Reimagining Thriving Ethics Programs without Ethics Committees.

With the increasing professionalization of clinical ethics, some hospitals and health systems utilize both ethics committees and professional clinical ethicists to address their ethics needs. Drawing upon historical critiques of ethics committees and their own experiences, the authors argue that, in ethics programs with one or more professional clinical ethicists, ethics committees should be dissolved when they fail to meet minimum standards of effectiveness. The authors outline several criteria for assessing effectiveness, describe the benefits of a model that places primary responsibility for ethics work with professional clinical ethicists-the PCE-primary model, and offer suggestions for alternative ethics program structures that empower healthcare professionals to contribute to ethics work in ways more tailored to their strengths and skills while minimizing the shortcomings of ethics committees.

Propelling Clinical Ethics Forward: Insights from the 2022 Unconference.

Propelling Clinical Ethics Forward: A Working Unconference was held from 28-29 April 2022 in Atlanta, Georgia. The event, the third installment in an ongoing series of Clinical Ethics Unconferences, brought together 77 individuals from 40 institutions to exchange innovative practices and collaborate to address issues facing the field of clinical ethics. In this article the authors highlight the five major themes that emerged from the 2022 Unconference, including: (1) tackling new and old problems in clinical ethics practice; (2) evolving models of clinical ethics structure and delivery; (3) defining the scope of clinical ethics work; (4) addressing racism, ableism, and underrepresentation in clinical ethics work; and (5) collecting and utilizing data effectively. The authors also reflect on what was learned from the first three Unconferences and offer suggestions for future Unconferences.

Barriers to Patient Involvement in Decision-Making in Advanced Cancer Care: Culture as an Amplifier.

In advanced cancer care, patient preferences regarding treatment are sometimes insufficiently integrated in the decision-making process. This can be the case with patients from non-Western cultural backgrounds undergoing treatment in the US. This study aimed to understand oncology and palliative care physicians' and nurses' perceptions of factors that impact involvement in treatment decisions by patients from diverse cultural backgrounds. Seventeen participants (6 MDs, 9 RNs, and 2 NPs) were interviewed using a semi-structured guide. Interviews were analyzed using conventional content analysis. Findings revealed six barriers to patient involvement in decision-making: language, socio-economic status, educational status, gender, family attitudes, and healthcare providers' behavior and attitudes. Participants did not view culture itself as a barrier to patient involvement, but rather, noted culture-amplified barriers that occurred with patients across all cultural backgrounds. To overcome these barriers, a wider integration of cultural competence in patient care is needed.

Responding to Cultural Limitations on Patient Autonomy: A Clinical Ethics Case Study.

This paper is a clinical ethics case study which sheds light on several important dilemmas which arise in providing care to patients from cultures with non-individualistic conceptions of autonomy. Medical professionals face a difficult challenge in determining how to respond when families of patients ask that patients not be informed of bad medical news. These requests are often made for cultural reasons, by families seeking to protect patients. In these cases, the right that patients have to their own medical information in order to make autonomous decisions is in tension with the possibility that patients could hold values that require limiting their autonomy with regard to medical information disclosure, often based on the idea that family should take on difficult decision-making as an act of care. We describe one such case, of an 83-year old Russian woman whose husband requested she not be informed of a new cancer diagnosis. The appropriate response to this request was to ask the patient about her values separately, without disclosing any medical information until her values were clear. This patient indicated she wanted the care team to uphold her husband's request. This response makes the importance of determining a patient's values before moving forward with disclosure clear: she would not have wanted to be informed of her cancer. We describe our conversation strategy, which allowed value exploration without disclosure and highlighted that the obligation to respect a patient's autonomy sometimes includes an obligation to allow a patient to choose to limit their own autonomy. This case also highlights that this kind of conversation prioritizes the patient's values rather than the family's or care team's, centering patients in the way that is ethically appropriate.

Organ transplant and Covid-19 vaccination: Considering the ethics of denying transplant to unvaccinated patients.

