Variation in the design of Do Not Resuscitate orders and other code status options: a multi-institutional qualitative study.
BMJ quality & safety
BACKGROUND: US hospitals typically provide a set of code status options that includes Full Code and Do Not Resuscitate (DNR) but often includes additional options. Although US hospitals differ in the design of code status options, this variation and its impacts have not been empirically studied.DESIGN AND METHODS: Multi-institutional qualitative study at 7 US hospitals selected for variability in geographical location, type of institution and design of code status options. We triangulated across three data sources (policy documents, code status ordering menus and in-depth physician interviews) to characterise the code status options available at each hospital. Using inductive qualitative methods, we investigated design differences in hospital code status options and the perceived impacts of these differences.RESULTS: The code status options at each hospital varied widely with regard to the number of code status options, the names and definitions of code status options, and the formatting and capabilities of code status ordering menus. DNR orders were named and defined differently at each hospital studied. We identified five key design characteristics that impact the function of a code status order. Each hospital's code status options were unique with respect to these characteristics, indicating that code status plays differing roles in each hospital. Physician participants perceived that the design of code status options shapes communication and decision-making practices about resuscitation and life-sustaining treatments, especially at the end of life. We identified four potential mechanisms through which this may occur: framing conversations, prompting decisions, shaping inferences and creating categories.CONCLUSIONS: There are substantive differences in the design of hospital code status options that may contribute to known variability in end-of-life care and treatment intensity among US hospitals. Our framework can be used to design hospital code status options or evaluate their function.
View details for DOI 10.1136/bmjqs-2020-011222
View details for PubMedID 33082165
- Response to "Will We Code for Default ECMO?": Clarifying the Scope of Do-Not-ECMO Orders. AMA journal of ethics 2019; 21 (10): E926?929
Treatability Statements in Serious Illness: The Gap Between What is Said and What is Heard
CAMBRIDGE QUARTERLY OF HEALTHCARE ETHICS
2019; 28 (3): 394?404
Empirical work has shown that patients and physicians have markedly divergent understandings of treatability statements (e.g., "This is a treatable condition," "We have treatments for your loved one") in the context of serious illness. Patients often understand treatability statements as conveying good news for prognosis and quality of life. In contrast, physicians often do not intend treatability statements to convey improvement in prognosis or quality of life, but merely that a treatment is available. Similarly, patients often understand treatability statements as conveying encouragement to hope and pursue further treatment, though this may not be intended by physicians. This radical divergence in understandings may lead to severe miscommunication. This paper seeks to better understand this divergence through linguistic theory-in particular, H.P. Grice's notion of conversational implicature. This theoretical approach reveals three levels of meaning of treatability statements: (1) the literal meaning, (2) the physician's intended meaning, and (3) the patient's received meaning. The divergence between the physician's intended meaning and the patient's received meaning can be understood to arise from the lack of shared experience between physicians and patients, and the differing assumptions that each party makes about conversations. This divergence in meaning raises new and largely unidentified challenges to informed consent and shared decision making in the context of serious illness, which indicates a need for further empirical research in this area.
View details for DOI 10.1017/S096318011900029X
View details for Web of Science ID 000477671000003
View details for PubMedID 31368425
- What Does the Word "Treatable" Mean? Implications for Communication and Decision-Making in Critical Illness CRITICAL CARE MEDICINE 2019; 47 (3): 369?76
- No Escalation of Treatment: Moving Beyond the Withholding/Withdrawing Debate AMERICAN JOURNAL OF BIOETHICS 2019; 19 (3): 63?65
- We Convey More Than We (Literally) Say AMERICAN JOURNAL OF BIOETHICS 2018; 18 (9): 1?3
Assessing clinical ethics consultation: processes and outcomes.
