Is there a need for a clear advice? A retrospective comparative analysis of ethics consultations with and without recommendations in a maximum-care university hospital

Abstract

Background The theory and practice of ethics consultations (ECs) in health care are still characterized by many controversies, including, for example, the practice of giving recommendations. These controversies are complicated by an astonishing lack of evidence in the whole field. It is not clear how often a recommendation is issued in ethics consultations and when and why this step is taken. Especially in a facilitation model in which giving recommendations is optional, more data would be helpful to evaluate daily practice, ensure that this practice is in line with the overarching goals of this approach and support the development of standards. Methods We analyzed all consultations requested from an EC service working under a facilitation approach at a maximum-care university hospital in Germany over a period of more than 10 years. Our aim was to better understand why—and under what circumstances—some consultation requests result in a recommendation, whereas others can be sufficiently addressed solely by facilitated meetings. We especially wanted to know when and why clients felt the need for clear advice from the EC service while in other cases they did not. We compared ethics consultations in terms of the differences between cases with and without recommendations issued by the ethics consultants using χ2 difference tests and Welch’s t-test. Results A total of 243 ECs were carried out between September 2008 and December 2019. In approximately half of the cases, a recommendation was given. All recommendations were issued upon the request of clients. When physicians asked for an EC, the consultation was significantly more likely to result in a recommendation than when the EC was requested by any other party. ECs in cases on wards with ethics rounds resulted in comparably fewer recommendations than those in wards without ethics rounds. When interpersonal conflicts were part of the problem or relatives were present in the meeting, clients less frequently asked for a recommendation. Conclusion From the client’s point of view, there does not seem to be only one “right” way to provide ethics consultations, but rather several. While facilitated meetings are obviously appreciated by clients, there also seem to be situations in which a recommendation is desired (especially by physicians). Further empirical and theoretical research is needed to validate our single-center results and re-evaluate the role of recommendations in ethics consultations.

Interconsultas urológicas a un Servicio de Ética Clínica en un hospital de IV nivel

“…En el campo de la urología, se ha logrado reducir el sufrimiento y las limitaciones físicas causadas por la patología oncológica genitourinaria por medio de la subespecialización, innovación quirúrgica, cuidado multidisciplinario, y desarrollo de medicamentos. 8 Es importante tener en cuenta que, aun con el advenimiento de estos avances en el manejo de la enfermedad oncológica, los pacientes con estas patologías (principalmente en estadios avanzados) presentan necesidades durante la historia natural de su enfermedad que no son cumplidas, y que en muchos casos no son discutidas. Aquí yace la importancia de establecer una adecuada comunicación con los pacientes y sus familiares con respecto a la evolución de la enfermedad y a las alternativas que existen para su manejo.…”

Ethics experts and fetal patients: a proposal for modesty

“…The role of the ECS here is much more characterized by the skills required to support others (health care professionals as well as patients and relatives) in decision-making and to mediate between the parties in a conflict. Giving recommendations is not precluded [ 8 , 15 , 16 ], but it is not the first and foremost duty of the ECS. We choose to concentrate on the recommended ethics facilitation approach when describing the processes and challenges of ethics consultation in prenatal medicine in the following chapters.…”

Bedeutung des Klinischen Ethikkomitees (KEKs) für Klinikmitarbeiter einer neurologischen Fachklinik

“…Die Empfehlung des KEKs wurde in 94 % der Fälle umgesetzt. Obgleich die Zentrale Ethikkommission bereits 2006 eine Stellungnahmezur"EthikberatunginderklinischenMedizin"veröffentlichte, in der sie die Entwicklung der Ethikberatung begrüßt und zur Einrichtung solcher klinischen Angebote ausdrücklich aufrief [14], wird derzeit immer noch diskutiert, ob KEKs überhaupt eine konkrete Handlungsempfehlung aussprechen sollten [15]. Dies liegt möglicherweise mitunter daran, dass in Deutschland "bisher keine Empfehlungen oder Standards für die Implementierung und die Arbeit klinischer Ethikberatungen" [14] existieren.…”