Recently, a number of organ transplant centers in the United States have proposed to only allow patients who have received the Covid-19 vaccination to be active on their transplant waiting list. This raises numerous ethical issues. This analysis utilizes current empirical data and the guidelines on the ethics of organ allocation published by the Organ Procurement and Transplant Network to guide our ethical reasoning. We conclude that it would be permissible to mandate Covid-19 vaccination as a condition of being listed for an organ transplant at a transplant center and offer recommendations for how to do so.

A Model for Standardized and Proactive Advance Care Planning.

As the importance of Advance Care Planning (ACP) has become well-known and accepted, health systems have begun placing more emphasis on ACP. However, many health systems still have not standardized this process, and most health systems still approach ACP in a reactive-rather than proactive-manner. This paper discusses one system's innovative approach to ACP that standardizes ACP in the inpatient and outpatient settings, while focusing on a proactive rather than reactive orientation to ACP.

Addressing Burnout in Pharmacy Residency Programs.

Addressing health care provider burnout has become a top priority for many health care systems. Unfortunately, a paucity of literature is available on preventing and managing burnout in pharmacy residents despite an increase in articles on the prevalence of pharmacy burnout. This limits the ability of pharmacy managers to understand and address burnout in this high-risk population. Until further investigation into the most beneficial, evidence-based strategies for managing burnout in this population is conducted, this commentary offers strategies to address and mitigate burnout in pharmacy residency training programs based on the available interdisciplinary literature.The authors have first-hand experience with burnout and aim to begin a paradigm shift to emphasize well-being and reshape the culture of postgraduate training. Dr. Potter has dedicated time to developing programming and founded an interprofessional well-being organization called Mindfulness in Newly Developing Students of Healthcare (MINDS) for health care students and providing recommendations for pharmacy residency programs. As a program director, Dr. Cadiz focuses on the development of realistic and effective strategies to eliminate burnout and foster well-being in her pharmacy residency training program.

Palliative Sedation, Compassionate Extubation, and the Principle of Double Effect: An Ethical Analysis.

Palliative sedation is a well-recognized and commonly used medical practice at the end of life for patients who are experiencing refractory symptoms that cannot be controlled by other means of medical management. Given concerns about potentially hastening death by suppressing patients' respiratory drive, traditionally this medical practice has been considered ethically justifiable via application of the ethical doctrine known as the Principle of Double Effect. And even though most recent evidence suggests that palliative sedation is a safe and effective practice that does not hasten death when the sedative medications are properly titrated, the Principle of Double Effect is still commonly utilized to justify the practice of palliative sedation and any risk-however small-it may entail of hastening the death of patients. One less common clinical scenario where the Principle of Double Effect may still be appropriate ethical justification for palliative sedation is when the practice of palliative sedation is pursued concurrently with the active withdrawal of life-sustaining treatment-particularly the practice of compassionate extubation. This case study then describes an unconventional case of palliative sedation with concurrent compassionate extubation where Principle of Double Effect reasoning was effectively employed to ethically justify continuing to palliatively sedate a patient during compassionate extubation.

Demonstrating Value Through Tracking Ethics Program Activities Beyond Ethics Consultations.

Demonstrating value is an ongoing process and requirement for institutional survival for ethics programs. Although our ethics program has significantly increased our ethics consultation volume and maintains a robust database that tracks ethics consultation data, these data regarding ethics consultations alone do not accurately represent the program's overall activities and value to the institution. The roles and responsibilities of clinical ethicists extend beyond clinical ethics consultation, and there are many other ways that clinical ethicists contribute and add value to their institutions. This article describes our ethics program's early efforts to systematically track ethics program activities outside of ethics consultations as a way to demonstrate additional value to the institution that goes beyond ethics consultation. By systematically tracking activities such as internal ethics education sessions, conference presentations, publications, grants, committee/policy work, and other activities, our ethics program has been able to gather substantial quantitative data that highlight our program's numerous activities and outreach, both within and outside the institution, that provide additional value to the institution beyond our ethical consultation activities.