Medicine and law
2013; 32 (2): 141-152
The vast majority of hospitals use clinical ethics consultation (CEC) as a service to address ethical issues in patient care. Both proponents and critics alike recognize a need to evaluate CEC. I review three outcomes of CEC that have been formally evaluated: healthcare cost, clinical indicators in the intensive care unit, and user satisfaction. These outcome indicators cannot be used to evaluate the worth of CEC because they are contingent and outside of the consultant's control. However, the failure of outcomes-based assessment poses no threat to CEC since the service is continually justified by the fundamental necessity of resolving ethical problems in patient care. While outcome indicators can be used as heuristics to investigate quality issues in CEC, process indicators can capture the quality of CEC more directly. Therefore, further research should be directed toward developing process-based conceptual models for CEC and various methods for assessing these processes.
View details for PubMedID 23967789
How individual ethical frameworks shape physician trainees' experiences providing end-of-life care: a qualitative study.
Journal of medical ethics
OBJECTIVES: The end of life is an ethically challenging time requiring complex decision-making. This study describes ethical frameworks among physician trainees, explores how these frameworks manifest and relates these frameworks to experiences delivering end-of-life care.DESIGN: We conducted semistructured in-depth exploratory qualitative interviews with physician trainees about experiences of end-of-life care and moral distress. We analysed the interviews using thematic analysis.SETTING: Academic teaching hospitals in the United States and United Kingdom.PARTICIPANTS: We interviewed 30 physician trainees. We purposefully sampled across three domains we expected to be associated with individual ethics (stage of training, gender and national healthcare context) in order to elicit a diversity of ethical and experiential perspectives.RESULTS: Some trainees subscribed to a best interest ethical framework, characterised by offering recommendations consistent with the patient's goals and values, presenting only medically appropriate choices and supporting shared decision-making between the patient/family and medical team. Others endorsed an autonomy framework, characterised by presenting all technologically feasible choices, refraining from offering recommendations and prioritising the voice of patient/family as the decision-maker.CONCLUSIONS: This study describes how physician trainees conceptualise their roles as being rooted in an autonomy or best interest framework. Physician trainees have limited clinical experience and decision-making autonomy and may have ethical frameworks that are dynamic and potentially highly influenced by experiences providing end-of-life care. A better understanding of how individual physicians' ethical frameworks influences the care they give provides opportunities to improve patient communication and advance the role of shared decision-making to ensure goal-aligned end-of-life care.
View details for DOI 10.1136/medethics-2020-106690
View details for PubMedID 33593875
- More than Conveying Information: Informed Consent as Speech Act. The American journal of bioethics : AJOB 2021; 21 (5): 1?3
Recognizing the Role of Language in the Hidden Curriculum of Undergraduate Medical Education: Implications for Equity in Medical Training.
Academic medicine : journal of the Association of American Medical Colleges
Medical education involves a transition from "outsider" to "insider" status, which entails both rigorous formal training and an inculturation of values and norms via a "hidden curriculum." Within this transition, the ability to "talk the talk" designates an individual as an insider, and learning to talk this talk is a key component of professional socialization. This article uses the framework of "patterns of medical language" to explore the role of language in the hidden curriculum of medical education, exploring how students must learn to recognize and participate fluently within patterns of medical language in order to be acknowledged and evaluated as competent trainees. The authors illustrate this by reframing the objectives for medical education which are outlined by the Association of American Medical Colleges as a series of overlapping patterns of medical language which students are expected to master before residency. We propose that many of these patterns of medical language are learned through trial-and-error, taught via a hidden curriculum rather than through explicit instruction. Medical students come from increasingly diverse backgrounds and therefore begin medical training further from or closer to insider status. Thus, evaluative practices based on patterns of medical language, which are not explicitly taught, may exacerbate and perpetuate existing inequities in medical education. This article aims to bring awareness to the importance of medical language within the hidden curriculum of medical education, to the role of medical language as a marker of "insider" status, and to the centrality of medical language in evaluative practices. We conclude by offering possible approaches to ameliorate the inequities that may exist due to current evaluative practices, and call for further discussion and innovation to explicitly address the role of language in the hidden curriculum of medical education.
View details for DOI 10.1097/ACM.0000000000003657
View details for PubMedID 32769473
Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study.
Journal of general internal medicine
Moral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems.We investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees.Semi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress.Sixteen internal medicine residents in the US and fourteen junior doctors in the UK.The work was analyzed using thematic analysis.Some drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it.This research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries' healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.
