Table 3 CEC intervention delivery context
From: Clinical ethics consultations: a scoping review of reported outcomes
Name of intervention | Intervention Coded As | Description | CEC requestor | CEC deliverer | Training/experience of deliverer | Reference # |
|---|---|---|---|---|---|---|
Proactive Ethics Intervention | Clinical Ethics Consultation | 9 step process initiated prior to the identification of an ethical issue or request for ethics evaluation (differing from consultation) consisting of a series of encounters involving a bioethicist in the care of ICU patients with an LOS of 5 days + | No request is made as approach is proactive and defined as the point in care in which "no ethical issues have [been] identified and no request for an ethics evaluation has been made" | Standardly involves 2 staff members involving a clinical ethicist and a research assistant | The ethicist involved has completed Master's, PhD, and fellowship, and has (3) years of experience as a clinical ethicist in a major U.S. hospital; the activities of the ethicist were overseen by 3 individuals with "years of experience" in ethics consultation | [48] |
Clinical Ethics Consultation | Clinical Ethics Consultation | A consultative, supportive, and educational function in which the main function is to secure that value issues are recognized and dealt with in a competent way | Physicians | Hospital Ethics Committee | Study denotes that ~ 87% of informants (CEC deliverers) had familiarity with CEC whereas remaining deliverers had only recently experienced CEC | [49] |
Ethics Case Reflection Sessions | Clinical Ethics Consultation | Similar structure to ethics rounds in which an ECR session is organized as meetings involving the interprofessional team and the external facilitator | Interprofessional | External facilitator | Article does not discuss training/credentials of the EC < but does denote training/experience as a potential limitation | [50] |
Clinical Ethics Consultation | Clinical Ethics Consultation | An “individual but tethered” approach in which the individual consultant on the case remains in consultation and communication with other CHE faculty members, but is assigned to the case individually | Nursing | Individual Ethics Consultant | Article does not discuss the training/credentials of the EC | [51] |
Ethics Consultation System | Clinical Ethics Consultation | Vague description, but the individual consultant coordinates work with the ethics committee | Treating Medical Team or by relatives | Individual Ethics Consultant | Does not identify training/credentials of the EC | [52] |
Ethics Consultation Service (ECS) | Clinical Ethics Consultation | Individual intervention performed by consultant, followed by a weekly, hour-long ethics case review conference to review recent consultations. For complex consultations, discussion with the Healthcare Ethics Committee occurs | Does not explicitly specify but indirectly alludes to staff and family as options | Individual Ethics Consultant | ECS staffed by 2 clinical ethicists who combined have 40 + years of clinical practice experience, each having completed advanced degrees and mentorship in ethics | [53] |
Clinical Ethics Support | Moral Case Deliberation | Interprofessional reflection on ethical dilemmas encountered in clinical work conducted through scheduled interprofessional meetings held every third month. A 60 min author-led session began with open-ended requests to the team members who thereafter collectively decided on the situation of discussion. Each participant reflects on the situation and the ethical issues involved. A value conflict is identified, and suggestions for response/resolution are discussed | No request is made due to nature of intervention | CES Leader | Leader belongs to department of nursing; facilitator “may be healthcare professional or even a philosopher-ethicist” with the role of promoting ethics dialogue | [54] |
Proactive Ethics Consultation | Clinical Ethics Consultation | Consults offered in response to latent or manifest conflicts rather than specific consultation requests. Adhered to a general process model including review of the medical record, discussion with healthcare team and family, assessment of issue, timely meetings as appropriate, and recommendation for next step | No request is made due to nature of intervention | Individual Ethics Consultant | Article does not discuss the training/credentials of the EC | [55] |
Hospital Ethics Committee Consultation Service | Clinical Ethics Consultation | Members of the service evaluate the clinical situation through interviews with healthcare professionals, | The sample was not selected based on having requested a CEC. Healthcare professionals who had been involved in a particular ethics consultation case were recruited as part of a larger online study. A subset of these participants participated in the qualitative study | Hospital Ethics Committee | Article does not discuss the training/credentials of the EC | [56] |
