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Lying is Not an Option for Clinical Ethics Consultants [Comment]

Dubler, Nancy Neveloff
PMID: 33945421
ISSN: 1536-0075
CID: 4866242

The unique moral permissibility of uncontrolled lung donation after circulatory death

Parent, Brendan; Caplan, Arthur; Angel, Luis; Kon, Zachary; Dubler, Nancy; Goldfrank, Lewis; Lindner, Jacob; Wall, Stephen P
Implementing uncontrolled donation after circulatory determination of death (uDCDD) in the United States could markedly improve supply of donor lungs for patients in need of transplants. Evidence from U.S. pilot programs suggests families support uDCDD, but only if they are asked permission for using invasive organ preservation procedures prior to initiation. However, non-invasive strategies that confine oxygenation to lungs may be applicable to the overwhelming majority of potential uDCDD donors that have airway devices in place as part of standard resuscitation. We propose an ethical framework for lung uDCDD by: (1) initiating post mortem preservation without requiring prior permission to protect the opportunity for donation until an authorized party can be found; (2) using non-invasive strategies that confine oxygenation to lungs; and (3) maintaining strict separation between the healthcare team and the organ preservation team. Attempting uDCDD in this way has great potential to obtain more transplantable lungs while respecting donor autonomy and family wishes, securing public support, and enabling authorized persons to affirm or cease preservation decisions without requiring evidence of prior organ donation intent. It ensures prioritization of life-saving, the opportunity to allow willing donors to donate, and respect for bodily integrity while adhering to current ethical norms.
PMID: 31550420
ISSN: 1600-6143
CID: 4105452

Ethics of gender-affirming care

Seigel, W M; Folkers, K M; Dubler, N N
The ethical practice of medicine requires identifying the interests and rights of patients and creating a corresponding set of obligations and duties to fulfill those interests and rights. Transgender and gender nonconforming (TGNC) patients have special needs surrounding their gender identity that present unique ethical challenges for medical professionals, family members, and the patient themself. While there is a strong moral imperative to provide gender-affirming care to TGNC patients to mitigate the risk of depression, suicide, and other poor mental health outcomes, these care options must be considered alongside a developing person's capacity for understanding and consent, especially in a pediatric setting. As bioethical processes and principles are best understood as part of an analysis of the life stories of patients, we explore ethical issues surrounding gender-affirming care for TGNC patients throughout the life cycle in a series of case descriptions.
EMBASE:626786744
ISSN: 2523-3785
CID: 3757262

Meaningful Use of Electronic Health Records for Quality Assessment and Review of Clinical Ethics Consultation

Sanelli-Russo, Susan; Folkers, Kelly McBride; Sakolsky, William; Fins, Joseph J; Dubler, Nancy Neveloff
Evolving practice requires peer review of clinical ethics (CE) consultation for quality assessment and improvement. Many institutions have identified the chart note as the basis for this process, but to our knowledge, electronic health record (EHR) systems are not necessarily designed to easily include CE consultation notes. This article provides a framework for the inclusion of CE consultation notes into the formal EHR, describing a developed system in the Epic EHR that allows for the elaborated electronic notation of the CE chart note. The implementation of the "meaningful use" criteria for EHR, mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, requires that health professionals meet certain standards for quality, efficiency, and safety, all of which overlap with the goals of standardization, peer review, and quality improvement within CE consultation.
PMID: 29565797
ISSN: 1046-7890
CID: 3001012

Victimization and Vulnerability: A Study of Incarceration, Interpersonal Trauma, and Patient-Physician Trust

Junewicz, Alexandra; Kleinert, Kelly J; Dubler, Nancy Neveloff; Caplan, Arthur
Despite the critical importance of patient-physician trust, it may be compromised among vulnerable patients, such as (1) incarcerated patients and (2) those patients who have been victims of trauma. The purpose of this study was to examine patient-physician trust among forensic and civilian psychiatric inpatient populations and to explore whether it varied based on a patient's history of incarceration and/or victimization. A trust survey (WFPTS) and a trauma instrument (LEC-5) were administered to 93 patients hospitalized on forensic and civilian psychiatric hospital units in a large, urban public hospital. Results showed no difference in patient-physician trust between incarcerated and civilian patients. Similarly, there was no effect of a history of physical assault or sexual assault on ratings of patient-physician trust. However, the hospitalized civilian and forensic patients who reported being the victim of weapons assault had significantly lower patient-physician trust scores than their counterparts.
PMID: 27553865
ISSN: 1573-6709
CID: 2221482

Lesson From the New York City Out-of-Hospital Uncontrolled Donation After Circulatory Determination of Death Program