Adaptive Fisher method detects dense and sparse signals in association analysis of SNV sets.

BACKGROUND: With the development of next generation sequencing (NGS) technology and genotype imputation methods, statistical methods have been proposed to test a set of genomic variants together to detect if any of them is associated with the phenotype or disease. In practice, within the set, there is an unknown proportion of variants truly causal or associated with the disease. There is a demand for statistical methods with high power in both dense and sparse scenarios, where the proportion of causal or associated variants is large or small respectively. RESULTS: We propose a new association test - weighted Adaptive Fisher (wAF) that can adapt to both dense and sparse scenarios by adding weights to the Adaptive Fisher (AF) method we developed before. Using simulation, we show that wAF enjoys comparable or better power to popular methods such as sequence kernel association tests (SKAT and SKAT-O) and adaptive SPU (aSPU) test. We apply wAF to a publicly available schizophrenia dataset, and successfully detect thirteen genes. Among them, three genes are supported by existing literature; six are plausible as they either relate to other neurological diseases or have relevant biological functions. CONCLUSIONS: The proposed wAF method is a powerful disease-variants association test in both dense and sparse scenarios. Both simulation studies and real data analysis indicate the potential of wAF for new biological findings.

Impact of protocolized diuresis for de-resuscitation in the intensive care unit.

OBJECTIVE: Administration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill. METHODS: This was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria. RESULTS: A total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR - 2257 (- 5676-920) mL vs 265 (- 2283-3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated. CONCLUSIONS: This study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.

Inpatient Mortality and 30-Day Readmission Rates Associated with Troponin Testing in Patients without Acute Myocardial Infarction.

OBJECTIVE: Troponin values above the threshold established to diagnose acute myocardial infarction (AMI; >99th percentile) are commonly detected in patients with diagnoses other than AMI. The objective of this study was to compare inpatient mortality and 30-day readmission rate in patients with troponin I (TnI) above and below the 99th percentile in those with type 1 AMI and type 2 myocardial injury. METHODS: Between January 1, 2016 and December 31, 2016, there were 56,895 inpatient hospitalizations; of these 14,326 (25.2%) patients received troponin testing. We evaluated mortality and readmissions in the entire cohort based on the primary discharge International Classification of Diseases, Tenth Edition (ICD-10) diagnosis and grouped into type 1 AMI versus other diagnoses comprising the type 2 AMI group (including ICD-10 codes for congestive heart failure, sepsis, and other). Among those with TnI drawn, we evaluated in-hospital mortality and 30-day readmissions based on troponin values > 99th percentile (≥ 0.1 ng/ml). RESULTS: Among the entire cohort, the inpatient mortality rate was significantly higher in those with TnI testing (5.0%, 95% CI 4.6%-5.3%) compared to those without testing (0.7%, 95% CI 0.6%-0.7%, P < 0.01). In the tested cohort 3,743 (26%) patients had troponin levels above the 99th percentile (> 0.1 ng/ml), and 10,583 (74%) had troponin levels below the 99th percentile (≤ 0.1 ng/ml). Comparing type 2 AMI with type 1 AMI and troponin testing, TnI values ≥ 0.1 ng/ml were associated with higher inpatient mortality (11.6% vs. 3.9%) and 30-day readmission rates (16.9% vs. 10.7%). CONCLUSIONS: A higher inpatient mortality and 30-day readmission rates were found in patients with type 2 AMI compared to type 1 AMI group.

Integrating Ethics Education and Training Into Palliative Medicine Fellowships: A Response to Vig and Merel.

In a recent American Journal of Hospice and Palliative Medicine article entitled "Ethics Education During Palliative Medicine Fellowship," Dr Elizabeth Vig and Dr Susan Merel detail the ethics curriculum of the University of Washington School of Medicine's Palliative Medicine Fellowship, including their efforts in the past several years to increase and bolster the fellowship's ethics curriculum. This letter builds upon this topic and discusses some other strategies and methods for ethics education and training that fellowship programs may consider adopting to bolster their ethics curriculum.