Paul R. Helft

Medical ethics education: where are we? Where should we be going? A review.

Purpose The authors’ primary goal was to provide a comprehensive and current review of the literature surrounding ethics education for medical students. Following this review, the authors summarize the deficits in the current literature and provide recommendations for future inquiries on medical ethics education. Method In 2004, the authors searched MEDLINE and PubMed using the following search terms: ethics, ethics education, medical ethics education, curriculum, undergraduate medical education, virtue, role model, philosophy of medicine, and outcomes research. No limit was placed on dates for this literature search. Articles whose primary focus was professionalism were excluded because the professionalism literature tends to focus on competencies and postgraduate education, whereas the primary focus of this study was on undergraduate education. Literature on physicians as role models to medical students as a form of teaching medical ethical ethics was excluded as well because the current discussion examines the formal undergraduate medical ethics curricula. Also excluded were reports from foreign countries (unless there were no equivalent studies in the United States). The authors found almost no literature exploring students’ backgrounds (cultural, religious, socioeconomic, etc.) and the teaching of medical ethics in medical schools. Otherwise, the authors reviewed everything they could find, regardless of imperfections in individual reports such as small sample size or poor research methodology. Results The review, which encompassed articles from 1978 to 2004, revealed that deep shortcomings exist in the literature on medical ethics education. Deficits exist in all areas of the literature: (1) theoretical work done on the overall goals of medical ethics education; (2) empirical studies that attempt to examine outcomes for students; (3) studies examining teaching methods in medical ethics education, and (4) studies evaluating the effectiveness of various teaching methods. Conclusions There are substantial opportunities for contribution to the literature on medical ethics education in all of the areas where deficits exist. The literature suggests that two points of view exist regarding the purpose of teaching medical ethics: (1) that it is a means of creating virtuous physicians; and (2) that it is a means of providing physicians with a skill set for analyzing and resolving ethical dilemmas. This dichotomy made it difficult to arrive at a consensus regarding the goals of medical ethics education. The field would benefit from further theoretical work aimed at better delineating the core content, core processes, and core skills relevant to the ethical practice of medicine. The time has come to organize an effort to improve and validate medical ethics education. In the end, effective medical ethics education will further the goals of medicine in dramatic and tangible ways.

The Patient–Doctor Relationship and Online Social Networks: Results of a National Survey

ABSTRACTBACKGROUNDThe use of online social networks (OSNs) among physicians and physicians-in-training, the extent of patient–doctor interactions within OSNs, and attitudes among these groups toward use of OSNs is not well described.OBJECTIVETo quantify the use of OSNs, patient interactions within OSNs, and attitudes toward OSNs among medical students (MS), resident physicians (RP), and practicing physicians (PP) in the United States.DESIGN/SETTINGA random, stratified mail survey was sent to 1004 MS, 1004 RP, and 1004 PP between February and May 2010.MEASUREMENTSPercentage of respondents reporting OSN use, the nature and frequency of use; percentage of respondents reporting friend requests by patients or patients’ family members, frequency of these requests, and whether or not they were accepted; attitudes toward physician use of OSNs and online patient interactions.RESULTSThe overall response rate was 16.0% (19.8% MS, 14.3% RP, 14.1% PP). 93.5% of MS, 79.4% of RP, and 41.6% of PP reported usage of OSNs. PP were more likely to report having visited the profile of a patient or patient’s family member (MS 2.3%, RP 3.9%, PP 15.5%), and were more likely to have received friend requests from patients or their family members (MS 1.2%, RP 7.8%, PP 34.5%). A majority did not think it ethically acceptable to interact with patients within OSNs for either social (68.3%) or patient-care (68.0%) reasons. Almost half of respondents (48.7%) were pessimistic about the potential for OSNs to improve patient–doctor communication, and a majority (79%) expressed concerns about maintaining patient confidentiality.CONCLUSIONPersonal OSN use among physicians and physicians-in-training mirrors that of the general population. Patient–doctor interactions take place within OSNs, and are more typically initiated by patients than by physicians or physicians-in-training. A majority of respondents view these online interactions as ethically problematic.

