Credentialing Character: A Virtue Ethics Approach to Professionalizing Healthcare Ethics Consultation Services.

In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One argument they offer against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates.Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one's role as a moral agent and reflection on one's progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project.

"We have nothing left to bury."

After miscarrying in the hospital at eleven weeks, a patient gratefully accepts the hospital's offer to take advantage of a program for low-income patients that provides burial for fetal remains and a memorial plaque for the gravesite. However, a hospital employee accidentally incinerates the remains, and the error is not discovered until after the ashes are discarded. Two commentaries offer opposing arguments in response to the question whether, to avoid adding to the patient's grief, it is ethically permissible for the clinicians not to disclose the error to her and to proceed with having the name put on a plaque at the burial ground.

Screening for Atrial Fibrillation in the Older Population: A Randomized Clinical Trial.

Importance: Atrial fibrillation (AF) is a major cause of preventable strokes. Screening asymptomatic individuals for AF may increase anticoagulant use for stroke prevention. Objective: To evaluate 2 home-based AF screening interventions. Design, Setting, and Participants: This multicenter randomized clinical trial recruited individuals from primary care practices aged 75 years or older with hypertension and without known AF. From April 5, 2015, to March 26, 2019, 856 participants were enrolled from 48 practices. Interventions: The control group received standard care (routine clinical follow-up plus a pulse check and heart auscultation at baseline and 6 months). The screening group received a 2-week continuous electrocardiographic (cECG) patch monitor to wear at baseline and at 3 months, in addition to standard care. The screening group also received automated home blood pressure (BP) machines with oscillometric AF screening capability to use twice-daily during the cECG monitoring periods. Main Outcomes and Measures: With intention-to-screen analysis, the primary outcome was AF detected by cECG monitoring or clinically within 6 months. Secondary outcomes included anticoagulant use, device adherence, and AF detection by BP monitors. Results: Of the 856 participants, 487 were women (56.9%); mean (SD) age was 80.0 (4.0) years. Median cECG wear time was 27.4 of 28 days (interquartile range [IQR], 18.4-28.0 days). In the primary analysis, AF was detected in 23 of 434 participants (5.3%) in the screening group vs 2 of 422 (0.5%) in the control group (relative risk, 11.2; 95% CI, 2.7-47.1; P = .001; absolute difference, 4.8%; 95% CI, 2.6%-7.0%; P < .001; number needed to screen, 21). Of those with cECG-detected AF, median total time spent in AF was 6.3 hours (IQR, 4.2-14.0 hours; range 1.3 hours-28 days), and median duration of the longest AF episode was 5.7 hours (IQR, 2.9-12.9 hours). Anticoagulation was initiated in 15 of 20 patients (75.0%) with cECG-detected AF. By 6 months, anticoagulant therapy had been prescribed for 18 of 434 participants (4.1%) in the screening group vs 4 of 422 (0.9%) in the control group (relative risk, 4.4; 95% CI, 1.5-12.8; P = .007; absolute difference, 3.2%; 95% CI, 1.1%-5.3%; P = .003). Twice-daily AF screening using the home BP monitor had a sensitivity of 35.0% (95% CI, 15.4%-59.2%), specificity of 81.0% (95% CI, 76.7%-84.8%), positive predictive value of 8.9% (95% CI, 4.9%-15.5%), and negative predictive value of 95.9% (95% CI, 94.5%-97.0%). Adverse skin reactions requiring premature discontinuation of cECG monitoring occurred in 5 of 434 participants (1.2%). Conclusions and Relevance: In this randomized clinical trial, among older community-dwelling individuals with hypertension, AF screening with a wearable cECG monitor was well tolerated, increased AF detection 10-fold, and prompted initiation of anticoagulant therapy in most cases. Compared with continuous ECG, intermittent oscillometric screening with a BP monitor was an inferior strategy for detecting paroxysmal AF. Large trials with hard clinical outcomes are now needed to evaluate the potential benefits and harms of AF screening. Trial Registration: ClinicalTrials.gov Identifier: NCT02392754.

Is Screening for Atrial Fibrillation in Canadian Family Practices Cost-Effective in Patients 65 Years and Older?

