John La Puma

Ethics consultation: skills, roles, and training.

A clinical ethics consultant gathers information firsthand at the patients bedside. The consultants special clinical skills include the ability to identify and analyze ethical problems; use reasonable clinical judgment; communicate effectively; negotiate and facilitate negotiations; and teach others how to construct their own ethical frameworks for medical decision making. Appropriate roles for the consultant include those of professional colleague, negotiator, patient and physician advocate, case manager, and educator. The training necessary for an ethics consultant includes substantial patient care experience, instruction in health care law and moral reasoning, and preparation in medical humanism. We favor a clinical model for ethics consultation. When urgent care is needed, other consultants promptly see the patient; the clinical ethics consultant can be expected to do the same.

Medical Staff Privileges for Ethics Consultants: An Institutional Model

On January 1, 1991, the Joint Commission required hospitals to be equipped for resolving moral dilemmas that arise in the care of a patient. Regulation of those professing expertise in clinical ethics is new and untested yet must be evaluated and further developed to protect patients from practitioners who lack expertise in clinical ethics but may promote themselves as qualified. The authors report the development of standard criteria for clinical ethics consultation privileges as one model to protect patients. An institutional medical staff model utilizing approved credentialing mechanisms is a generous umbrella under which patients may be protected, qualified clinical ethicists may practice, and continuous quality improvement may be sought.

The clinical ethicist at the bedside

In this paper we attempt to show how the goal of resolving moral problems in a patients care can best be achieved by working at the bedside.We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patients bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on secondhand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patients case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.

An Annotated Bibliography of Psychiatric Medical Ethics

We offer an annotated bibliography of psychiatric medical ethics that we hope will be useful for psychiatrists and other mental health professionals who are interested in the moral dimensions of psychiatric care. We present the educational and clinical rationale for the bibliography, ways to use the bibliography, and the bibliography itself. Using the American Psychiatric Association’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry as a principled framework, we selected references based primarily on educational and clinical relevance for physicians. We include both empirical and conceptual analyses of the ethical issues seen daily in the office, clinic, hospital, nursing home, and in society at large.

Outpatient clinical ethics.

ConclusionIdentification, analysis, and resolution of outpatient ethical problems require the physician’s explicit consideration of th epersonal, social, financial, psychological, and emotional aspects of care, and the use of clinical judgment. Clinicians can separate the patient’s interests and desires from the interests and desires of others and can recognize conflicts that arise from dual loyalties in particular clinical situations. Physicians’ communications and negotiations with outpatients can enhance both patient autonomy and physician autonomy. Primary care physicians can practice preventive ethics by helping their patients outline their goals for future medical care. Finally, as citizens informed on matters of health, physicians have professional and social responsibilities to educate the public and promote the common good.

The Ethics of Pressure Sore Prevention and Treatment In The Elderly: A Practical Approach

The management of pressure sores in elderly patients raises a number of ethical dilemmas for health care professionals. Aggressive treatment of advanced pressure sores is often inconsistent with the overall goals of therapy. Private and public funding for effective prevention and early treatment are restricted and constrained. Little information is available that proves treatment efficacy. Health care professionals and their institutions are often stigmatized by the occurrence of a pressure sore even though accountabilities may lie in the natural history of the disease. We use case analysis to identify ethical dilemmas in pressure sore prevention and management and suggest a framework for ethical decisionmaking so that health care professionals and public policy analysts can make informed judgments about patients and standards of quality care.