Structured Multidisciplinary MEDM (medical ethical decision-making) | Clinical Ethics Consultation | All participants but the chair (primarily responsible for the process) are directly involved in caretakers’ (differs from consultations in that they are consulted in complicated/exceptional situation requiring external expertise).Sessions are scheduled when the provider/parent have doubts about moral justification of a child’s treatment. Meetings are chaired by an impartial ethicist. Follows 5 steps (same steps for deliberation then reporting): (1) exploration of elements to be considered, presented by representative of every professional group involved; (2) agreement on ethical dilemma/investigate possible solns; (3) analysis of solns; (4) decision-making; (5) planning actions (e.g., who will inform parents. scheduling next meeting, guaranteeing child's comfort | Not specified but indicates that sessions scheduled when provider/parent expresses doubt about moral justification | Chair of MEDM | Does not identify credentials other than chair being an ethicist | [58] |
Hospital Ethics Committee Consultation Service | Clinical Ethics Consultation | Specific steps include data gathering and issue identification by a staff bioethicist. Team meets as a committee first and then meets with individual healthcare providers. Consultant discusses with patient and the family or surrogates, and the HCPs. Deliberation than occurs by the committee | Does not identify requestor | Hospital Ethics Committee | Does not identify training/credentials of the ECs | [57] |
Moral Case Deliberation (MCD) | Moral Case Deliberation | A group dialogue in which professionals (sometimes with patients and families) jointly investigate a moral question emerging from a situation experienced in daily practice led by a trained facilitator | Participants specifically recruited to participate in MCD for purpose of study | Trained Facilitator | Does not identify training/credentials of the ECs | [59] |
Proactive Ethics Consultation | Clinical Ethics Consultation | A consultation provided to the clinical team to increase the team’s attention to decision-making and communication process issues; consultation had both structured and unstructured dimensions | Not applicable due to nature of intervention | Two clinicians | Specifically trained in clinical ethics | [60] |
Clinical Ethics Consultation Service (CECS) | Clinical Ethics Consultation | Individual but tethered style where staff individually engages with key participants associated with a given ethics consultation, but that individual remains in communication and consultation with other CHE faculty members throughout the process | Anyone in patient’s care can request including physicians, nurses, social workers, other staff, patients, and families t | Individual Consultant from Faculty of Centre for Healthcare Ethics | Does not identify training/credentials of the ECs | [61] |
Clinical Ethics Committee | Clinical Ethics Consultation | Case is brought to the committee and is subsequently deliberated on by members | Evaluated clinicians who brought cases forward to the committee for consultation | Can be delivered either by committee alone, or CEC in conjunction with professionals involved in the case/on the ward | Article does not identify training/experience of ECs, but does identify that members are interdisciplinary and identifies exclusions from the process including patient-representatives, lawyers, and ethicists | [62] |
Clinical Ethics Consultation Service | Clinical Ethics Consultation | Cases are sent by email/fax to front office of the program. The front office removes identifying info and passes onto the consultation teams who collectively formulate advice for the case and reply within a week | Medical team, ethics committee, physicians, families, nurses | Three person consultation team | 17 volunteer educators/researchers including scholars of biomedical ethics, philosophy/ethics, legal, nurses, and doctors | [63] |
Ethics Consultation | Clinical Ethics Consultation | General steps included (1) medical review, (2) ethical diagnosis, (3) recommendations of next steps, (4) documentation of consultation in patient's medical record, (5) follow-up by ethics consultant. No standardized protocol across hospital sites | Not applicable as participants randomized to either received consultation (intervention) or not (control) | Individual Ethics Consultant | “Trained, experienced medical ethics consultation service” comprised of individuals skilled in facilitating communication, and are knowledgeable in ethics and the law, and are officially backed by an institutional ethics committee | [64] |
