Table 7 Clinical factors reporting

Nonbeneficial treatment

and

Mortality

and

Suffering

Patients receiving ventilation and/or receiving artificial nutrition and hydration between intervention and control

Died in Hospital

Amount of perceived patient suffering from provider perspective, patient perspective, and/or surrogate perspective

Record review (Medical record review)

Record review (Medical record review)

Qualitative interviews (“daily interviews”)

Receiving ventilation (median days):

Intervention (N = 56): N = 15

Control (N = 52): N = 14

Receiving artificial nutrition and hydration (median days):

Intervention (N = 56): N = 17

Control (N = 52) l: N = 16

Intervention (N = 174): N = 56 (32.2)

Control (N = 210): N = 52 (24.8)

Nurses/Physicians in the intervention arm reported 65.6% had "little suffering" or were "free of suffering with 52.6% of patients/surrogates reporting the same. In the control arm, the figures were 58.9% and 57.9% respectively

[48]

Impact of CEC on the decision

Agreement with decision, treatment plan changed significantly after CEC

Survey (Likert scale)

Majority of clinical caregivers and family members agreed with the decision reached in the CEC (81.3%, 71.8%); both healthcare providers and patient/ family members perceived similar degrees of changes in the treatment plan following CEC

[55]

Quality of communication index

Presence of advance directive, DNR order, orders to withhold/withdraw life-sustaining treatment, limits of care, consultations requested for pastoral care, social services, pain management

Record review (Patient chart review (observational tool developed to gather documentation from medical records—score of "1" given each time an entry appeared in the record)

Ethics proactive group had significantly higher communication scores than other 2 groups; patients who died had significantly higher communication scores than those discharged alive; significant diff in proactive ethics group compared to baseline/control in having DNR and other life-sustaining tx decisions made in course of ICU care, decisions to withhold/withdraw life-sustaining treatments (communication & decision-making)

[60]

Consultant response to requests

Consultant suggestions for changes in treatments and orders

Record review (Consultant records)

Consultant suggested changing/discontinuing orders in 48/104 cases

[68]

Consultant response to requests

Consultant suggestions for changes in treatments and orders

Record review (Consultant records)

Consultant made specific recommendations in 48/51 cases; DNR order recommended in 13 cases and written in 12/13 cases

[69]

Consensus

and

Implementation Rate

Whether there was consensus amongst CEC participants regarding recommendation

Whether CEC recommendation was implemented

Record review (Medical chart review (each CEC is documented using semi-structured protocol for patient record)

High mutual consensus rate amongst all participants in CECs (90.8–96.5%); no significant difference btwn patient groups (ICU, LCU, PCU aka high consensus for all groups)

High rates of implementation/adherence to final CEC recommendation (89.7–100%); no significant difference btwn patient groups (ICU, LCU, PCU aka high implementation rate for all groups)

[70]

Less Use of Coercion

Less use of coercion

Survey

13% to a large degree and 26% to some degree believed ethics activities led to less use of coercion. 51 respondents formulated additional outcomes. The four most prevalent were: heightened awareness of ethical challenges, a lower threshold for raising and discussing ethical challenges among colleagues, an increased concern with patient/user needs and interests, and increased knowledge (i.e., of ethics, law, clinical practice)

[72]

Adherence to CEC Recommendations

Whether the CEC recommendations were followed

Record review (Retrospective chart review)

In all cases the recommendations of the consultants were followed with the exception of 1 patient who died before the consult could be completed. However, in some instances, delay occurred in the implementation of recommendations

[74]

Change in Patient Management

Whether the consultation resulted in a change in patient management

Survey (Yes/No question)

(8) to pay attention to feelings = 7.9 (9) to improve mutual understanding = 8.0 (10) to improve mutual cooperation = 7.9 (11) to active my job motivation = 9.7 (12) to frees my mind = 6.7 (13) to make me a better professional = 7.3 (14) to improve quality of care indirectly = 7.7 (15) to better ground decisions and reflect more on them = 7

[77]

Change in patient management

Did the consultation change patient management

Mixed methods (Survey and medical chart review)

Respondents said 18 consultations changed patient management considerably, 16 changed management slightly, and 10 did not change patient management. The chart review demonstrated that most management changes occurred because consultation persuaded physicians to withhold life support therapies that physicians had planned to use. However, 7 consultations persuaded physicians to give life support therapies they had not planned to use. Consultations changed management in at least half of cases involving questions of adults' competence to refuse therapy or of proxy decision making for incompetent adults. Consultations sometimes persuaded physicians to override parents' medical decisions for their children when those decisions appeared contrary to the child's presumed interests. Few consultations changed the use of laboratory tests or limb restraints for terminal patients

