大型学术医学中心的伦理咨询：回顾性、纵向分析。

Ethics Consultations at a Major Academic Medical Center: A Retrospective, Longitudinal Analysis.

机构信息

Brigham and Women's Hospital, Boston, Massachusetts, USA.

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

出版信息

AJOB Empir Bioeth. 2020 Oct-Dec;11(4):275-286. doi: 10.1080/23294515.2020.1818879. Epub 2020 Sep 17.

DOI:10.1080/23294515.2020.1818879

PMID:32940565

Abstract

BACKGROUND

Evidence suggests that healthcare professionals feel inadequately equipped to manage ethical issues that arise, resulting in ethics-related stress. Clinical ethics consultation, and preventive ethics strategies, have been described as ways to decrease ethics-related stress, however information is limited regarding specific sources of ethical concern.

METHODS

The purpose of this study was to conduct a retrospective, longitudinal analysis of a comprehensive database of ethics consultations, at a major academic medical center in the Northeast United States in order to: (1) Discern major sources of ethical concern, (2) Evaluate how these have changed over time in their content and frequency, (2a) Evaluate trends in nurse versus physician-initiated requests.

RESULTS

Six major reasons for requesting an ethics consult were identified: Conflict Over Goals of Care, Decisional Capacity, Withholding/Withdrawing Treatment, Proxy Decision Making, Communication, and Behavior. Themes were operationally defined by the study team. An increase in requests related to Conflict Over Goals of Care (β = 0.7, 95% CI = 0.2-1.2, = 0.008) and Discharge Planning (β = 2.2, 95% CI = 1.4-3.1, < 0.001), and a trend toward increased number of consults for behavior-related consults from nurses (median 6.5% versus 2.3%, = 0.07) were noted. Nurses were significantly more likely than physicians to request ethics consultation for Communication (yearly median 10.4% of cases vs 1.3% of cases, = 0.01), whereas, physicians were significantly more likely to request ethics consultation for Proxy Decision-Making than nurses (yearly median 26.0% of cases vs 13.0%, = 0.005) and for Decision-Making Capacity (yearly median 7.5% of cases vs 4.0%, = 0.04).

CONCLUSIONS

This study revealed several noteworthy and previously unidentified trends in consultation requests, and several important distinctions between the sources of ethical concern nurses identify versus those physicians identify. These findings can be used to develop future preventive-ethics frameworks.

摘要

背景

有证据表明，医疗保健专业人员觉得自己无法妥善处理出现的伦理问题，因此感到伦理相关的压力。临床伦理咨询和预防伦理策略被描述为减少伦理相关压力的方法，但是关于具体的伦理关注来源的信息有限。

方法

本研究的目的是对美国东北部一家主要学术医疗中心的全面伦理咨询数据库进行回顾性、纵向分析，以：（1）发现主要的伦理关注来源，（2）评估其在内容和频率上随时间的变化，（2a）评估护士与医生发起请求的趋势。

结果

确定了请求伦理咨询的六个主要原因：治疗目标冲突、决策能力、治疗中止/撤回、代理决策、沟通和行为。研究小组对主题进行了操作定义。与治疗目标冲突（β=0.7，95%CI=0.2-1.2， =0.008）和出院计划（β=2.2，95%CI=1.4-3.1， <0.001）相关的请求增加，以及护士请求与行为相关的咨询的数量呈上升趋势（中位数 6.5%对 2.3%， =0.07）。与医生相比，护士更有可能因沟通（每年中位数占病例的 10.4%，占病例的 1.3%， =0.01）而请求伦理咨询，而医生则更有可能因代理决策（每年中位数占病例的 26.0%，占病例的 13.0%， =0.005）和决策能力（每年中位数占病例的 7.5%，占病例的 4.0%， =0.04）而请求伦理咨询。