Table 6 Process factors reporting

Reasoning for Accessing CEC

For what purposes do the participants contact the CEC

Qualitative Interviews

Doctors report contacting CEC in order to receive moral backing for decisions that were made, obtaining an elucidation of the ethical aspects of the case, to receive concrete advice, and to have the case discussed by people that are not directly involved in the case, or a combination of one or more of these reasons

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Consolidating Care and Clarifying Perspectives

Striving for common care goals and creating a shared vision of care in the specific case

Involved several sub-processes: deliberating ethics (ethical reflection); unifying interactions (increased interprofessional understanding and agreement, providing basis for decision making and common care objectives, increasing shared understandings leading to unity within the team); group strengthening (contributing to atmosphere of mutual understanding/acknowledgement); decision grounding (decision grounded in multidisciplinary perspective)

Qualitative Interviews

Core category of consolidating care

Consolidating care—striving for common care goals and creating a shared view of care in the specific case. Consolidating care by clarifying perspectives. This involved multiple processes: a) deliberating ethics (raising and clarifying ethical values and relating them to possible courses of action), b) unifying interactions (increasing interprofessional understanding and agreement, providing a basis for decision making and common care objectives; increased shared understandings contributing atmosphere of mutual understanding/acknowledgement) C) group strengthening—contributing atmosphere of mutual understanding/acknowledgement; d) decision grounding—decision grounded in multi-disciplinary perspective

Core category supported by related process of clarifying perspectives

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Support

Support regarding interpersonal relationships and interactions among patients, family, nurses, and physicians

Survey

10/13 nurses (13 who responded to this question) (77%) felt that the most important aspect of CEC involved support regarding interpersonal relationships and interactions among patient, family, nurses, and physicians

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Facilitating Advanced Communication (Helpfulness)

Helpfulness in identifying, analyzing, and resolving ethical issues, helpful in educating all parties, and in helping parties present their personal views

Survey (Likert scale)

Healthcare providers and family members found the CEC to be helpful in identifying the ethical issue (87.7%, 86.7%); analyzing ethical issues (86.5%, 84.6%); and resolving ethical issues (73.9%, 71.2%); helping to educate all parties (80.0%, 81.9%); and helping parties present their personal point of view (80.9%, 84.5%)

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Moving It Along (Advancing Care)

Transitioning the patient out of the hospital setting—can be constrained if any decision for care or implementation of care is not morally acceptable. In

volved 3 stages: (1) moral questioning; (2) seeing the big picture; (3) coming together

Qualitative Interviews

Core category of Moving it Along, relates to transitioning care and the tension created when there is a moral issue that impedes progress of the patient in the system. 3 stages: (1) Moral questioning—identifies reasons for calling the ethics consultation service (i.e. varied perceptions, asking questions, calling the question); (2) Seeing the big picture—comprised of two sub-themes: opening to new ideas and consensus-building; (3) Coming together—realistic and ethically acceptable resolution was achieved through (a) working on the same page—variety of ethics interventions employed such as interview, consultation write-up, and meeting with stakeholders, professionals valued ethics consultations because of the improved communication and respect. They believed their questions were heard and that their point of view was taken seriously, education and new information about decision making principles were valued. (b) resolving and reflecting—some professionals expressed dissatisfaction when expectations were not met; for e.g., expectation to have a solution and clear specific plan

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Consensus Regarding Care Achieved

Whether goal of HCEC was achieved (for HCEC group: if any of the morally acceptable options suggested by the individual ethics consultant was followed; for UC group: if patients/family members and health care team members agreed on options for goals of medical care)

Record review (Review of Medical Record/HCEC Record)

85% of patients in HCEC group reached consensus re: goal of medical care after HCEC service vs 24% in UC group reached consensus**

Considering crossover, 35 pts who received HCEC service more likely to reach consensus than 27 pts who didn't

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Impact of MCD

Individual participants’ experience of MCD and results of MCD for Care Practice

Qualitative interviews and focus groups

Robust set of qualitative data reported. See study for data set

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Integrating Familial Perspectives

Bringing together elements considered by family as crucial to the end-of-life decision making process; active listening, asking the right questions so that families could bring to the fore what really mattered to the patient and family, and exploring possible options

Qualitative Interviews

"Of the participants who did have access to a clinical ethicist during the process of decision-making, the value of the ethicist was clearly stated":—illuminating important and relevant questions that no one else was asking (asking the right questions); listening to families (active listening); exploring possible options

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Evaluation of CEC Service (Impact)

Rating by attending physician of consultation's importance in clarifying ethical issue, educating team, increasing their confidence in patient management, and in making patient management decisions

Survey

Physicians reported finding consultation to be either "very" or "somewhat" important in clarifying ethical issues (95%), educating the team (100%), increasing confidence (93%), and managing patients (95%)