View details for DOI 10.1007/s11606-020-06314-y
View details for PubMedID 33111237
- Introduction: Through the Lens of Linguistic Theory CAMBRIDGE QUARTERLY OF HEALTHCARE ETHICS 2019; 28 (3): 392?93
- Response to Commentaries: When "Everyday Language" Contributes to Miscommunication in Serious Illness CAMBRIDGE QUARTERLY OF HEALTHCARE ETHICS 2019; 28 (3): 433?38
- Student Perspectives on the "Step 1 Climate" in Preclinical Medical Education ACADEMIC MEDICINE 2019; 94 (3): 302?4
A Multi-Institution Collaboration to Define Core Content and Design Flexible Curricular Components for a Foundational Medical School Course: Implications for National Curriculum Reform.
Academic medicine : journal of the Association of American Medical Colleges
Medical educators have not reached widespread agreement on core content for a U.S. medical school curriculum. As a first step toward addressing this, five U.S. medical schools formed the Robert Wood Johnson Foundation Reimagining Medical Education collaborative to define, create, implement, and freely share core content for a foundational medical school course on microbiology and immunology. This proof-of-concept project involved delivery of core content to preclinical medical students through online videos and class time interactions between students and facilitators. A flexible, modular design allowed four of the medical schools to successfully implement the content modules in diverse curricular settings. Compared to the prior year, student satisfaction ratings after implementation were comparable or showed a statistically significant improvement. Students who took this course at a time point in their training similar to when the USMLE Step 1 reference group took Step 1 earned equivalent scores on National Board of Medical Examiners-Customized Assessment Services microbiology exam items. Exam scores for three schools ranged from 0.82 to 0.84, compared to 0.81 for the national reference group; exam scores were 0.70 at the fourth school, where students took the exam in their first quarter, two years earlier than the reference group. This project demonstrates that core content for a foundational medical school course can be defined, created, and used by multiple medical schools without compromising student satisfaction or knowledge. This project offers one approach to collaboratively defining core content and designing curricular resources for preclinical medical school education that can be shared.
View details for PubMedID 30801270
- "Not Shared" Need Not Mean "Not Patient Centered": Deciding That a Patient Is Not a Candidate. JAMA internal medicine 2019; 179 (6): 851?52
Student Perspectives on the "Step 1 Climate" in Preclinical Medical Education.
Academic medicine : journal of the Association of American Medical Colleges
The United States Medical Licensing Examination (USMLE) Step 1 was implemented in the 1990s as the most recent version of the National Board of Medical Examiners' preclinical licensing examination originally created in the late 1960s. For the purposes of state licensure, the exam is pass/fail, but the Step 1 numeric score has in recent years become central to the residency application and selection process. Consequently, a medical student's Step 1 score is increasingly viewed as a key outcome of preclinical medical education.In this Invited Commentary, students from various institutions across the country draw on their shared experiences to argue that the emphasis on Step 1 for residency selection has fundamentally altered the preclinical learning environment, creating a "Step 1 climate." The authors aim to increase awareness of the harms and unintended consequences of this phenomenon in medical education. They outline how the Step 1 climate negatively impacts education, diversity, and student well-being, and they urge a national conversation on the elimination of reporting Step 1 numeric scores.