Health Care Ethics Consultation (HCEC) | Clinical Ethics Consultation | Case consultation following the bioethics consultation taskforce: (1) gather relevant data; (2) clarify relevant concepts; (3) clarify related normative issues; (4) help to identify a range of morally acceptable options; (5) facilitate consensus | Physicians and Nurses | Individual Ethics Consultant | Listed as having doctoral degrees, > decade of training in clinical medicine, > 20 h of clinical ethics educational courses and years | [65] |
Clinical Ethics Consultation Service (CECS) | Clinical Ethics Consultation | Facilitative model to assist clinical team's decision making. Referrals accepted by consultant/fellow to decide on appropriate response Level 1: attendance by fellow/consultant at multidisciplinary team mtg to identify/clarify ethical concerns Level 2 (more complex cases): multidisciplinary clinical team and CECS response team (> 3 members) meet, chaired by fellow/clinical lead, committed to convening within 48 h of referral | Does not specify but model is to assist clinical team in decision making and responding to the clinical team specifically | Three Person team consisting of clinical lead, pediatric fellow, and administrative officer | CCHEL consisted of medical specialist clinical lead, pediatric fellow, and administrative officer. Clinical lead requires postgraduate training in ethics and fulfilment of core competencies listed in study consisting of knowledge core competencies, and skill core competencies (see Table 2 of article). Fellow advanced training in pediatrics and selection criteria requires postgraduate studies in ethics and core competencies are developed under supervision of clinical lead. Recruited by expression of interest and members are required to have some, but not all core competencies listed in Table 2 | [66] |
Moral Case Deliberation (MCD) | Moral Case Deliberation | Structured deliberations using either a dilemma conversation method or a Socratic dialogue conversation method facilitated by a trained facilitator | Not applicable | Trained MCD Facilitator | Individuals involved in dissemination of MCD process consisted of location manager, spiritual caregivers, and social workers and help was sought from an academic expertise group in clinical ethics support; MCD facilitators (17 individuals) trained specifically to step into this role—specific training/roles/experience of facilitators not discussed outside of denoting specific training from aforementioned individuals to step into this role | [67] |
Formal Ethics Consultation Service | Clinical Ethics Consultation | Responding to the physician requests, seeing the patient, speaking with the involved parties, making recommendations, writing a formal report in the medical record | Physician (internal, family, geriatrics, surgery, psychiatry, pediatrics, obstetrics, emergency) | Internist | 102 consultations performed by a board- certified internist who completed a fellowship in clinical ethics; there are no other formal mentions of training/experience, but study does mention "physician-ethicists" suggesting some background in ethics | [68] |
Clinical Ethics Consultation (CEC) | Clinical Ethics Consultation | 4 step consultation procedure: (1) elaboration of ethical question; (2) gathering of data/info from CEC participants, (3) identification/discussion of ethical arguments, (4) recommendation on course of action Uses a semi-structured protocol and documented in patient record | Discipline of requestor not indicated | Trained facilitator | Training in clinical ethics | [70] |
Formal Ethics Consultation Service | Clinical Ethics Consultation | Consultant interviewed/examined patient, reviewed medical record and interviewed requesting physician/other HCPs in circle of care/family members, consultant and attending physician ethicist wrote assessment and recommendations in medical record | Physician (internal, surgery, neurology, neonatology, pediatrics, geriatrics, dermatology) | Consulting team | Members of the consulting team were health care professionals that had "expertise in clinical ethics", were completing an ethics fellowship, and resource persons had expertise in law and moral philosophy | [69] |
Clinical Ethicist Involvement | Clinical Ethics Consultation | Does not address delivery | Not clearly indicated | Clinical Ethicist | Experienced in identification, analysis, and resolution of ethical issues encountered by patients at the bedside, often being due to conflict of values | [71] |
Clinical Ethics Support Structures | Clinical Ethics Consultation | Venues for ethical discussion; most commonly municipalities had established "ethics reflection groups" in nursing homes, home-based care, and sheltered housing. In an ERG, professionals typically bring their own actual cases to be discussed among the colleagues. Sessions usually last 30–90 min | Not indicated | Ethics Consult Facilitator | Does not identify training/experience of ECs | [72] |
Clinical Ethics Committee Consultation | Clinical Ethics Consultation | Does not discuss in depth but identifies clinical ethics consultation provided by a committee | Clinicians, patients, next of kin, managers, patient ombudsman | Clinical Ethics Committee | Does not identify training/experience of ECs | [73] |
