Optimising the documentation practices of an Ethics Consultation Service.

A formal Ethics Consultation Service (ECS) can provide significant help to patients, families and hospital staff. As with any other form of clinical consultation, documentation of the process and the advice rendered is very important. Upon review of the published consult documentation practices of other ECSs, we judged that none of them were sufficiently detailed or structured to meet the needs and purposes of a clinical ethics consultation. Thus, we decided to share our method in order to advance the practice of ethics consultation. Here, we describe a method of ECS documentation practice, including use of a formal consult report template, as well as a log for maintaining a chronological record of the consultations performed. These two documents facilitate order and organisation of the ECS. They also enable the ECS to keep an account of professional time and experience, enable quick consult trend assessments (by consult theme or ward, for example) and establish a potential registry of consults for future research study. This method of documentation, we believe, not only contributes significantly to the primary purpose of the consultation-namely, the evincing and sharing of ethical opinion about a case-but also enables consultants to improve their practice and to pursue research on clinical ethics consultation.

Social responsibilities of bioethics.

Urban bioethics can draw on elements of city life and view them under the moral perspective of social responsibility of creating the personal, cultural, social, and economic environment in which persons can be responsible personally as they interpret actions on themselves and creatively respond to them in an ongoing community of agents.

How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting.

OBJECTIVE: To characterize the informed consent process in routine, primary care office practice. DESIGN: Cross-sectional, descriptive evaluation of audiotaped encounters. SETTING: Offices of primary care physicians in Portland, Oregon. PARTICIPANTS: Internists (54%) and family physicians (46%), and their patients. MEASUREMENTS AND MAIN RESULTS: Audiotapes of primary care office visits from a previous study of doctor-patient communication were coded for the number and type of clinical decisions made. The discussion between doctor and patient was scored according to six criteria for informed decision making: description of the nature of the decision, discussion of alternatives, discussion of risks and benefits, discussion of related uncertainties, assessment of the patient's understanding and elicitation of the patient's preference. Discussions leading to decisions included fewer than two of the six described elements of informed decision making (mean 1.23, median 1.0), most frequent of these was description of the nature of the decision (83% of discussion). Discussion of risks and benefits was less frequent (9%), and assessment of understanding was rare (2%). Discussions of management decisions were generally more substantive than discussions of diagnostic decisions (p = .05). CONCLUSIONS: Discussions leading to clinical decisions in these primary care settings did not fulfill the criteria considered integral to informed decision making. Physicians frequently described the nature of the decision, less frequently discussed risks and benefits, and rarely assessed the patient's understanding of the decision.

Medical futility: response to critiques.

Six years ago, we proposed a patient benefit-centered definition of medical futility that included both quantitative and qualitative components. We distinguished between an effect of a treatment that is limited to some part of a patient's body and a benefit that improves the patient as a whole. The quantitative portion of our definition stipulated that physicians should regard a treatment as futile if empirical data show that the treatment has less than a 1 in 100 chance of benefiting the patient. The qualitative portion of our definition stipulated that if a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, physicians should consider the treatment futile. In this paper, we clarify and modify our original proposal and respond to the following major criticisms: 1) Medical futility is simply an attempt to increase the power of the physician over the patient and to repeal recent hard-gained advances in patient autonomy; 2) no professional or societal consensus has been achieved about the definition of futility; 3) futility is a value-laden determination, the usurpation of which by medicine is inappropriate unless only a so-called value-free or strict physiologic definition of futility is used; 4) the concept of futility is not practically useful because empirical treatment data cannot be applied with certainty to any given patient; 5) futility undermines our pluralistic society and threatens, among other things, the free exercise of religion; and 6) because cost considerations will ultimately dictate all such decisions, futility is an unnecessary concept.

The advent of the "unpatients'.

Predictive diagnosis by molecular methods will change the scientific basis of prognostics. At the same time, it will change the ethical dimensions of the relation among patients, their doctors and other providers of care.

Attitudes toward assisted suicide and euthanasia among physicians in Washington State.

BACKGROUND: Despite considerable public interest in legalizing physician-assisted suicide and euthanasia, little is known about physicians' attitudes toward these practices. METHODS: We sent questionnaires to 1355 randomly selected physicians in the state of Washington, including all hematologists and oncologists and a disproportionately high number of internists, family practitioners, psychiatrists, and general surgeons. To avoid ambiguity in our survey, instead of "physician-assisted suicide," we used the phrase "prescription of medication [e.g., narcotics or barbiturates] or the counseling of an ill patient so he or she may use an overdose to end his or her own life." Instead of "euthanasia," we used the phrase "deliberate administration of an overdose of medication to an ill patient at his or her request with the primary intent to end his or her life." RESULTS: Of the 1355 eligible physicians who received our questionnaire, 938 (69 percent) responded. Forty-eight percent of the respondents agreed with the statement that euthanasia is never ethically justified, and 42 percent disagreed. Fifty-four percent thought euthanasia should be legal in some situations, but only 33 percent stated that they would be willing to perform euthanasia. Thirty-nine percent of respondents agreed with the statement that physician-assisted suicide is never ethically justified, and 50 percent disagreed. Fifty-three percent thought assisted suicide should be legal in some situations, but only 40 percent stated that they would be willing to assist a patient in committing suicide. Of the groups surveyed, hematologists and oncologists were most likely to oppose euthanasia and assisted suicide, and psychiatrists were most likely to support these practices. CONCLUSIONS: The attitudes toward physician-assisted suicide and euthanasia of physicians in Washington State are polarized. A slight majority favors legalizing physician-assisted suicide and euthanasia in at least some situations, but most would be unwilling to participate in these practices themselves.