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Identification of Ethical Issues

Did consultants identify issues that requesters had not recognized

Mixed methods (Survey and Medical Chart Review

Respondents said 14 consultations identified ethical issues that requesters had not recognized; medical charts partially substantiated physician responses. Physicians demonstrated high recognition of ethical issues involving providing or withholding life support. Physicians demonstrated low recognition of issues involving proxy decision making for incompetent adults and issues concerning terminal care

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Process Hypotheses (Impact)

Process hypotheses are consistent with the goals of the consortium's consensus statement and serve an important role in ethics in ICUs in helping to a) identify ethical issues; b) analyze ethical issues; c) resolve ethical issues; d) educate about ethical issues; e) help present personal views

Survey (Likert scale)

70% agreement or strong agreement among family members that the CEC helped to identify (8/8), analyze (6/8), resolve (6/8), educate (6/8), was responsive to personal values (7/8), helped to educate others about ethical issues (6/8), was helpful (6/8), informative (6/8), supportive (7/8), and fair (6/8). Three of the 8 family members thought the CEC was stressful (40%). All but 1 physician agreed or strongly agreed with the positive process measures

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Process (Impact)

Subjective evaluations of CEC process: respectful of values, CEC helped in identifying, analyzing, resolving, educating, presenting view

Survey (5-point Likert scale: strongly disagree, disagree, neutral, agree, strongly agree)

87% of nurses and physicians and patients/surrogates agreed or strongly agreed that CEC were helpful. More than 90% of nurses and physicians agreed or strongly agreed that they would seek them again and recommend them to others. Even though patients/surrogates found CEC somewhat more stressful than nurses/physicians, 80% agreed or strongly agreed that they would seek them again or recommend them to others. 13 surrogates disagree or strongly disagreed with CEC recommendations, yet 7 would seek them again or recommend them to others

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Helpfulness/Positive impact in their perceived role

Perceptions of clinical ethicist’s greatest positive impact on the case

Survey

43% of ethicists perceive their greatest positive impact in consultation is to identify or clarify key issues and options in care, followed by assisting in finalizing end of life care plan (15%) and support participants (14%). 25% of nurses believed the ethicist's greatest positive impact was to assist in finalizing end of life care plan (25%), followed by allow participants to voice/discuss (21%) and identify or clarify key issues and options in care (25%). 22% of physicians identified allow participants to voice/discuss, followed by identify or clarify key issues and options in care (17%), and then explain legal issues (13%) and support participants (13%). Only 4% of physicians identified "assist in finalizing end of life care plan", contrary to ethicists and nurses

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Purpose

What reasons were the cases brought to the committee and what role does the committee specifically fulfill in the case

Qualitative interviews

Conflicts between professionals regarding solutions was embedded in many cases but not explicitly stated as a motivation. All cases were submitted with the purpose of getting decision-making support in decisions where ethical challenges were salient. the most common reason for requesting was to obtain a systematic and comprehensive analysis of a difficult ethical dilemma from a more distant position outside the team. Among other reasons cited were helping clinicians deal with fundamental questions of a problem, getting a critical evaluation, getting specific advice in cases involving life and death decisions, creating an opportunity to share responsibility with others, getting moral support in a non treatment decision when treatment was medically indicated,

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Perceived Helpfulness (Impact/Purpose)

In what ways was the ethics consultation helpful to families and what did the consultation do to help the families

Qualitative interviews

Content analysis of interviews yielded that ethics consultations are helpful to patients and families in the following domains: clinical clarity, moral or legal clarity, motivation, facilitation, implementation, interpretation, consolation and support

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Expectations (Impact/Purpose)

And

Overall Assessment of CEC and impact on values

Respondent’s expectations of the CEC

Mixed methods (Survey—yes/no, and optional free text response)

Survey (11 items adapted from a tool developed by White, Dunn and Homer [47] and outcomes measures for EC (ASBH 2011)

Top 6 expectations of CEC were: facilitate communication between team and pt/family, clarify/define a plan of care, provide a neutral perspective, provide information, facilitate communication among team members, and provide a safe space

Overall assessment of ECS was favourable. More than 90% felt the consultant explained things well, more than 80% felt the consultation validated the team's approach and provided support, and more than 70% felt the ECS clarified uncertainty, gave them a better understanding of ethical issues, and helped resolve a patient care problem. More than 80% felt the CEC recommendations were consistent with the organization's values, respected the respondent's values, and were consistent with their personal values. More than 60% felt the CEC helped clarify the values of the patient and/or patient's family, and helped respondents clarify their own values. Qualitative interviews uncovered some comments suggesting the EC could have communicated more effectively with members of the health care team

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Importance of EC

Importance of EC to participants

Survey (Likert scale)