Wall, Stephen P; Kaufman, Bradley J; Williams, Nicholas; Norman, Elizabeth M; Gilbert, Alexander J; Munjal, Kevin G; Maikhor, Shana; Goldstein, Michael J; Rivera, Julia E; Lerner, Harvey; Meyers, Chad; Machado, Marion; Montella, Susan; Pressman, Marcy; Teperman, Lewis W; Dubler, Nancy N; Goldfrank, Lewis R
STUDY OBJECTIVE: In 2006, the Institute of Medicine emphasized substantial potential to expand organ donation opportunities through uncontrolled donation after circulatory determination of death (uDCDD). We pilot an out-of-hospital uDCDD kidney program for New York City in partnership with communities that it was intended to benefit. We evaluate protocol process and outcomes while identifying barriers to success and means for improvement. METHODS: We conducted a prospective, participatory action research study in Manhattan from December 2010 to May 2011. Daily from 4 to 12 pm, our organ preservation unit monitored emergency medical services (EMS) frequencies for cardiac arrests occurring in private locations. After EMS providers independently ordered termination of resuscitation, organ preservation unit staff determined clinical eligibility and donor status. Authorized parties, persons authorized to make organ donation decisions, were approached about in vivo preservation. The study population included organ preservation unit staff, authorized parties, passersby, and other New York City agency personnel. Organ preservation unit staff independently documented shift activities with daily operations notes and teleconference summaries that we analyzed with mixed qualitative and quantitative methods. RESULTS: The organ preservation unit entered 9 private locations; all the deceased lacked previous registration, although 4 met clinical screening eligibility. No kidneys were recovered. We collected 837 notes from 35 organ preservation unit staff. Despite frequently recounting protocol breaches, most responses from passersby including New York City agencies were favorable. No authorized parties were offended by preservation requests, yielding a Bayesian posterior median 98% (95% credible interval 76% to 100%). CONCLUSION: In summary, the New York City out-of-hospital uDCDD program was not feasible. There were frequent protocol breaches and confusion in determining clinical eligibility. In the small sample of authorized persons we encountered during the immediate grieving period, negative reactions were infrequent.
PMID: 26626335
ISSN: 1097-6760
CID: 1863432

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants

Fins, Joseph J; Kodish, Eric; Cohn, Felicia; Danis, Marion; Derse, Arthur R; Dubler, Nancy Neveloff; Goulden, Barbara; Kuczewski, Mark; Mercer, Mary Beth; Pearlman, Robert A; Smith, Martin L; Tarzian, Anita; Youngner, Stuart J
Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.
PMID: 26913652
ISSN: 1536-0075
CID: 1965472

Right-to-Try Laws: Hope, Hype, and Unintended Consequences

Bateman-House, Alison; Kimberly, Laura; Redman, Barbara; Dubler, Nancy; Caplan, Arthur
PMID: 26413841
ISSN: 1539-3704
CID: 1882622

Uncontrolled Organ Donation After Circulatory Determination of Death: US Policy Failures and Call to Action

Wall, Stephen P; Munjal, Kevin G; Dubler, Nancy N; Goldfrank, Lewis R
In the United States, more than 115,000 patients are wait-listed for organ transplants despite that there are 12,000 patients each year who die or become too ill for transplantation. One reason for the organ shortage is that candidates for donation must die in the hospital, not the emergency department (ED), either from neurologic or circulatory-respiratory death under controlled circumstances. Evidence from Spain and France suggests that a substantial number of deaths from cardiac arrest may qualify for organ donation using uncontrolled donation after circulatory determination of death (uDCDD) protocols that rapidly initiate organ preservation in out-of-hospital and ED settings. Despite its potential, uDCDD has been criticized by panels of experts that included neurologists, intensivists, attorneys, and ethicists who suggest that organ preservation strategies that reestablish oxygenated circulation to the brain retroactively negate previous death determination based on circulatory-respiratory criteria and hence violate the dead donor rule. In this article, we assert that in uDCDD, all efforts at saving lives are exhausted before organ donation is considered, and death is determined according to "irreversible cessation of circulatory and respiratory functions" evidenced by "persistent cessation of functions during an appropriate period of observation and/or trial of therapy." Therefore, postmortem in vivo organ preservation with chest compressions, mechanical ventilation, and extracorporeal membrane oxygenation is legally and ethically appropriate. As frontline providers for patients presenting with unexpected cardiac arrest, emergency medicine practitioners need be included in the uDCDD debate to advocate for patients and honor the wishes of the deceased.
PMID: 24268427
ISSN: 0196-0644
CID: 831192

Quality attestation for clinical ethics consultants: a two-step model from the American Society for Bioethics and Humanities

Kodish, Eric; Fins, Joseph J; Braddock, Clarence 3rd; Cohn, Felicia; Dubler, Nancy Neveloff; Danis, Marion; Derse, Arthur R; Pearlman, Robert A; Smith, Martin; Tarzian, Anita; Youngner, Stuart; Kuczewski, Mark G
PMCID:4849543
PMID: 24092588
ISSN: 0093-0334
CID: 1420532