Ethics Case Consultation | Clinical Ethics Consultation | A team of three members that rotates monthly. New consultants attend the medical ethics course offered to medical students at New York Medical College and then function as an observer on the consultation team prior to becoming a primary team member. A review of the chart is completed, then interviews with the patient if capacitated, appropriate family members and staff. A written assessment of the case that includes documentation of the facts, an analysis of ethical issues, conclusions and recommendations is prepared | Of the 20 consults (most cases involved the withholding or withdrawing of therapy), 15 were requested by physicians, 1 by a patient's family, 2 by nurses, and 2 by a hospital administrator. In general, a CEC may be requested by the patient's attending physician, house staff, nursing staff, social workers connected with the case, the patient, family members or proxies | Individual Ethics Consultant | Team always consists of one physician, while other members may be nurses, social workers, nutrition specialists, clergy, or train members of the general community. No specific training/experience discussed | [74] |
Clinical Ethics Consultation Service | Clinical Ethics Consultation | This study does not specifically address the delivery | Patient’s primary physician | Ethicist/Ethics Consultant | Denotes some experience/familiarity with the field. No training/experience specifically mentioned | [75] |
Clinical Moral Case Deliberation | Moral Case Deliberation | Meeting with an average of 10 HCPs who systematically reflect on moral issues that emerge in a clinical case they have experienced. Reflection takes 45 min—"one day" and is facilitated by ethicist and structured by a "means of conversation method" which is selected to suit the specific goal(s) of the deliberation. The role of the ethicist is to facilitate rather than give substantial advise nor morally justify/legitimize a decision | Not applicable due to nature of the intervention | Ethicist | Facilitated by a senior ethicist | [76] |
Ethics Consultation Service | Clinical Ethics Consultation | Consultant discusses case with requestor; reviews chart and talks individually with members of care team, patient, family; writes consultation report in patient's chart including ethical analysis/discussion/recommendations | Physicians (pediatrics, medicine, family medicine, surgery, gynecology), nurse, medical student, chaplain | Ethicist | Provided by a family-physician-ethicist who spends his time teaching and practicing family medicine, teaching in clinical ethics, and providing consultation | [77] |
Ethics Consultation Service | Clinical Ethics Consultation | Ethics consultation | Any member of the healthcare team or from patients and families | Three Clinical Ethicists | Does not discuss training/experience of ECs | [78] |
Ethics Consultation Service | Clinical Ethics Consultation | The bioethics committee provides a 2-step consultation service. 1st the committee chair reviews the pt's chart within 24 h & interviews the pt, family, physicians, other caregivers to identify the ethical issues. The chairman then meets with the requesting physician to suggest ways for resolving the issue, and writes recommendations in the chart. 2nd step the bioethics committee reviews the consultation at its bi-monthly meeting to develop a consensus about managing similar cases in the future | Physician | Ethics Committee | Committee includes 8 physicians and eight nonphysicians chosen given their interest, and their ability to promote patient interests. One of the authors (HSP) chairs the committee and is an internist with fellowship training in bioethics | [79] |
Clinical Ethics Committee Consultation | Clinical Ethics Consultation | In case of moral conflict, involved individuals request support from CEC. At least 2 CEC members decide whether a request is suitable to be discussed by consultation. If appropriate, consultation is scheduled. All individuals are invited to state perspective and CEC members moderate discussion | Anyone involved in the conflict include staff, patients, and/or relatives | Unclear whether provided by team or individual | All members trained according to curricula standards of the Academy of Ethics in Medicine including theoretical/practical training pertaining to teaching ethics, organisation, and the process of counselling; advanced courses are available; usually one moderator is an Ethicist | [80] |