Necessary Collusion: Prognostic Communication With Advanced Cancer Patients

As a young oncologist, I find myself wrestling with many of the most difficult issues in the practice of oncology: making difficult trade-offs between risk and benefits of arduous treatments, finding sources of strength to deal with the devastating realities of patients’ situations, and determining how to communicate important information to patients in ways that give them honest and useful information, but still allow them to preserve some hope for the future. It is this last issue on which I offer my thoughts here. I have noticed that although common wisdom holds that we should give accurate and honest prognostic information to patients at all times, in practice this is hard to do. So, I find myself engaging in a process of communication about prognosis with patients which, in a sense, allows the cold, hard facts to come out over time, as opposed to presenting them up front. I have found other oncologists who seem to use a similar strategy. I do this because it is a style of communication which, I think, “works” for me and my patients: patients come to deal with the painful knowledge of their ultimate outcomes over time in ways that I think allow them to cope along the way. But I have continuously asked myself whether this is the “right” way to communicate. Is such a strategy of communication ethical? Looking to the literature about prognostic communication with patients with advanced cancer, two lines of thought dominate. The first suggests that patients want accurate estimates of their prognosis and that accurate estimates benefit patients by allowing them to make end-of-life plans consistent with their values. The second suggests that patients desire, above all, to maintain hope for their situations, and that the “management of hope” permits the prognosticating oncologist to take some liberties with prognostic estimates in order to preserve the patient’s ability to maintain hope. These two lines of thinking appear to be at odds with one another. Is there, however, an ethical way of resolving the tensions between these two views? In the end, I believe that except in instances where stark frankness is openly requested, a style of communication that allows patients to dictate most of the flow of prognostic information or to avoid it is an ethical strategy of prognostic communication. I will refer to this strategy as “necessary collusion.” By collusion I mean the spoken or unspoken agreement we sometimes enter into with some patients to avoid or delay discussing a definitive, numerical prognostic estimate of life expectancy. This article is an examination of whether such collusion is ethical. I am going to argue that such collusion can be ethical, because of certain special characteristics of the situation of patients with advanced cancer and their relationships with their oncologists.

Use of the Internet to Obtain Cancer Information Among Cancer Patients at an Urban County Hospital

PURPOSE To evaluate rates, predictors, and barriers to use of the Internet to obtain cancer information among a cohort of cancer patients at an urban county hospital. PATIENTS AND METHODS Of 208 cancer patients approached, 200 patients completed a structured interview study examining Internet use, perceptions of the accuracy of Internet information, and barriers to use. RESULTS Only 10% of participants reported using the Internet themselves to obtain cancer information. Another 21% reported exposure to Internet information through proxies. The most common barrier to Internet use cited was lack of Internet access, with 44% reporting that they would use the Internet to obtain cancer information if they had Internet access. Younger age and more years of formal education were significantly associated with Internet use, although race and income were not. Less education, African American race, and female sex were associated with lower estimates of the accuracy of Internet information. Fewer years of formal education was associated with increased likelihood of reporting confusion after reading Internet information. CONCLUSION Very few cancer patients in this study of a cohort of generally disadvantaged individuals used the Internet themselves to obtain cancer information, although many more desired to do so. Significant opportunities for Web-based interventions aimed at improving cancer care outcomes in this population of cancer patients exist. However, further study will be needed to determine how to make such intervention accessible, trustworthy, and understandable to the disadvantaged.

The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act

Background: Since the passage of the Patient Self-Determination Act, numerous policy mandates and institutional measures have been implemented. It is unknown to what extent those measures have affected end-of-life care, particularly with regard to the do-not-resuscitate (DNR) order. Methods: Retrospective cohort study to assess associations of the frequency and timing of DNR orders with advance directive status, patient demographics, physician’s specialty and extent of documentation of discussion on end-of-life care. Results: DNR orders were more frequent for patients on a medical service than on a surgical service (77.34% vs 64.20%, p = 0.02) and were made earlier in the hospital stay for medicine than for surgical patients (adjusted mean ratio of time from DNR orders to death versus total length of stay 0.30 for internists vs 0.21 for surgeons, p = 0.04). 22.18% of all patients had some form of an advance directive in their chart, yet this variable had no impact on the frequency or timing of DNR ordering. Documentation of DNR discussion was significantly associated with the frequency of DNR orders and the time from DNR to death (2.1 days with no or minimal discussion vs 2.8 days with extensive discussion, p<0.01). Conclusions: The physician’s specialty continues to have a significant impact on the frequency and timing of DNR orders, while advance directive status still has no measurable impact. Additionally, documentation of end-of-life discussions is significantly associated with varying DNR ordering rates and timing.