We present an economic evaluation of a recently completed cohort study in which 2054 seniors were screened for atrial fibrillation (AF) in 22 Canadian family practices. Using a Markov model, trial and literature data were used to project long-term outcomes and costs associated with 4 AF screening strategies for individuals aged 65 years or older: no screening, screen with 30-second radial manual pulse check (pulse check), screen with a blood pressure machine with AF detection (BP-AF), and screen with a single-lead electrocardiogram (SL-ECG). Costs and outcomes were discounted at 1.5% and the model used a lifetime horizon from a public payer perspective. Compared with no screening, screening for AF in Canadian family practice offices using pulse check or screen with a blood pressure machine with AF detection is the dominant strategy whereas screening with SL-ECG is a highly cost-effective strategy with an incremental cost per quality-adjusted life-year (QALY) gained of CAD$4788. When different screening strategies were compared, screening with pulse check had the lowest expected costs ($202) and screening with SL-ECG had the highest expected costs ($222). The no-screening arm resulted in the lowest number of QALYs (8.74195) whereas pulse check and SL-ECG resulted in the highest expected QALYs (8.74362). Probabilistic analysis confirmed that pulse check had the highest probability of being cost-effective (63%) assuming a willingness to pay of $50,000 per QALY gained. Screening for AF in seniors during routine appointments with Canadian family physicians is a cost-effective strategy compared with no screening. Screening with a pulse check is likely to be the most cost-effective strategy.

Personal responsibility, regret, and medical stigma among individuals living with lung cancer.

Understanding the degree to which adults with lung cancer perceive personal responsibility for their disease, personal regret for actions that may have contributed to lung cancer, and potential stigmatization from others is important, because these perceptions and experiences may be linked with treatment nonadherence, feelings of isolation, avoidance of healthcare providers, and poor quality of life. The purpose of this study was to evaluate rates and intensity of these types of experiences and to characterize the extent to which they are linked with smoking status and psychological adjustment in those living with lung cancer. Adults with lung cancer (N = 213) were recruited from two major cancer centers to complete a mail survey. Perceived responsibility was frequent in those who had ever smoked (74-80%), whereas regret and feelings of stigmatization were less frequent. When present, however, personal regret and stigmatization were associated with adverse psychological outcomes, particularly for never smokers. These results are consistent with the theory of stereotype threat and have clinical implications for management of people with lung cancer.

Modeling intention to participate in face-to-face and online lung cancer support groups.

BACKGROUND: Lung cancer patients and survivors are significantly less likely to use support groups than those with other cancers. In this study, we evaluated the utility and specificity of the Behavioral Model for Vulnerable Populations for modeling intention to participate in face-to-face (F2F) and online lung cancer support groups. METHODS: Adults diagnosed with lung cancer (n = 230) completed measures assessing predisposing, enabling, and need factors associated with intention to use support services. RESULTS: Intention to join a F2F support group (found among 36.4% of survivors) was associated with positive attitude about F2F support groups, fewer perceived time constraints, less travel time from the clinic, and not having enough social support. Intention to join an online support group (34% of survivors) was associated with having more positive attitudes about online support, greater use of avoidance coping strategies, more comfort using computers, and fewer perceived time constraints. Demographics, medical history, health status, and psychological status were not associated with intention to join either type of group. CONCLUSIONS: Reducing barriers to participation and addressing attitudes about support services may be the most effective ways to increase utilization of lung cancer support services.

Predictors of finding benefit after lung cancer diagnosis.

OBJECTIVE: We examined benefit finding in patients with lung cancer, including level of benefit finding and change in benefit finding over time, and tested a predictive model postulating that greater impact of and engagement with the stressor promotes benefit finding. METHODS: Patients diagnosed with a primary lung cancer within the past 6 months (M=16 weeks post-diagnosis) completed measures of benefit finding, cancer-related intrusions, perceived stressfulness, coping, and demographic and medical information at study entry (T1; n = 118) and 3 months later (T2; n = 79). RESULTS: Level of benefit finding at both assessments was to a 'mild-to-moderate degree'. Benefit finding increased over time for patients with small cell carcinoma, but not for those with nonsmall cell carcinoma. The proposed model explained 33% of the variance in T1 benefit finding, and 64% (using T1 coping measures) and 71% (using T2 coping measures) of the variance in T2 benefit finding. Greater benefit finding was associated with having small cell lung cancer, higher cancer-related intrusions, lower perceived cancer-related stress, and greater approach-oriented coping. Positive reframing coping emerged as the single unique approach-oriented coping scale predicting benefit finding at T1, and emotional approach coping was the single unique approach-oriented coping scale predicting benefit finding at T2. CONCLUSION: Findings provide general support for a theoretical model positing that stressor impact and engagement with the stressor contribute to the development of benefit finding after cancer. Future research with larger, more diverse samples is needed to confirm and extend these findings.