Predictors of physician overweight and obesity in the USA: an empiric analysis

Purpose – Because patients are more likely to follow advice from healthy weight rather than overweight physicians, seeks to determine whether physician overweight could be predicted by self‐reported physician eating behaviors.Design methodology/approach – An anonymous, written, self‐administered, pre‐tested, confidential survey of practicing physicians in the Midwestern USA was undertaken.Findings – Most surveyed physicians (394 or 74 per cent) completed the survey. The results indicate that stress at home (OR 2.62, CI 1.35‐5.08) was most significantly and strongly predictive of physician overweight (BMI>25kg/m2), as were particular eating behaviors, including eating food provided at the medical office. Assessment of overall health was significantly and strongly inversely proportionally predictive (OR 0.43, CI 0.30‐0.62) of physician overweight as well.Research limitations/implications – The research implies that, like patients, practicing US physicians are susceptible to feelings other than hunger which ...

The Ethics Consultant and Ethics Committees, and their Acronyms: IRBs, HECs, RM, QA, UM, PROs, IPCs, and HREAPs

Much has been written about the role of hospital ethics committees. Ethics committees may have begun in Seattle in the early 1960s, but they were reified in. New Jersey by the Quinlan Court in the 1970s and thrived in the national bioethics movement of the 1980s. In this flurry of ethics activity, several new forms of ethics committees have evolved. New forms of ethics committees include patient care-oriented ethics committees (RM, QM, & QA). Many ethicists are familiar with mission-oriented ethics committees (IRBs & HECs). Such committees have taken on new roles, and Include PROs, IPCs, and HREAPs. In general, these committees are regulatory in nature and may often rely on rules and regulations to assess patient cases, research protocols, and health professional practices.

The Bookie, the Girlfriend, and the Vultures

To the Editors: We report the case of a patient whose access to life-sustaining treatment was nearly blocked, motivated in part by financial benefit, by his girlfriend-legal proxy. An 81-year-old w...

Flavor and Nutritional Competence

of ma in ta in ing confidentiali ty, the obligation toward not doing ha rm (i.e., nonmalefieence), a n d conce rns about just ice . Moreover, even if the inves t iga tors in th i s recent s t u d y did not know the his tory of sickle-cell screening , the e n o r m o u s at tent ion tha t h a s been paid to counse l ing a n d tes t ing for HIVinfection should have precipi ta ted some u n d e r s t a n d i n g of the salient moral concerns involved wi th sickle-cell counse l ing a n d testing. It is impor tan t to e n s u r e tha t those sc reened under s t and clearly the m e a n i n g of tes t ing positive for sickle-cell trait (perhaps th rough careful prea n d pos t t es t counsel ing) and the potential need to keep th is in format ion confidential . Al though this informat ion may have been par t of the informed c o n s e n t process used in th is s tudy, the reader c a n n o t be su re of this . Nevertheless, the lack of c o m m i t m e n t to u n d e r s t a n d i n g whether par t ic ipants actually received pos t t es t counse l ing is disconcerting. Screening p rog rams m u s t have adequa te m e c h a n i s m s in place to e n s u r e tha t pa r t i c ipan t s not be h a r m e d as a resul t of being screened, tha t sc reen ing be voluntary, tha t counse l ing about screening be nondirective, a n d tha t those invited to participate in s u c h sc reen ing p rog rams be t reated fairly. SatiSfying these r equ i r emen t s takes time, s u g g e s t i n g tha t t es t ing for sickle-cell trait in the emergency d e p a r t m e n t m a y not be ap* propriate. As efforts to m a p the h u m a n genome move forward, it is quite likely tha t tes ts for myr iad genet ic d isorders will soon become available. The in format ion available from these tes t s may be qui te sensit ive. Thus , while prevent ion is a laudable goal, it need not be p u r s u e d at every oppor tuni ty . Careful deliberation about nonmedica l ou tcomes needs to be incorporated into the calculus for de t e rmin ing when, a n d whether , particular preventive in te rvent ions are a p p r o p r i a t e . J E m ~ ¢ S06AmV, m~, MD, MPH, MA, Program in Medica l Ethics, Divis ion of General Internal Medicine, Center f o r S t u d y o f Aging a n d H u m a n Development , Center f o r Heal th Policy Research a n d Educat ion, D u k e University, Durham. NC 27710