View details for PubMedID 30570499
The long-term impact of a comprehensive scholarly concentration program in biomedical ethics and medical humanities
BMC MEDICAL EDUCATION
2018; 18: 204
There is a strong and growing interest in biomedical ethics and medical humanities (BEMH) within medical education for facilitating key components of medical professionalism and ethics, clinical communication and observational skills, and self-care and reflective practices. Consequently, United States (US) medical institutions have begun to incorporate BEMH through formal Scholarly Concentrations (SCs). This is the first study to examine the impact of a US BEMH SC, from student experience in medical school to post-graduate development, as perceived by graduate physicians.Graduated students who participated in the BEMH SC or did extensive BEMH research prior to the BEMH SC's establishment (n =?57) were sampled for maximum variation across graduating years. In telephone surveys and interviews, participants discussed the perceived impact of the BEMH SC on (a.) student experience during medical school and (b.) post-graduate development. Interviews were audiotaped, transcribed, and de-identified. The authors iteratively generated a codebook; two raters coded independently, adjudicated codes, and completed inter-rater reliability (IRR) tests. The authors subsequently conducted a team-based thematic analysis, identifying emergent themes.Nineteen BEMH graduates were interviewed. Results were analyzed according to (a.) student experience and (b.) post-graduate development. Overall, respondents perceived impacts in reinforcing knowledge and skills in clinical ethics; solidifying self-care and reflective practices; refining a sense of professional identity and integrity for ethically challenging situations; and promoting student skills, productivity, and later careers involving BEMH.A comprehensive US BEMH SC achieved the purported aims of BEMH in medical education, with graduate physicians perceiving persisting effects into clinical practice. Furthermore, the structure and format of a SC may offer additional advantages in promoting student scholarly skill and productivity, career development, and professional identity formation-core competencies identified across clinical training and ethics programs. Our findings indicate that a BEMH SC is effective in achieving a range of desired immediate and post-graduate effects and represent a particularly promising venue for BEMH in medical education. We believe these findings to be of critical significance to medical educators and administrators when considering how best to incorporate BEMH into SCs and medical curricula.
View details for DOI 10.1186/s12909-018-1311-2
View details for Web of Science ID 000442961400002
View details for PubMedID 30153822
View details for PubMedCentralID PMC6114241
Approaches to parental demand for non-established medical treatment: reflections on the Charlie Gard case
JOURNAL OF MEDICAL ETHICS
2018; 44 (7): 443?47
View details for PubMedID 29776977
Dispute between physicians and family on surgical treatment for an infant with ultra short gut syndrome: the perspective of an Ethics Committee
JOURNAL OF PERINATOLOGY
2018; 38 (7): 781?84
View details for PubMedID 29970914
Building a Trustworthy Precision Health Research Enterprise
AMERICAN JOURNAL OF BIOETHICS
2018; 18 (4): 1?2
View details for PubMedID 29621462
Challenges to code status discussions for pediatric patients
2017; 12 (11): e0187375
In the context of serious or life-limiting illness, pediatric patients and their families are faced with difficult decisions surrounding appropriate resuscitation efforts in the event of a cardiopulmonary arrest. Code status orders are one way to inform end-of-life medical decision making. The objectives of this study are to evaluate the extent to which pediatric providers have knowledge of code status options and explore the association of provider role with (1) knowledge of code status options, (2) perception of timing of code status discussions, (3) perception of family receptivity to code status discussions, and (4) comfort carrying out code status discussions.Nurses, trainees (residents and fellows), and attending physicians from pediatric units where code status discussions typically occur completed a short survey questionnaire regarding their knowledge of code status options and perceptions surrounding code status discussions.Single center, quaternary care children's hospital.203 nurses, 31 trainees, and 29 attending physicians in 4 high-acuity pediatric units responded to the survey (N = 263, 90% response rate). Based on an objective knowledge measure, providers demonstrate poor understanding of available code status options, with only 22% of providers able to enumerate more than two of four available code status options. In contrast, provider groups self-report high levels of familiarity with available code status options, with attending physicians reporting significantly higher levels than nurses and trainees (p = 0.0125). Nurses and attending physicians show significantly different perception of code status discussion timing, with majority of nurses (63.4%) perceiving discussions as occurring "too late" or "much too late" and majority of attending physicians (55.6%) perceiving the timing as "about right" (p<0.0001). Attending physicians report significantly higher comfort having code status discussions with families than do nurses or trainees (p?0.0001). Attending physicians and trainees perceive families as more receptive to code status discussions than nurses (p<0.0001 and p = 0.0018, respectively).Providers have poor understanding of code status options and differ significantly in their comfort having code status discussions and their perceptions of these discussions. These findings may reflect inherent differences among providers, but may also reflect discordant visions of appropriate care and function as a potential source of moral distress. Lack of knowledge of code status options and differences in provider perceptions are likely barriers to quality communication surrounding end-of-life options.
View details for PubMedID 29095938