Optimism and prostate cancer-specific expectations predict better quality of life after robotic prostatectomy.

We examined the relations among generalized positive expectations (optimism), prostate-cancer specific expectations, and prostate cancer-related quality of life in a prospective sample of 83 men who underwent robotic assisted laparoscopic prostatectomy (RALP) for prostate cancer. Optimism was significantly associated with higher prostate cancer-specific expectations, ß = .36, p < .001. In addition, optimism and prostate cancer-specific expectations were independent prospective predictors of better scores on the following prostate cancer-related quality of life scales: Sexual Intimacy and Sexual Confidence; Masculine Self-Esteem (specific expectations only), Health Worry, Cancer Control, and Informed Decision Making (ßs > .21, ps < .05). When considered simultaneously, both optimism and specific expectations contributed uniquely to better Health Worry and Cancer Control scores, optimism was a unique predictor of better Sexual Intimacy and Sexual Confidence scores, and specific expectations uniquely predicted higher scores on Informed Decision Making. Although optimism and prostate-cancer specific expectations are related, they contribute uniquely to several prostate cancer-related quality of life outcomes following RALP and may be important targets for quality of life research with this population.

Development and evaluation of a decision aid for BRCA carriers with breast cancer.

BRCA+ breast cancer patients face high risk for a second breast cancer and ovarian cancer. Helping these women decide among risk-reducing options requires effectively conveying complex, emotionally-laden, information. To support their decision-making needs, we developed a web-based decision aid (DA) as an adjunct to genetic counseling. Phase 1 used focus groups to determine decision-making needs. These findings and the Ottawa Decision Support Framework guided the DA development. Phase 2 involved nine focus groups of four stakeholder types (BRCA+ breast cancer patients, breast cancer advocates, and genetics and oncology professionals) to evaluate the DA's decision-making utility, information content, visual display, and implementation. Overall, feedback was very favorable about the DA, especially a values and preferences ranking-exercise and an output page displaying personalized responses. Stakeholders were divided as to whether the DA should be offered at-home versus only in a clinical setting. This well-received DA will be further tested to determine accessibility and effectiveness.

A prospective report of changes in prostate cancer related quality of life after robotic prostatectomy.

In this prospective, longitudinal study the authors examined changes in cognitive, emotional, and interpersonal components of prostate cancer-related quality of life in 71 men who underwent robotic-assisted prostatectomy for prostate cancer. They identified significant changes across several quality-of-life domains from presurgery to 3-months and 1-year postsurgery. Although some components of quality of life returned to baseline by one year postsurgery, decrements in sexual intimacy, sexual confidence, and masculine self-esteem were enduring. These data can be used to guide patients in their expectations for quality of life following robotic prostatectomy and highlight the need for multidisciplinary approaches aimed at improving men's sexual adjustment after this procedure.

Health literacy, numeracy, and interpretation of graphical breast cancer risk estimates.

OBJECTIVE: Health literacy and numeracy are necessary to understand health information and to make informed medical decisions. This study explored the relationships among health literacy, numeracy, and ability to accurately interpret graphical representations of breast cancer risk. METHODS: Participants (N=120) were recruited from the Facing Our Risk of Cancer Empowered (FORCE) membership. Health literacy and numeracy were assessed. Participants interpreted graphs depicting breast cancer risk, made hypothetical treatment decisions, and rated preference of graphs. RESULTS: Most participants were Caucasian (98%) and had completed at least one year of college (93%). Fifty-two percent had breast cancer, 86% had a family history of breast cancer, and 57% had a deleterious BRCA gene mutation. Mean health literacy score was 65/66; mean numeracy score was 4/6; and mean graphicacy score was 9/12. Education and numeracy were significantly associated with accurate graph interpretation (r=0.42, p<0.001 and r=0.65, p<0.001, respectively). However, after adjusting for numeracy in multivariate linear regression, education added little to the prediction of graphicacy (r(2)=0.41 versus 0.42, respectively). CONCLUSION: In our highly health-literate population, numeracy was predictive of graphicacy. PRACTICE IMPLICATIONS: Effective risk communication strategies should consider the impact of numeracy on graphicacy and patient understanding.

