Faculty Bibliography

BACKGROUND: Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients' vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS: We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS: We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. CONCLUSIONS: Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide health-care decisions during disasters.

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report.

BACKGROUND: The discipline of health care ethics consultation (EC) has been limited by the lack of both high quality data and quality standards. To promote high quality ethics consultation practices, staff at the National Center for Ethics in Health Care within the Veterans Health Administration (VHA) developed 2 specific EC tools, ECWeb and the EC Feedback Tool. ECWeb is a web-based database tool that promotes process standards consistent with "CASES," VA's systematic approach to ethics consultation. The EC Feedback Tool, which links to ECWeb records, enables consultation participants to rate their experience on various aspects of EC. This paper describes the ethics consultation requests, processes, and evaluations from all facilities in our system. METHODS: We analyzed data from completed ethics consultations from ECWeb records initiated between October 2008 and September 2011. For each consultation record, users documented in ECWeb the data related to utilization of the EC service (e.g., type of consultation request, requester role (i.e., physician, nurse, patient). Additionally, ECWeb users documented, as applicable, various processes performed during the ethics consultation (e.g., capacity assessment (y/n), a face-to-face patient visit (y/n), and if the consult was identified as being symptomatic of underlying issues that are best addressed at the systems level). The EC Feedback Tool asked respondents to rate the ethics consultant(s) on 12 specific ethics knowledge and skill areas as well as their overall experience with ethics consultation, both on a 5 point Likert scale. RESULTS: We analyzed ECWeb data for 4628 completed consults from 140 facilities across theVHAhealth system .Median consultation volume per facility was 7 in 2009 (mean=9.6, range=0-60), 8 in 2010 (mean=12.4, range=0-106), and 8 in 2011 (mean =12.1, range=0-119). The majority of consultations were classified by the consultants as related to shared decision making (73%). Most consultations (63%) related to patients in the !

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

Clinical ethics consultation has become an important resource, but unlike other health care disciplines, it has no accreditation or accepted curriculum for training programs, no standards for practice, and no way to measure effectiveness. The Clinical Ethics Credentialing Project was launched to pilot-test approaches to train, credential, privilege, and evaluate consultants.

BACKGROUND: Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources. TASK FORCE SUGGESTIONS: In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.