Ethics Consultation | Clinical Ethics Consultation | Does not specify, but provides ethics consultation. Unclear whether such is provided by a team or the individual consultant | ICU nurses asked to identify patients in whom value-based treatment conflicts arose. Patients were then randomly assigned to CEC or control group | Ethics Consultation Service Members | If consultation offered/provided, was done by one of four members of ECS who "qualified at the advanced level of skills and knowledge consistent with that later recommended by the American Society for Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation" | [81] |
Ethics Consultation | Clinical Ethics Consultation | Each site followed a general process model of CEC which involved (1) consultation, (2) assessment of request, (3) ethical diagnosis, (4) recommendations, including further meetings, (5) documentation, (6) follow-up, (7) evaluation, (8) record keeping | ICU nurses asked to identify patients in whom value-based treatment conflicts arose. Patients were then randomly assigned to CEC or control group | Individual or Groups whose training and experience correspond to the advance levels of skills and knowledge recommended by ASBH Core Competencies | Consultations provided by individuals or groups whose "training and experience correspond to the advanced level of skills and knowledge recommended by the American Society for Bioethics and Humanities Core Competencies for Healthcare Ethics Consultations" | [82] |
Ethics Rounds | Clinical Ethics Consultation | Monthly ethics rounds (1 h each) for 6 months led by a moderator to help participants identify ethical problem discussed and clarify perspectives/arguments | Not applicable due to nature of intervention | Moderator | Leader of ethics rounds is a philosopher/ethicist | [83] |
Case Consultation | Clinical Ethics Consultation | Medical model: written memorandum containing ethical analysis and opinions about the cases were sent directly to primary physicians. Consultations handled primarily by the department of bioethics. The Ethics Committee handled primarily but not exclusively policy | Primary physicians or their designates | Department of Bioethics | 3 full-time bioethicists and two yearly bioethics fellows; no explicit mention of training/experience | [84] |
Ethics Consultation | Clinical Ethics Consultation | Upon initiation of CEC the consultant identifies the relevant clinical staff, patients, and surrogates and meets with them to ascertain the issues prompting the EC and try to reach agreement on the plan of care. EC are documented in the medical record. CEC are conducted by 1 or 2 members of a sub-group of the institution's ethics committee | Any healthcare provider, patient, or family member | Individual ethics consultant | Consultants have training in medical ethics; most consultants have clinical experience of more than 10 years in ethics | [85] |
Moral Case Deliberation | Moral Case Deliberation | A group of HCPs gather to deliberate on a moral case in their work in which the starting point is an actual experience. The group reflects on this, and the discussion is facilitated by a "specifically trained conversation facilitator" MCDs are facilitated only once for a number of sessions or in ongoing groups, coordinated and facilitated by the hospitals MCD steering group consisting of five professionals | Requests typically come from managers | MCD Conversation Facilitator | Denotes that steering group members come from "various segments of the organization" and in-company training for future MCD conversation facilitators is provided | [86] |
Clinical Ethics Consultation | Clinical Ethics Consultation | Nurses identify cases, ethicist reviews charts to determine additional questions that might warrant a complete EC, ethicist contacts the physician on record and explores options in helping with the issues identified. Where possible, ethicist initiates conversations with patients/families to ensure understanding of information conveyed to them by physicians/nurses/professionals. Ethicists attempts to ensure thoughts, feelings, etc. of patient/family are conveyed to the healthcare providers. Where possible, ethicist organizes patient care conferences that include the patient, family, surrogate, health care providers to identify issues needing decisions and to focus attention on reasonable options and likely outcomes. Chart notes are written by the ethicist to record all patient/family contacts once a consult is received | Nurses | Two Clinical Ethicists | One clinical ethicist has a PhD in philosophy and 20 + years of clinical ethics experience; the other ethicist is a doctoral candidate in philosophy with 4 years of clinical practice experience | [87] |
Ethics Consultation | Clinical Ethics Consultation | CEC service consisted of 2 physicians and a multidisciplinary team of consultants. 3 levels of consultation provided: (1) involves answering a relatively simple question by a single member of the consultation service; (2) involves facilitating a decision-making process with the healthcare team, patient and/or family, and is performed by the EC on call; (3) used for ethical dilemmas and involves a full multidisciplinary ethics consultation service review, facilitated by the on call EC. Each consultation is documented on an intake form | Members of healthcare team (physicians, residents, nurses, ancillary services) patients, or family | Various levels provided by individual consultant or combination of 2 physicians and a multidisciplinary team of consultants | 2 physicians certified in medical ethics; Consultants completed 6 month educational course in ethics consultation and participate in continuing education | [47] |