Supportive care needs in patients with lung cancer.

INTRODUCTION: The goal of this study was to characterize the prevalence and intensity of supportive care needs and interest in specific supportive care services among individuals with lung cancer. METHOD: Participants (n=109) were recruited from two medical centers in Southern California to complete questionnaires on physical and psychological functioning following diagnosis of lung cancer. RESULTS: Participants reported the greatest need in the physical and daily living domain, followed by psychological needs, health system and informational needs, and patient care support needs. The most common unmet need was a lack of energy and tiredness (75%). Higher levels of supportive care needs were associated with worse physical functioning (beta=-0.30, p<0.001), greater symptom bother (beta=0.25, p=0.008), lower satisfaction with health care (beta=-0.24, p=0.002), and higher levels of intrusive thoughts about cancer (beta=0.40, p<0.001). The sample was most interested in receiving additional information about their disease and treatment (61.0%), exercise-related information and support (54.3%), and assistance dealing with fatigue (46.7%). Over 91% expressed interest in at least one specific supportive care service, and 51.4% were interested in one or more psychological services. CONCLUSION AND IMPLICATIONS FOR CANCER SURVIVORS: Our findings suggest that lung cancer survivors have many unmet needs. Patients who report higher physical distress and intrusive stress symptoms, or lower satisfaction with their health care, may experience the highest level of supportive care need and intervention.

Need for cognition and psychosocial adjustment in prostate cancer patients and partners.

Individual differences in cognitive style, specifically need for cognition (NFC), may play an important role in facilitating communication and psychosocial adjustment to cancer during the presurgical period, a time marked by distress and the need to process disease-related information. This study examines the relations between NFC, adjustment, and communication in 106 prostate cancer patients and their partners within 2 weeks prior to radical prostatectomy. High NFC was significantly associated with better psychological adjustment for partners only, whereas for patients, communication with the medical team played a more important role. High NFC patients who were partnered with high NFC partners reported better dyadic communication compared with those who were partnered with low NFC partners. This study indicates that predictors of adjustment may differ for patients and partners, who are likely differentially affected by the disease process.

Posttraumatic growth in prostate cancer survivors and their partners.

We examined posttraumatic growth (PTG) in men treated for prostate cancer and their partners 1 year after surgery. Levels of PTG in prostate cancer survivors and their partners were similar and modest. For survivors, higher levels of presurgery negative affect, and coping by using positive reframing and emotional support were associated with higher levels of PTG 1 year following surgery. For partners, PTG 1 year after the patient's surgery was higher in partners who were partnered to employed patients, were less educated, endorsed higher cancer-specific avoidance symptoms of stress at presurgery, and used positive reframing coping. Quality of life was largely unrelated to PTG in survivors or partners. Findings suggest that psychological disruption associated with the cancer experience and coping are related to PTG in prostate cancer survivors and their partners.

The impact of a second breast cancer diagnosis on health related quality of life.

A growing of research documents the negative impact of recurrent breast cancer on quality of life (QOL), however few prospective investigations are available that compare QOL outcomes across different types of second cancer events (e.g., local/regional recurrence (LR) versus distant/metastatic recurrence (DR) versus a new primary breast cancer (NP)). In addition, although participant attrition is a major issue in this group of cancer patients, the potential impact of attrition or response bias on QOL outcomes is not typically examined. To address these issues, we prospectively examined QOL data obtained from a sample of women (n=140) participating in the Women's Healthy Eating and Living (WHEL) Study who experienced a second cancer event (LR, DR or NP). Women in our study reported significant worsening in most areas of QOL, except for emotional wellbeing, from pre- to post-second cancer event. Although the patterns of change to QOL differed slightly within each category (LR versus DR versus NP), participants were more similar than different in their QOL ratings. However, the perceived health status of women with DR was significantly lower than women with LR or NP. We also identify important sources of response bias that should be considered when interpreting findings. Specifically, women diagnosed with DR (a) were more likely to decline to complete the post-recurrence QOL questionnaire (27% refusal rate versus 14% LR and 13% NP), and (b) had higher death rates (28% death rate versus 4% LR and 6% NP) after agreeing to but before completing the post-second diagnosis QOL questionnaire.