Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling.

Introduction: Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers. Methods: This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis. Results: Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-ß) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief". Conclusions: Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.

Infertility Counseling and Misattributed Paternity: When Should Physicians Become Involved in Family Affairs?

Infertility specialists may be confronted with the ethical dilemma of whether to disclose misattributed paternity (MP). Physicians should be prepared for instances when an assumed father's evaluation reveals a condition known for lifelong infertility, for example, congenital bilateral absence of vas deferens (CBAVD). When there is doubt regarding a patient's comprehension of his diagnosis, physicians must consider whether further disclosure is warranted. This article describes a case of MP with ethics analysis that concludes that limited nondisclosure is most consistent with a physician's principled duties to inform, to respect patients' autonomy, and to employ nonmaleficence (including the avoidance of psychosocial harms).

Individual Experiences and Utilization of Supportive Resources in Adolescents and Young Adults with Cancer.

Background: Adolescents and young adults (AYAs) with cancer are often impacted by distress due to disease and treatment. Despite these concerns, prior research has found that AYAs do not utilize support resources, do not find these resources adequate, and or do not have adequate access to services. Objective: The objective of this project was to understand and identify AYA patient concerns and experiences throughout cancer treatment, what resources were utilized, how they were identified, and how supportive care resources for AYA cancer patients can be improved. Methods: Twenty-eight AYA cancer patients and survivors were interviewed on their experiences and utilization of supportive resources throughout cancer treatment. Qualitative data were analyzed using thematic analysis and organized through a priori framework examining specific domains of experience and resources utilized. Results: The most frequently discussed topic in qualitative interviews was the benefit of the health care team. Other frequently identified resources were generalized internet searches and webpages. Suggested unmet resource needs included supportive resources for family members and caregivers throughout the time of treatment. Conclusions: AYAs experience stress throughout treatment for cancer attributed to physical, practical, and psychosocial causes. Health care workers play a vital role in serving as an informative and supportive resource for their AYA patients. As such, health care workers and other supportive resources may alleviate these concerns, but these resources are still underexplored.

Moving It Along: A study of healthcare professionals' experience with ethics consultations.

BACKGROUND: Ethics consultation is the traditional way of resolving challenging ethical questions raised about patient care in the United States. Little research has been published on the resolution process used during ethics consultations and on how this experience affects healthcare professionals who participate in them. OBJECTIVES: The purpose of this qualitative research was to uncover the basic process that occurs in consultation services through study of the perceptions of healthcare professionals. DESIGN AND METHOD: The researchers in this study used a constructivist grounded theory approach that represents how one group of professionals experienced ethics consultations in their hospital in the United States. RESULTS: The results were sufficient to develop an initial theory that has been named after the core concept: Moving It Along. Three process stages emerged from data interpretation: moral questioning, seeing the big picture, and coming together. It is hoped that this initial work stimulates additional research in describing and understanding the complex social process that occurs for healthcare professionals as they address the difficult moral issues that arise in clinical practice.

Documented consent process for implantable cardioverter-defibrillators and implications for end-of-life care in older adults.

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at risk for life-threatening heart arrhythmias, and their use is increasingly common. However, these devices also confer risk for delivery of unexpected painful shocks during the dying process, thus reducing the quality of palliative care at the end of life. This scenario can be avoided by ICD deactivation in appropriate circumstances but patients will remain unaware of this option if not informed about it. It is not known how often end-of-life implications are discussed with patients prior to ICD implantation, when focus is primarily on the short-term potential complications of the device placement procedure itself. We conducted a retrospective chart review to determine how often end-of-life implications were discussed with patients as part of the informed consent process. We evaluated consent forms and related other chart documentation for 91 patients (ranging from age 60 to 89 years) undergoing first-time ICD placement at a mid-western academic medical center from 2006-2008. Only one chart documented any discussion of end-of-life implications, in a case where the issue was raised by a patient who noted that quality of life was their main focus. Consent was provided by a health care surrogate in only four of the 91 cases. In conclusion, patients giving consent for ICD implantation may be uninformed about the device's potential future impact on end-of-life care, the dying process, and the option for device deactivation. Truly informed consent requires that both short- and long-term potential implications be reviewed with patients.

HCEC pearls and pitfalls: suggested do's and don't's for healthcare ethics consultants.

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

An ethics conflict and culture: should this kidney be used?

The practice of nursing in transplant medicine is often fraught with ethical complexity. It is especially so when children are involved as potential living donors. This is no less true when the donor "child" is of consenting age, and when the intended recipient is the parent. This case is presented by a clinical ethics consultant to whom a nurse turned with her discomfort over the situation faced as a renal transplant coordinator. The part played by ethnicity and traditional Korean culture is highlighted.

Pastoral products or pastoral care? How marketplace language affects ministry in veterans hospitals.

The author describes a veterans hospital context of healthcare ministry in which marketplace terminology, adopted institutionally, also impacts the Chaplain Service. He highlights specific elements of this commercialization of pastoral care, such as computerized documentation of "spiritual products" delivered in increments of ten minute units. Noting the power of language both to describe and create realities, the author suggests likely risks accompanying benefits of healthcare chaplaincy carried out on marketplace terms.