Going Backwards to Fill in the Missing Processes for Training and Evaluation of Clinical Bioethicists: What Has Been Needed for Decades to Move Real Professionalism Forward.

As the field of clinical bioethics has moved from its pioneers, who turned their attention to ethics problems in clinical medicine and clinical and animal research, to today's ubiquity of university degrees and fellowships in bioethics, there has been a steady drumbeat to professionalize the field. The problem has been that the necessary next steps-to specify the skills, knowledge, and personal and professional attributes of a clinical bioethicist, and to have a method to train and evaluate mastery of these standards-are lacking. Ordinarily, the path to professionalism in medicine starts with the intellectual pioneers. Then come those who develop early experience in clinical settings. Then comes the specification of the skills, knowledge, and personal and professional attributes needed to perform the activities of the new specialty or subspecialty. And only then, after a method to train and evaluate levels of mastery from novice to advanced practitioner has been developed, comes credible credentialing and certification/licensing. Unfortunately, the field of clinical bioethics has skipped these steps. Rather, a credential, that is, the Healthcare Ethics Consultant (HEC) certification, was created by a small group within the bioethics professional association, the American Society of Bioethics and Humanities (ASBH), without community agreement or necessary input. Further, the testing of processes to train HECs and to evaluate their levels of mastery of competencies was prematurely forwarded as sufficient evidence of competence in clinical ethics. That is, the credential, offered by the ASBH for a fee upon passing an exam, based on how many hours one has been involved in clinical consultation, about which there is no field agreement on how such consultations ought to be conducted and for which controversial standards have been set by a few, is being touted as evidence of competence in clinical bioethics. In their article, "Competencies and Milestones for Bioethics Trainees," Sawyer and colleagues identify the central weakness of these claims to professionalization and provide the field the first substantive assessment tool and method to train and evaluate competencies. The tool these authors present is the real next step forward for true professionalization of the field of clinical bioethics.

How Hospital Leaders and Risk Managers Can Nurture Ethics-Driven Lawyering.

How hospital lawyers assess legal risk in clinically and ethically complex cases can shape risk management operations, influence clinicians' morale, and affect the care patients receive. This article suggests that many disagreements, particularly those involving key ethical and legal questions arising from a patient's care, should launch a process that might include family meetings, early palliative care integration, and ethics consultation or committee review of clinical teams' and surrogates' reasons and perspectives. This article also explains why exploration of these perspectives can motivate fuller understanding of the sources of clinical and ethical disagreements and inform the approach to legal advice that hospital executives and risk managers should foster.

Building an Organizational Ethics Program on a Clinical Ethics Foundation.

Organizational ethics programs often are created to address tensions in organizational values that have been identified through repeated clinical ethics consultation requests. Clinical ethicists possess some core competencies that are suitable for the leadership of high-quality organizational ethics programs, but they may need to develop new skills to build these programs, such as familiarity with healthcare delivery science, healthcare financing, and quality improvement methodology. To this end, we suggest that clinical ethicists build organizational ethics programs incrementally and via quality improvement projects undertaken in collaboration with senior clinical leaders. Organizational ethics programs often differ from clinical ethics programs in their membership and processes, and likely will require ethicists to forge new partnerships with a wide array of organizational leaders. With attention to the ways that organizational ethics programs differ from clinical ethics programs, and investment in quality improvement methodology and formal institutional needs assessments, clinical ethics leaders can position an organizational ethics program to advocate effectively for visible and compelling alignment of leadership decision making with the values of the organization.

Comprehensive Quality Assessment in Clinical Ethics.

Scholars and professional organizations in bioethics describe various approaches to "quality assessment" in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes "quality" in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, iin this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction.

Moving Towards a New Hospital Model of Clinical Ethics.

The role of clinical ethics consultant in hospitals was created about 30 years ago. Since that time, two very different models for clinical ethics consultation, and who should perform it, have arisen: clinician ethicists and nonclinician ethicists, or bioethicists. Neither model provides everything that hospitals might need, and both include perspectives that are not ideal for hospital practice. It's time for a new model, one designed specifically to meet the needs of hospital patients, one we might call the hospital model of clinical ethics (HMCE).

Implications of the Revised Common Rule for Human Participant Research.

This paper looks at the implications of changes to the regulatory governance of human participant research that can be expected with implementation of the Revised Common Rule (RCR). The RCR refers to revisions of the existing federal regulations that govern the performance of research involving human subjects (ie, clinical research) in the United States and, under certain circumstances, when such research is also performed outside the United States. The term "common" is included because it refers to the fact that these regulations, often referred to as Code of Federal Regulations 46, is the common denominator regulations agreed to across a wide swath of federal agencies.