Scope and Outcomes of Surrogate Decision Making Among Hospitalized Older Adults

IMPORTANCE Hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care. OBJECTIVE To describe the scope of surrogate decision making, the hospital course, and outcomes for older adults. DESIGN, SETTING, AND PARTICIPANTS Prospective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions. MAIN OUTCOMES AND MEASURES Clinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement. RESULTS According to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P < .001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P < .001), and length of stay (median, 6 days for patients and 7 days for surrogates; P < .001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P < .001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P < .001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record. CONCLUSIONS AND RELEVANCE Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.

Cancer patients' attitudes toward future research uses of stored human biological materials.

The policy debate concerning informed consent for future, unspecified research of stored human biological materials (HBM) would benefit from an understanding of the attitudes of individuals who contribute tissue specimens to HBM repositories. Cancer patients who contributed leftover tissue to the Indiana University Cancer Center Tissue Bank under such conditions were recruited for a mail survey study of their attitudes. Our findings suggest that a clear majority of subjects would permit unlimited future research on stored HBMs without re-contact and re-consent, and a significant minority appear to desire ongoing control over future research uses of their tissue. These differences merit further investigation and suggest that a policy of blanket consent for all future, unspecified research would be premature.

A phase II trial of irinotecan, 5-fluorouracil and leucovorin combined with celecoxib and glutamine as first-line therapy for advanced colorectal cancer.

Objectives: Preclinical and clinical data indicate that cyclooxygenase-2 (COX-2) is a bona fide molecular target for colorectal cancer (CRC). Glutamine may decrease chemotherapy-associated diarrhea. This study was designed to address whether the addition of celecoxib, a COX-2 inhibitor, and glutamine would improve the efficacy and decrease the toxicities of the irinotecan, fluorouracil and leucovorin (IFL) regimen. Methods: All patients received the original IFL regimen plus celecoxib (400 mg, po, every 12 h continuously while on trial) and glutamine (10 g, po, every 8 h continuously while on chemotherapy). Results: Of the 41 patients enrolled, 40 patients received between 1 and 6 cycles of treatment. This regimen was associated with significant toxicities: 45.0% had grade 3 diarrhea, 35.0% grade 3/4 neutropenia, 22.5% hospitalization, 10.0% deep vein thrombosis and 2 treatment-related deaths. The overall response rate was 47.2%. The median progression-free survival was 6.7 months. The median overall survival was 16.3 months. The 12-month overall survival rate was 54.8%. COX-2 expression was present in 63.2% of the specimens evaluated. There was no significant correlation between COX-2 expression and response to chemotherapy (p = 0.739). Conclusion: The addition of celecoxib and glutamine appears not to improve the efficacy or decrease the toxicities of IFL for the treatment of metastatic CRC.

Oncology nurses' narratives about ethical dilemmas and prognosis-related communication in advanced cancer patients.

Background: Oncology nurses routinely encounter ethical dilemmas when caring for advanced cancer patients, particularly concerning prognosis-related communications. Nurses experience uncertainty and barriers to providing quality end-of-life care; thus, more information is needed about recognizing and managing these dilemmas and to clarify their role in these situations. Objective: The purposes of this study were to (1) describe the frequency and types of ethical dilemmas experienced by oncology nurses caring for advanced cancer patients and (2) to summarize their written comments about prognosis-related communications. Methods: This was a content analysis of narrative comments provided by 137 oncology nurses who completed a mailed national survey of members of the Oncology Nursing Society. Results: The most frequently reported ethical dilemmas encompassed uncertainties and barriers to truth telling, familial and cultural conflict, and futility. Physician-nurse teams were considered optimal for delivering prognosis-related information. Nurses offered strategies for facilitating these communications. They also expressed the need for more education about how to engage in prognosis-related discussions and for better methods for relaying this information among team members to avoid “working in the dark.” Conclusions: Oncology nurses routinely experience ethical dilemmas, and there is a need for clarification of their role in these circumstances. Healthcare providers would benefit from interdisciplinary education about prognosis-related discussions. Attention to managing familial conflict and understanding cultural variations associated with illness, death, and dying is also needed. Implications for Practice: Findings reveal new information about ethical dilemmas encountered by nurses and strategies for improving end-of-life communications with advanced cancer patients.

Brain Death Revisited: The Case for a National Standard

The concept of brain death--first defined decades ago--still presents medical, ethical, and legal challenges despite its widespread acceptance in clinical practice and in law. This article reviews the medicine, law, and ethics of brain death, including the current inconsistencies in brain death determinations, which a lack of standardized federal policy promotes, and argues that a standard brain death policy to be used by all hospitals in all states should be created.