Wayne Shelton

The effect of a family support intervention on family satisfaction, length-of-stay, and cost of care in the intensive care unit.

Objective:The study examined the effect of adding a full-time family support coordinator to the surgical intensive care unit team on family satisfaction, length-of-stay, and cost in the surgical intensive care unit. Design, Setting, and Patients:A quasi-experimental design was conducted in two phases: baseline (8 mos) and intervention (10 mos) phases. Data on family satisfaction, length-of-stay, and costs from both phases were collected. Interventions:The intervention added a new role, the family support coordinator, to the surgical intensive care unit team. The family support coordinator functioned as a liaison between the patient’s family and the health care team. Measurements and Main Results:The results revealed that generally the intervention was associated with increases in family satisfaction with communication for all surgical intensive care unit team members, with physicians, social workers, and respiratory care therapists showing increases in significance. The largest increase was for physician communication (p = .0034). Families also rated their perceptions of the quality of care provided to their family members by various members of the surgical intensive care unit team. Mean ratings increased for all areas of care, with respiratory and nursing care showing the largest increases. Families’ perceptions of the care and treatment they received during the stay of their family member showed increases in all areas of satisfaction between baseline and intervention, particularly those areas most related to the intervention. Conclusions:The implementation of the family support coordinator intervention increased family satisfaction across a range of parameters. Although there were decreases in length-of-stay and costs, they were not statistically significant. Further research is needed to determine whether intervention refinement could produce lower length-of-stay and costs.

Difficult Hospital Inpatient Discharge Decisions: Ethical, Legal and Clinical Practice Issues

Every day, in every hospital, hospital staff members, patients, and families wrestle with critically important discharge decisions. Those decisions can raise complex issues with significant ethical, as well as clinical, legal, and financial implications. The area deserves, yet for some reason has largely escaped, attention by medical ethicists. To be sure, in most instances hospital discharge planning and implementation occur smoothly, without conflict and with adequate results. Typically, at some point during an inpatient’s care, the patient’s physician will determine that the patient no longer needs inpatient care and is ready for discharge, either to home or to some post-acute care setting. At that point, the discharge staff, generally social workers or nurses, will work with the patient and/or family to complete a discharge plan. If the plan calls for discharge to post-acute setting such as a nursing home or adult home, discharge staff will assist the patient and family to identify and secure admission to such facilities. If the plan calls for discharge home with special services or equipment, staff will assist the patient and family to secure those services or equipment. The process is shaped by clinical, legal and financial imperatives. The clinical imperative, of course, is to develop and implement a discharge plan that will ensure the patient’s continued recovery and reduce the risk of rehospitalization. A hospital’s principal legal obligations relating to patient discharges are set forth in Medicare’s Conditions of Participation for hospitals (42 CFR §482.43). State regulations generally overlap those Medicare requirements but may amplify them (e.g., in New York, 10 NYCRR §405.9). The Medicare regulations direct hospitals, among duties:

The Role of Social Work in the ICU: Reducing Family Distress and Facilitating End-of-Life Decision-Making

Abstract The costs associated with Intensive Care Units (ICUs) are high and at times invasive ICU care may not be beneficial, particularly for those patients admitted to ICUs who have little hope of recovery. The process of clarifying medical goals for these patients is often facilitated by addressing psychosocial factors. Social workers in the ICU are uniquely qualified to assess and address many of the complex psy-chosocial circumstances and can clarify potential misperceptions, enhancing communication among patients (if capacitated), their families, and the medical team members. This can not only help improve quality of life for very sick and dying patients in the ICU and their families, but may also reduce the likelihood of decision-making conflicts from arising. Further studies need to be done to investigate the effectiveness of social work interventions in reducing family distress, avoiding care that is unwanted by patients, and demonstrating cost-saving benefits.

Structuring a Written Examination to Assess ASBH Health Care Ethics Consultation Core Knowledge Competencies

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities (ASBH) has published core knowledge competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization.

A Comparison of General Medical and Clinical Ethics Consultations: What Can We Learn From Each Other?

Despite the emergence of clinical ethics consultation as a clinical service in recent years, little is known about how clinical ethics consultation differs from, or is the same as, other medical consultations. A critical assessment of the similarities and differences between these 2 types of consultations is important to help the medical community appreciate ethics consultation as a vital service in todays health care setting. Therefore, this Special Article presents a comparison of medical and clinical ethics consultations in terms of fundamental goals of consultation, roles of consultants, and methodologic approaches to consultation, concluding with reflections on important lessons about the physician-patient relationship and medical education that may benefit practicing internists. Our aim is to examine ethics consultation as a clinical service integral to the medical care of patients. Studies for this analysis were obtained through the PubMed database using the keywords ethics consultation, medical consultation, ethics consults, medical consults, ethics consultants, and medical consultants. All English-language articles published from 1970 through August 2011 that pertained to the structure and process of medical and ethics consultation were reviewed.