Medical planning and response for a nuclear detonation: a practical guide.

This article summarizes major points from a newly released guide published online by the Office of the Assistant Secretary for Preparedness and Response (ASPR). The article reviews basic principles about radiation and its measurement, short-term and long-term effects of radiation, and medical countermeasures as well as essential information about how to prepare for and respond to a nuclear detonation. A link is provided to the manual itself, which in turn is heavily referenced for readers who wish to have more detail.

Training in clinical ethics: launching the clinical ethics immersion course at the Center for Ethics at the Washington Hospital Center.

In May 2011, the clinical ethics group of the Center for Ethics at Washington Hospital Center launched a 40-hour, three and one-half day Clinical Ethics Immersion Course. Created to address gaps in training in the practice of clinical ethics, the course is for those who now practice clinical ethics and for those who teach bioethics but who do not, or who rarely, have the opportunity to be in a clinical setting. "Immersion" refers to a high-intensity clinical ethics experience in a busy, urban, acute care hospital. During the Immersion Course, participants join clinical ethicists on working rounds in intensive care units and trauma service. Participants engage in a videotaped role-play conversation with an actor. Each simulated session reflects a practical, realistic clinical ethics case consultation scenario. Participants also review patients' charts, and have small group discussions on selected clinical ethics topics. As ethics consultation requests come into the center, Immersion Course participants accompany clinical ethicists on consultations. Specific to this pilot, because participants' evaluations and course faculty impressions were positive, the Center for Ethics will conduct the course twice each year. We look forward to improving the pilot and establishing the Immersion Course as one step towards addressing the gap in training opportunities in clinical ethics.

Unaltered ethical standards for individual physicians in the face of drastically reduced resources resulting from an improvised nuclear device event.

When disaster disrupts healthcare and other systems, the ethical allocation of resources should follow principles of justice, defined as fairness, established for normal clinical practice. Standards of clinical practice may be altered during disaster, but ethical standards must remain centered on prioritizing the treatment of patients according to need and the effectiveness of treatment. Should resources become extremely limited, it is fair to restrict their use to patients who have the highest needs, provided that the intervention is effective. When resources become more available, patients with lower priority can be increasingly accommodated.

Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making.

This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as "the most lives saved," needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.

Building esprit de corps: learning to better navigate between "my" patient and "our" patient.

Excellence in the care of hospital patients, particularly those in an intensive care unit, reflects esprit de corps among the care team. Esprit de corps depends on a delicate balance; each clinician must preserve a sense of personal responsibility for "my" patient and yet participate in the collaborative work essential to the care of "our" patient. A harmful imbalance occurs when a physician demands total control of the decision-making process, especially concerning end-of-life treatment options. Although emotional factors may push a physician to claim decision-making exclusivity, compounded by a legal framework that overemphasizes individual responsibility, esprit de corps can be preserved through timely communication among clinicians and a recognition that optimal care for "my" patient requires effective team practice.

Hiring a hospital staff clinical ethicist: creating a formalized behavioral interview model.

This paper presents the behavioral interview model that we developed to formalize our hiring practices when we, most recently, needed to hire a new clinical ethicist to join our staff at the Center for Ethics at Washington Hospital Center.

Curbside consultation re-imagined: Borrowing from the conflict management toolkit.

Curbside ethics consultations occur when an ethics consultant provides guidance to a party who seeks assistance over ethical concerns in a case, without the consultant involving other stakeholders, conducting his or her own comprehensive review of the case, or writing a chart note. Some have argued that curbside consultation is problematic because the consultant, in focusing on a single narrative offered by the party seeking advice, necessarily fails to account for the full range of moral perspectives. Their concern is that any guidance offered by the ethics consultant will privilege and empower one party's viewpoint over-and to the exclusion of-other stakeholders. This could lead to serious harms, such as the ethicist being reduced to a means to an end for a clinician seeking to achieve his or her own preferred outcome, the ethicist denying the broader array of stakeholders input in the process, or the ethicist providing wrongheaded or biased advice, posing dangers to the ethical quality of decision-making. Although these concerns are important and must be addressed, we suggest that they are manageable. This paper proposes using conflict coaching, a practice developed within the discipline of conflict management, to mitigate the risks posed by curbside consultation, and thereby create new "spaces" for moral discourse in the care of patients. Thinking of curbside consultations as an opportunity for "clinical ethics conflict coaching" can more fully integrate ethics committee members into the daily ethics of patient care and reduce the frequency of ethically harmful outcomes.