, the high volume of referrals at RCH is similar to the volume reported in a 5-year study at Zurich University Children's Hospital 13. In addition to receiving a high volume of referrals relative to many other centres, the RCH clinical ethics service experienced a trend of increasing numbers of consultations over time.…”

“…Recently, several paediatric-specific studies have also been published, primarily from the US context 9–14. Three themes that emerge from existing studies are the large proportion of case referrals for children less than a year old,7–9 13 14 the diversity of case typologies used,9 10 15 16 and the way in which the case sets vary depending on the nature and focus of the hospital 10 17…”

Bioética clínica al lado del enfermo. Creación y experiencia de un servicio de ética clínica en un hospital universitario

“…El hecho de que la experiencia reportada por otros autores se pueda calificar como similar a la nuestra, ratifica y justifica las consultorías éticas como una ayuda apreciable en la resolución de los conflictos ético-clínicos institucionales [17,20].…”

“…Con base en la literatura mundial se determinaron cinco grupos (tabla 4) para la categorización de los dilemas éticos [15,16,17]. Los autores del presente artículo, por separado, clasificaron cada uno de los casos en uno de los cinco grupos.…”

Strategies to Improve Health Care Ethics Consultation: Bridging the Knowledge Gap

“…Much has changed since 2000, when the prior national study was completed. More recent studies have examined HCEC practices in a single US institution [16][17][18][19][20][21], at institutions outside the US [22][23][24][25][26], and at 44 children's hospitals [27]. But none of these studies can be used to draw conclusions about general hospitals in the US.…”