[79]

Nonbeneficial treatment

Number of days in the ICU and life-sustaining treatments in patients who died before discharge

Record review (Medical record data)

In those pts who died before discharge, there was a reduction in ICU days (p = .03), days receiving artificial nutrition/hydration (p = .05), percent on ventilation (p = .08), and days receiving ventilation (p = .05) in pts receiving an ethics consultation compared with control pts

[81]

Nonbeneficial treatment

and

ICU days, hospital days, and life-sustaining treatments in those patients who did not survive to hospital discharge (because these represent a failure to achieve a fundamental goal of medicine the authors called them "nonbeneficial treatment")

Record review (Medical record data (prior to and after entry to the study)

Among those patients who received the intervention (n = 173), compared with control pts (n = 156) but did not survive to discharge from hospital, hospital days (P = .01), days spent in the ICU (P = .03), and days receiving ventilation (P = .03) were reduced. Days receiving artificial nutrition/hydration (P > .50 for all outcomes) showed no significant differences between groups. A pattern towards reduction of hospital and ICU days associated with CEC pts vs UC was observed at all the hospitals

Mortality

Hypothesized that CEC would not increase mortality relative to UC

Record review (Medical record data)

No significant difference in mortality rate between those patients who received CEC and those who did not

[82]

Agreement between the ICU team and patients/surrogates

and

Provision of palliative and chaplaincy services

Agreement between the ICU team and patients/surrogates on goals of care (i.e. to limit life-sustaining interventions, withdraw life-sustaining treatments), and agreement reached on various other conflicts

Provision of palliative and chaplaincy services

Record review (Pre-post CEC chart review of DNR orders entered, and [presumably] medical record data [unspecified which data relates to measuring agreement])

Record review (Pre-post CEC chart review of palliative care and chaplaincy consultations, recommendations for these services by the ethics consultants)

After CEC all 17 patients in the WOLST (withdrawal of life sustaining therapy) group reached agreement to withdraw life sustaining therapies. 5 had DNR orders prior to CEC and 12 additional patients had DNR orders after CEC. Among 25 patients in the LOLST (limitation of life sustaining therapy) group, agreement was achieved to limit life sustaining therapy for 19 patients. Of these patients, 6 already had a DNR order prior to CEC; DNR orders were entered for an additional 13 patients post CEC. In the "other" group (various ethical issues group), agreement between parties was achieved in 9 out of 11 cases; following CEC 3 additional patients had a DNR order entered

After CEC, recommendations were made for an additional 8 (15%) palliative care and 9 (17%) chaplaincy consultation

[85]

Change in patient management

Effect of CEC on patient management

Survey

Statistically significant differences in scores could not be shown from year to year. However, there are trends. In 1993 the lowest satisfaction scores (average 3.7) were given in the category of shared decision making. In 1994 and 1995 these scores increased (3.8 and 4.5) with efforts to address the low scores seen previously. In 1994 the lowest satisfaction scores were for increased knowledge of ethics issues with the consultation (average 3.3) and documentation adequacy (3.8)

[47]

Quality of Care

Improvement in quality of patient care

Record review (Patient medical records)

Robust data. See study

[89]

Patient related outcomes

Related to the plan of care

Survey (yes/no item)

Only 32% of respondents indicated the patient's plan of care changed as a result of the CEC

[90]

Patient treatment changes

Treatment changes as a result of EC

Record review (Medical record data)

Robust data. See study

[91]

Changes in Treatment Decisions

and

Improvement on organizational level

Reported change in treatment plans as a result of the MCD

This domain includes 3 items: (1) I and my co-workers become more aware of recurring ethically difficult situations; (2) contributes to the development of practices/policies in the workplace; (3) I and my co-workers examine more critically the existing practices/policies in the workplace/organization

Qualitative interviews

Survey (Euro MCD instrument)

Reported change in treatment plans as a result of the MCD

[93]

Patient Status at Discharge

Patients’ status at hospital discharge

Record review (Medical Record Review/HCEC Record Review)

79% pts in HCEC group and 72% pts in UC died at hospital discharge (p = .56)

[65]