Over 90% of physicians and social workers agreed or strongly agreed that the ethics consultant was important in identifying and analyzing ethical issues. 70% agreed or strongly agreed that the consultant was important in resolving ethical issues, 74% agreed or strongly agreed that the EC was important in increasing confidence in patient management. Only 2 of 4 family members agreed the EC was important for identifying and analyzing ethical issues, educating the family, and increasing confidence in patient management. 3 of 4 families strongly disagreed that the EC was important for resolving ethical issues. Interviews with physicians and social workers express positivity with the CEC, and appreciated the help and hand-holding, another said it was good at delineating issue sand allowed for different views to be voiced

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Process of Deliberation (Harvest) (Impact/Purpose)

Authors use the term "harvest" to identify nurses' reporting of MCD impact on professional practice. "Harvest" includes cooperation; developing a critical attitude towards practice; empowerment and enhancement; understanding; boundaries, limitations and self-care; quality of care; and exploring policy, paradigms and vision

Qualitative interviews

Intervention revealed team conflicts, but did not solve them. Existing concerns regarding solutions were not addressed given that participants were afraid of hierarchical structure on wards and in departments, further hindering implementation of solutions. Solutions can be too complex or existing ambiguity in terms of solutions can remain. Disappointment was expressed because consultation was marred by communication barriers. Record was a sufficient instrument to communicate the solution. Though some participants had questions at the end of consultation, most participants felt discussion was useful to solve the ethical conflict, reveal the underlying team conflict, and to contact the CEC in case of further ethical conflict

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Program Impact

What is the role/purpose of the EC in relation to the perceived ethical issues

Mixed methods (Medical record/case note review and qualitative interview)

EC is described as preventative—assess family ability to be a partner in case, identifies barriers to decision-making, builds trust between the medical team and family, and sets expectations about ECMO early on. All 30 physicians regard early EC protocol positively and note that without the protocol, ethics would be consulted only when conflict is intractable. Bedside nurses, APPs, and fellows recognize additional benefit of establishing EC as a routine being that involving ethics is not seen as a failure or action of a whistleblower

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Awareness of Others Perspectives and Interests

and

Allowing Deeper Exploration and Insight

and

Enhanced Collaboration

and

Concrete Results

Participants voiced appreciation that all MCD participants were encouraged to contribute and that disagreements were discussed in less polarizing ways

MCD enabled teams to explore in great detail how they handled a given protocol and why they had done so. Participants appreciated the time MCD offers for talking about cases, restoring participants' sensitivity to the particularity of the case at hand

This domain included 5 items: (1) Greater opportunity for everyone to have their say; (2) better mutual understanding of each other’s reasoning and acting; (3) enhances mutual respect amongst co-workers; (4) I and my co-workers manage disagreements more constructively; (5) more open communication among co-workers

This domain contains 3 items: (1) Find more courses of action in order to manage the ethically difficult situation; (2) consensus is gained amongst co-workers in how to manage ethically difficult situations; (3) enables me and my co-workers to decide on concrete actions in order to manage ethically difficult situations

Qualitative interviews and focus groups

Qualitative interviews and focus groups

Survey (Euro MCD Instrument)

Survey (Euro MCD Instrument)

Participants voiced appreciation that all MCD participants were encouraged to contribute and that disagreements were discussed in less polarizing ways

MCD enabled teams to explore in great detail how they handled a given protocol and why they had done so. Participants appreciated the time MCD offers for talking about cases, restoring participants' sensitivity to the particularity of the case at hand

Most frequently experienced outcomes during MCD session (t1, n = 22): "better mutual understanding of reasoning and behavior (84%)", "more open communication among co-workers (82%)". Most frequently experienced outcomes in daily work after MCD sessions (t1, n = 22): "enhances mutual respect among co-workers (55%)

Least often experienced outcomes in daily work after MCD sessions: "enables me and my co-workers to decide on concrete steps to manage ethically difficult situations (75%)"

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Impact on Practice

First line managers’ experiences of what Moral Case Deliberation meant for daily practice

Qualitative interviews

Managers experienced an enhanced ethical climate including a closer knit and more emotionally mature team and morally strengthened individuals. Their experience was ethics leaving its mark on everyday work, and more morally grounded actions. Despite perceptions of organizational barriers, managers felt inspired to continue ethics work

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Value

Moral space that was created, allowing for reflection, analysis, negotiation, and processing of ethical problems (intrapersonal and interpersonal worth of ethics consultation)

Qualitative interviews

Intrapersonal Worth

Ethics service created a moral space that allowed participants to respond to the emotional, cognitive, and behavioural demands presented by ethical problem

Interpersonal Worth

Consults allowed participants to respond to other parties involved in the ethical question including patients, family members, and team members

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