Early Intervention Ethics Consultation | Clinical Ethics Consultation | Routine EC instituted for patients within 72 h of cannulation on ECMO delivered by a single consultant for the duration of the case. EC is thoroughly recorded in the record and the quality of the programme is supported by an interdisciplinary medical ethics committee | Not applicable due to nature of intervention | Individual ethics consultant | Denotes that they are "certified ethics healthcare consultants (HEC-C)" with 25 + years of experience (a palliative care physician, and a professional healthcare chaplain) with additional academic training in bioethics and clinical consultation Committee members are from diverse disciplines who have served on the committee for a long period of time and/or have completed clinical ethics fellowships or bioethics masters’ programs | [88] |
Proactive Clinical Ethics Consultation | Moral Case Deliberation | "PEACE" (pediatric ethics and communication excellence) rounds. Ethicist used probing questions to uncover situational risk factors/early indicators of ethical conflict. Ethicist provided just in time education and coaching on effective communication about sensitive topics; prompted team members to discuss potentially difficult ethical aspects of management, explore rationale for limiting treatment, consider consensus around survival, and make specific recommendations about code status and goals of care | Not applicable due to nature of intervention | Individual Ethics Consultant | Does not discuss the training/credentials of the EC | [89] |
Ethics Consultation Service | Clinical Ethics Consultation | Ethics facilitation approach to CEC focused on supporting key stakeholders to appreciate the perspective of others, elucidating the ethical issues, and improving communication | Anyone involved in the care of patients (including patients and families) | Interdisciplinary Team | The service is a volunteer interprofessional team including physicians, nurses, social workers, lawyers, chaplains, pharmacists, and hospital administration with varying levels of training and experience | [90] |
Ethics Consultation | Clinical Ethics Consultation | Consultant reviewed medical chart, examined patient if appropriate, and talked individually with members of medical team and family. After evaluation, consultant entered formal consultative report in chart, including assessment, ethical analysis, and recommendations. Follow-up meetings with HC team member and family arranged as needed. Cases were presented to hospital ethics committee. Self-described method of consultant was a dispute resolution following a stepwise approach | 83% (of 23 CEC) were requested by attending physicians, two in conjunction with the parents of the patient, and one with a social worker. Two (9%) consultations were requested by parents alone, and one (4%) by a social worker alone. One consultation was requested by the pediatric house staff as part of an ethical case conference | Individual Ethics Consultant | Singular consultant described as a "middle-aged, white, male board certified internist with medical ethics training as a visiting professor and scholar at several ethics centers." | [91] |
Moral Case Deliberation | Moral Case Deliberation | Sessions used the MCD dilemma method, which consists of 10 steps and lasted between 50–116 min | Board overseeing transgender clinical care in the Netherlands introduced MCD to complement the two team's regular clinical care and decision-making processes | Certified MCD Facilitators | The MCD sessions were led by trained and certified MCD facilitators employed by the Department of Medical Humanities of the Amsterdam University Medical Centers | [93] |
Moral Case Deliberation | Moral Case Deliberation | Interprofessional workplace meetings led by an external facilitator who helped staff to reflect systematically on concrete ethical issues. Consisted of 5–12 participants held monthly for 8 months, lasting 60–90 min | Not applicable given intervention method | External facilitator | Does not discuss credentials of facilitator | [92] |
Clinical Ethics Consultation | Clinical Ethics Consultation | Small teams of funded faculty ethics consultants; not discussed in this paper, but described in additional publication authors cite in paper | Healthcare professionals (physicians, nurses, social workers, etc.) | Ethics Consultant | only denotes that they "meet healthcare ethics consultation criteria" | [94] |