Top Ten Tips Palliative Care Clinicians Should Know About Their Work's Intersection with Clinical Ethics.

Palliative care (PC) subspecialists and clinical ethics consultants often engage in parallel work, as both function primarily as interprofessional consultancy services called upon in complex clinical scenarios and challenging circumstances. Both practices utilize active listening, goals-based communication, conflict mediation or mitigation, and values explorations as care modalities. In this set of tips created by an interprofessional team of ethicists, intensivists, a surgeon, an attorney, and pediatric and adult PC nurses and physicians, we aim to describe some paradigmatic clinical challenges for which partnership may improve collaborative, comprehensive care.

Patient vs. Community Engagement: Emerging Issues.

BACKGROUND: The value proposition of including patients at each step of the research process is that patient perspectives and preferences can have a positive impact on both the science and the outcomes of comparative effectiveness research. How to accomplish engagement and the extent to which approaches to community engagement inform strategies for effective patient engagement need to be examined to address conducting and accelerating comparative effectiveness research. OBJECTIVES: To examine how various perspectives and diverse training lead investigators and patients to conflicting positions on how best to advance patient engagement. RESEARCH DESIGN: Qualitative methods were used to collect perspectives and models of engagement from a diverse group of patients, researchers and clinicians. The project culminated with a workshop involving these stakeholders. The workshop used a novel approach, combining World Café and Future Search techniques, to compare and contrast aspects of patient engagement and community engagement. SUBJECTS: Participants included patients, researchers, and clinicians. MEASURES: Group and workshop discussions provided the consensus on topics related to patient and community engagement. RESULTS: Participants developed and refined a framework that compares and contrasts features associated with patient and community engagement. CONCLUSIONS: Although patient and community engagement may share a similar approach to engagement based on trust and mutual benefit, there may be distinctive aspects that require a unique lexicon, strategies, tactics, and activities.

Defining chronic pain ethics.

OBJECTIVE: To identify current issues in the diagnosis and treatment of chronic pain. DESIGN: Focus groups were convened to discuss the current issues in chronic pain care. Commentary was analyzed across focus groups using an interpretivist method of qualitative data analysis. Setting. Focus groups were held in five major US cities throughout the United States. PARTICIPANTS: Key stakeholders working and thinking about the issues surrounding chronic pain, including people with pain, providers, insurance and pharmaceutical industry representatives, law enforcement agents, and advocacy groups. OUTCOME MEASURES: Qualitative data was analyzed to determine if consensus regarding the current issues in the diagnosis and treatment of chronic pain exist. RESULTS: Six major themes emerged regarding chronic pain, all of which contained an ethical component: 1) reducing disparities in access to pain care among the young, elderly, and lower socioeconomic groups, 2) defining quality of care in pain management, 3) the need to train qualified providers and training programs in pain medicine, 4) the need for evidence-based public policy regarding opioid use and diversion, 5) the need to raise awareness about chronic pain as a disease to prevent stigmatization and discrimination, and 6) promotion of multimodal therapies for pain care as a way of diverting attention from opioid abuse problem. CONCLUSIONS: There is nationwide consensus among those holding a stake in the diagnosis and treatment of chronic pain regarding the ethical issues that must be addressed. Raising awareness about chronic pain, improving access and outcomes to quality pain care, and resolving public policy debates about the use of opioids in chronic pain populations are the first steps to ensuring a morally justifiable approach to chronic pain management in the 21st century.

The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines Domain 8: ethical and legal aspects of care.

In 2001, leaders with palliative care convened to discuss the standardization of palliative care and formed the National Consensus Project for Quality Palliative Care. In 2004, the National Consensus Project for Quality Palliative Care produced the first edition of Clinical Guidelines for Quality Palliative Care. The Guidelines were developed by leaders in the field who examined other national and international standards with the intent to promote consistent, accessible, comprehensive, optimal palliative care through the health care spectrum. Within the guidelines there are eight domains to the provision of palliative care. This article focuses on the last, but very significant Domain 8--Ethical and Legal Aspects of Care.

Physicians charged with opioid analgesic-prescribing offenses.

OBJECTIVE: To provide a "big picture" overview of the characteristics and outcomes of recent criminal and administrative cases in which physicians have been criminally prosecuted or charged by medical boards with offenses related to inappropriate prescribing of opioid analgesics. DESIGN: We identified as many criminal and administrative cases of these types as possible that occurred between 1998 and 2006. Cases were identified using a wide variety of sources, including organizational and government agency databases, published news accounts, and Web sites. Factual characteristics of these cases and their outcomes, and of the physicians involved, were then further researched using additional sources and methods. SETTING: Study findings are intended to apply to practicing U.S. patient care physicians as a whole. PATIENTS OR OTHER PARTICIPANTS: There were no patients or participants in this study. Outcome Measures. We analyzed the numbers and types of cases and physicians involved, criminal and administrative charges brought, case outcomes and sanctions, specialties, and other characteristics of the physicians involved. RESULTS: The study identified 725 doctors, representing an estimated 0.1% of practicing patient care physicians, who were charged between 1998 and 2006 with criminal and/or administrative offenses related to prescribing opioid analgesics. A plurality of these (39.3%) were General Practice/Family Medicine physicians, compared with 3.5% who were self-identified or board-certified pain specialists. Physicians in this sample were more likely to be male, older, and not board certified (P < 0.001). Drug Enforcement Administration (DEA) criminal and complaint investigations averaged 658 per year (2003-2006) and "for cause" surrenders of DEA registrations averaged 369.7 (2000-2006). CONCLUSIONS: Criminal or administrative charges and sanctions for prescribing opioid analgesics are rare. In addition, there appears to be little objective basis for concern that pain specialists have been "singled out" for prosecution or administrative sanctioning for such offenses.

"Show me" bioethics and politics.

Missouri, the "Show Me State," has become the epicenter of several important national public policy debates, including abortion rights, the right to choose and refuse medical treatment, and, most recently, early stem cell research. In this environment, the Center for Practical Bioethics (formerly, Midwest Bioethics Center) emerged and grew. The Center's role in these "cultural wars" is not to advocate for a particular position but to provide well researched and objective information, perspective, and advocacy for the ethical justification of policy positions; and to serve as a neutral convener and provider of a public forum for discussion. In this article, the Center's work on early stem cell research is a case study through which to argue that not only the Center, but also the field of bioethics has a critical role in the politics of public health policy.

On the road to reform: advocacy and activism in end-of-life care.

This paper argues that the general public is, and should be, an important source of activity in end-of-life care reform. Two roles for the public are described: personal advocacy and public activism. The first relates to the role of private citizens in advocating on their own or a loved one's behalf at the end of life to secure quality palliative care. The second relates to the role of leaders in mobilizing reform efforts on behalf of the larger society. These roles overlap and often function to bolster one another. Numerous examples of how advocacy often transforms into activism and how activism relies on advocacy are given, drawn from the experience of directing Community-State Partnerships to Improve End-of-Life Care, a national program housed at Midwest Bioethics Center in Kansas City, Missouri.