The Effect of a Family Support Intervention on Physician, Nurse, and Family Perceptions of Care in the Surgical, Neurological, and Medical Intensive Care Units

Many patients in the intensive care unit (ICU) have predictable medical and discharge outcomes, but some trajectories are marked with medical uncertainty. Stressed family-surrogates receive multiple medical updates from a variety of personnel. These circumstances can lead to confusion, which may result in conflicts and dissatisfaction with care. This study examined the effects of adding a family support coordinator to the surgical, neurological, and medical ICUs on family, physician, and nurse satisfaction with communication and care. A quasi-experimental design was conducted in 2 sequential phases (baseline and intervention). The data sources were 2 surveys: (1) Family Satisfaction Survey and (2) Nurse and Physician Perception and Satisfaction Survey. Family Satisfaction Survey data, a combined data set, were collected in the 3 ICUs. Nurse and Physician Perception and Satisfaction Survey data were collected from the attending physicians and critical care nurses in the medical and neurological ICUs. Results show that family ratings of satisfaction with ICU team communication and care generally increased as a result of the intervention. Overall, physician and nurse perceptions of communication and care did not change as a result of the intervention.

For lack of a better plan: A framework for ethical, legal, and clinical challenges in complex inpatient discharge planning

This article proposes a new theoretical framework for analyzing complex inpatient hospital discharge dilemmas. Each component of the framework is defined, illustrated with a hypothetical case, and discussed from legal,ethical and practical problem solving viewpoints. Patients who lack reasonable and safe discharge plans invariably challenge existing interpretations of autonomy, capacity, and justice. Such cases often require legal advice and sometimes intervention from the judicial system when alternatives are exhausted. As an extension of previous work on discharge planning (Swidler et al., 2007), this work strives to provide medical professionals with an organized way of approaching inpatient discharge barriers and to encourage new ways of considering and designing healthcare policy both to reduce discharge delays and also better to serve patients.

Understanding the Dynamics of the Patient–Physician Relationship: Balancing the Fiduciary and Stewardship Roles of Physicians

There has been growing concern about the effects on the patient–physician relationship of the increasing demands on physicians to balance their fiduciary and stewardship responsibilities, what has been called “double agency.” Various authors have proposed ways to restore patient centeredness to the patient–physician interaction. We have previously discussed the need to establish a patient–physician alliance to achieve this aim and to facilitate achieving this balance in mutual understanding. In this essay, we examine six concepts derived by Michael Balint from research seminars with primary care physicians. These six concepts are (a) the basic fault; (b) the physicians apostolic function; (c) the mutual investment company; (d) the drug “doctor”; (e) the deeper diagnosis; and (f) the conspiracy of anonymity. We believe these six concepts describe basic forces that shape the patient–physician relationship and allow for the development of an alliance between patients and physicians that can help preserve the essentials of the relationship.

A Broader Look At Medical Futility

This paper attempts to provide a descriptive theoretical overview of the medical futility debate. I will first argue that quantitative data cannot alone resolve the medical futility debate. I will then examine two aspects of medical futility, which I call the prospective and immediate, respectively. The first involves making prospective factual and value judgments about the efficacy of proposed medical interventions, while the latter involves making value judgments about ongoing medical conditions where the clinical data are clear. At stake is the nature and scope of individual rights. Thus, I maintain there is an undeveloped aspect to the medical futility debate and, briefly, analyze two political perspectives which give rise to different understandings of medical futility. The view that I will defend is that only a system with defined collective goals can accommodate a normative concept of medical futility. These larger questions are the value options which, if unaddressed, may be settled by default of economic grounds.

Respect for Donor Autonomy and the Dead Donor Rule

In spite of ongoing academic debates about the ethics of organ transplantation and the meaning and moral signiacance of death, the dead donor rule (dd rule) is meant to reassure the public that living people will not be sacriaced or abused in order to promote the interests of others in need of organs. A growing chorus of critics of the dd rule have offered a variety of alternative approaches to amend current policy. Elysa R. Koppelman (2003) proposes an entirely new system focused on showing respect for the expressed wishes of individual donors. Her system would drop the dd rule and allow individuals in “suspended states” to predetermine whether they wished to be organ donors. As she admits, however, her skeletal proposal is not yet suited for current medical, ethical, and social conditions and perceptions (Robertson 1999). Although I agree with Koppelman that we should be open to new understandings of how individuals are allowed to donate organs based on their autonomous wishes, I will argue that this goal can be better facilitated by: