Descripción de la experiencia de un servicio de consultoría en ética clínica en el período 2019-2021 / Description of the experience of a clinical ethics consultation service from 2019-2021

Introducción La consultoría en ética clínica (CEC) es un modelo útil de asesoría ética, pero con escasa implantación en Europa. En el presente artículo se comparte la experiencia de uno de los primeros servicios de consultoría ética en España. Material y métodos Estudio observacional retrospectivo de todas las consultas recibidas por el servicio de CEC del Hospital Universitario de La Princesa (Madrid, España) entre el 1 de septiembre de 2019 y el 31 de agosto de 2021. Se analizaron variables demográficas, logísticas y éticas de los casos. Resultados Se analizaron 63 casos, en los que se identificaron un total de 124 conflictos éticos. El 41% (n=26) de las consultas eran de carácter urgente y el 38% (n=24), preferentes. La evaluación inicial se realizó en menos de 24horas en 50 casos (79%). El servicio que consultó con mayor frecuencia fue Medicina Intensiva (9; 14%). Los medios de contacto preferidos fueron el busca (36; 57%), el sistema electrónico de historia clínica (13; 21%) o la conversación directa con el equipo consultor (7; 11%). Los problemas éticos más comunes estaban relacionados con la adecuación de medidas terapéuticas (24; 19%), el rechazo del tratamiento (19; 15%), la comunicación con el paciente o su familia (29; 23%) o la competencia del paciente (13; 11%). Conclusiones Los servicios de CEC proporcionan una asistencia rápida y eficiente para la resolución de problemas éticos en la práctica habitual. Su implementación en España es factible (AU)

Introduction Clinical ethics consultation services (CEC) are useful model for ethical counselling, albeit with scarce implementation in European countries. This article shares the experience of one of the first ethics consultation services in Spain. Materials and methods This work is a retrospective, observational study of all consultations received by the CEC service at La Princesa University Hospital (Madrid, Spain) from September 1, 2019 to August 31, 2021. The demographic, logistic, and ethical variables of the cases were analyzed. Results A total of 63 cases were analyzed in which a total of 124 ethical conflicts were identified. Forty-one percent of the cases (n=26) were emergency consultations and 38% (n=24) were preferential inquiries. An initial evaluation was performed with 24hours in 50 cases (79%). The department that consulted most often was the Intensive Care Unit (9; 14%). The preferred contact methods were via pager (36; 57%), the electronic medical record system (13; 21%), or direct conversations with consulting team (7; 11%). The most common ethical conflicts were those related to the adequacy of treatment measures (24; 19%), refusal of treatment (19; 15%), communication with the patient or his/her family (29; 23%), or the patient's capacity (13; 11%). Conclusion CEC services provide quick, efficient assistance for resolving ethical problems in daily practice. Their implementation in Spain is feasible (AU)

The role of online ethics consultation on mental health.

BACKGROUND: Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice. RESEARCH OBJECTIVE: To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness. ETHICAL CONSIDERATIONS: The research was conducted in accordance with the Declaration of Helsinki. RESEARCH DESIGN: This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan. PARTICIPANTS: The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users. FINDINGS: The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive. DISCUSSION: The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants. CONCLUSION: This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses' moral distress, building ethics into decision-making.

Development and Retrospective Review of a Pediatric Ethics Consultation Service at a Large Academic Center.

The primary objective was to review pediatric ethics consultations (PECs) at a large academic health center over a nine year period, assessing demographics, ethical issues, and consultant intervention. The secondary objective was to describe the evolution of PECs at our institution. This was a retrospective review of Consultation Summary Sheets compiled for PECs at our Academic Health Center between January 2008 and April 2017. There were 165 PECs reviewed during the study period. Most consult requests came from the inpatient setting, with the Pediatric and Neonatal Intensive Care Units being the highest utilizers. Consultation utilization increased over the study period. The most common patient age was less than one year. Physicians were most likely to request consultation. Patient Best Interest, Withholding/Withdrawing of Life Sustaining Therapy, and Provider Moral Distress were ethical issues most commonly identified by the consultants. Making recommendations was the most common consultant intervention. The ethics consultation process evolved over time from informal provider discussions, to a hospital infant care review committee, to a pediatric only consultation service, to a combined adult/pediatric consultation service, with variable levels of salary support for consultants. Ethics consultation requests are growing at our institution. Similarities in identified ethical issues exist between our findings and existing literature, however meaningful comparisons remains elusive secondary to variability in approaches to investigation and reporting. A combined paid/volunteer/trainee ethics consultation service model appears sustainable and real time ethics consultation is feasible using this approach.

Ethics Consultations Related to Opioid Use Disorder.

BACKGROUND: The opioid epidemic has resulted in an increased number of patients with opioid use disorder (OUD) hospitalized for serious medical conditions. The intersection between hospital ethics consultations and the opioid crisis has not received significant attention. OBJECTIVE: The aim of this study was to characterize ethics consult questions among inpatients with OUD at our institution, Massachusetts General Hospital. METHODS: We conducted a single-center retrospective cohort study of ethics consultations from January 1, 1993 to December 31, 2017 at Massachusetts General Hospital. RESULTS: Between 1993 and 2017, OUD played a central role in ethics consultations in 43 of 1061 (4.0%) cases. There was an increase in these requests beginning in 2009, rising from 1.4% to 6.8% of consults by 2017. Compared with other ethics cases, individuals with OUD were significantly younger (P < 0.001), more likely to be uninsured or underinsured (P < 0.001), and more likely to have a comorbid mental health diagnosis (P = 0.001). The most common reason for consultation involved continuation of life-sustaining treatment in the setting of overdose with neurological injury or severe infection. Additional reasons included discharge planning, challenges with pain management and behavior, and the appropriateness of surgical intervention, such as repeat valve replacement or organ transplant. Health care professionals struggled with their ethical obligations to patients with OUD, including when to treat pain with narcotics and how to provide longitudinal care for patients with limited resources outside of the hospital. CONCLUSION: The growing opioid epidemic corresponds with a rise in ethics consultations for patients with OUD. Similar factors associated with OUD itself, including comorbid mental health diagnoses and concerns about relapse, contributed to the ethical complexities of these consults.

Evaluating the Inpatient Pediatric Ethical Consultation Service.

OBJECTIVES: Pediatric ethical consultation services (ECSs) have been proliferating at medical centers, with little data available on evaluating their implementation. The objective of this study was to evaluate the pediatric ECS and understand the ethical issues occurring within a single quaternary-level pediatric hospital. METHODS: A retrospective chart review of documented ethics consultations at a large pediatric hospital from November 2010 to November 2013 was performed and data was abstracted per the US Department of Veterans Affairs' Domains of Ethics in Health Care. An anonymous, prospective survey regarding ethical issues encountered was distributed electronically to ∼3500 inpatient staff from November 2013 through January 2014. Ethical domains, demographics, feelings of distress by staff, and location of occurrence data were collected. These data were compared with formally documented ethics consults from the retrospective chart review and ECS activity during the same period. RESULTS: A total of 47 ethics consults were documented between 2010 and 2013, primarily in the domains of end-of-life care (19; 40%) and shared decision-making (17; 36%). Sixty-three staff members (92% female; 42% nurses; 20% attending physicians) logged an encountered ethical issue between November 2013 and January 2014, corresponding to only 5 documented ethics consults in the same time period. Domains included end-of-life care (18; 28.5%), shared decision-making (13; 20.6%), everyday workplace (11; 17.4%), professionalism (8; 12.6%), and resource allocation (7; 11%). Eighty-one percent of subjects reported personal or professional distress. CONCLUSIONS: On the basis of this single-center study in which we reviewed formal documentation, we determined that formal pediatric ECSs are underused, particularly for ethical domains that cause staff members moral distress.

Ethical difficulties in healthcare: A comparison between physicians and nurses.

BACKGROUND:: Advances in biomedical sciences, technologies and care practices have resulted in an increase in ethical problems and a resulting growth of difficulties encountered by health workers in their professional activity. OBJECTIVE:: The main objective of this study was to analyse knowledge in the ethical field and experience with and the propensity for using ethics consultations by nurses and physicians. METHODS:: Between March and June 2014, a cross-sectional observational study was conducted on a sample of 351 nurses and 128 physicians in four central Italian hospitals. For data collection, a semi-structured questionnaire was used, consisting of 21 items divided into four sections exploring (1) demographic and occupational characteristics, (2) knowledge in the ethics field, (3) experience with ethical issues and (4) the propensity to use ethics consultation. ETHICAL CONSIDERATIONS:: Research ethics approval was obtained from the Italian Nurses Professional Board. RESULTS:: The results show that both nurses and physicians are faced with ethically sensitive situations. Nurses were found to have better judgement concerning their own knowledge than physicians, but more physicians were found to have a deeper level of specific training in ethics issues. The propensity to ask for ethics consultations to address ethical issues was found to be significantly associated with the degree to which ethical issues have deepened (and the level of experience acquired in this field). CONCLUSION:: The presence of a consulting service that can lead to shared choices may represent, together with basic and continuing education, a valid support for professional growth in the ethical field for both physicians and nurses.

Lessons learned from nurses' requests for ethics consultation: Why did they call and what did they value?

BACKGROUND: An ongoing challenge for clinical ethics consultation is learning how colleagues in other healthcare professions understand, make use of, and evaluate clinical ethics consultation services. AIM: In pursuing such knowledge as part of clinical ethics consultation service quality assessment, clinical ethics consultation services can learn important information about the issues and concerns that prompt colleagues to request ethics consultation. Such knowledge allows for greater outreach, education, and responsiveness by clinical ethics consultation services to the concerns of clinician colleagues. DESIGN: This quality assessment project explores consultation requests and follow-up questionnaire responses voluntarily submitted from nurses who requested clinical ethics consultation. We present qualitative data analyzed using content analysis and constant comparison methods to identify key concerns that prompted requests as well as common themes among nurse requestors' evaluations of what was most important in clinical ethics consultations. Participants and context: A total of 41 nurses requesting clinical ethics consultation and 15 who returned the follow-up questionnaire. Ethical considerations: Our Office of Research Compliance and Quality Improvement determined that our project was not considered human subjects research and so did not require institutional review board approval or exemption. However, efforts were made to avoid any sense of coercion and all data were de-identified prior to analysis. FINDINGS: Our analysis revealed six main categories of issues that prompted nurses' requests for ethics consultation, as well as unifying themes around nurses' experiences, advocacy, and family support while caring for patients in the intersections of patients, families, and physicians. DISCUSSION: The insights gained from analyzing nurses' requests for and responses to clinical ethics consultation may serve as a resource for clinical ethics consultation services seeking to identify, respond to, and educate regarding issues of importance to nurse colleagues and may be a resource for nursing administrators and leadership seeking to identify and address common ethical issues nurses face. CONCLUSION: Ongoing work on clinical ethics consultation service quality improvement and engagement with our nursing colleagues about their concerns prompting-and their evaluations of-clinical ethics consultation are necessary.

Why Are There So Few Ethics Consults in Children's Hospitals?

In most children's hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children's hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are (1) ethics committee meetings, (2) Nursing Ethics Forum, (3) ethics Brown Bag workshops, (4) PICU ethics rounds, (5) Grand Rounds, (6) NICU Comprehensive Care Rounds, (7) Palliative Care Team (PaCT) case conferences, (8) multidisciplinary consults in Fetal Health Center, and (9) ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of "core competencies" than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple "moral spaces" in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today.

Structure, Operation, and Experience of Clinical Ethics Consultation 2007-2013: A Report from the Massachusetts General Hospital Optimum Care Committee.

We describe the structure, operation, and experience of the Massachusetts General Hospital ethics committee, formally called the Edwin H. Cassem Optimum Care Committee, from January 2007 through December 2013. Founded in 1974 as one of the nation's first hospital ethics committees, this committee has primarily focused on the optimum use of life-sustaining treatments. We outline specific sociodemographic and clinical characteristics of consult patients during this period, demographic differences between the adult inpatient population and patients for whom the ethics committee was consulted, and salient features of the consults themselves. We include three case studies that illustrate important consult themes during this period. Our findings expand knowledge about the structure and workings of hospital ethics committees and illustrate how one ethics committee has developed and utilized policies on end-of-life care. More generally, we model a sociological approach to the study of clinical ethics consultation that could be utilized to contextualize institutional practices over time.

The Evolution of American Hospital Ethics Committees: A Systematic Review.

During the 1970s and 1980s, legal precedent, governmental recommendations, and professional society guidelines drove the formation of hospital ethics committees (HECs). The Joint Commission on Accreditation of Health Care Organization's requirements in the early 1990s solidified the role of HECs as the primary mechanism to address ethical issues in patient care. Because external factors drove the rapid growth of HECs on an institution-by-institution basis, however, no initial consensus formed around the structure and function of these committees. There are now almost 40 years of empirical studies on the composition, administration, and activities of HECs in the United States. We conducted a systematic review of the available empirical literature on HECs to describe their evolution. As HECs changed over time, they increased their total number of members and percentage of members from nursing and the community. Although physicians increasingly chaired these committees, their presence as a percentage of overall members declined. The percentage of administrative members remained steady, although committees became increasingly likely to have at least one administrative member. HECs were also increasingly likely to report to an administrative body or to the board of trustees or directors rather than to the medical staff. Finally, consultation volume increased steadily over time. There has not, however, been a national survey of the composition of ethics committees, their administration, or volume of consultation in more than 10 years, despite increasing calls for professional standards and quality improvement assessments among HECs.

Gender and Race in the Timing of Requests for Ethics Consultations: A Single-Center Study.

BACKGROUND: Clinical ethics consultants are expected to "reduce disparities, discrimination, and inequities when providing consultations," but few studies about inequities in ethics consultation exist.1 The objectives of this study were (1) to determine if there were racial or gender differences in the timing of requests for ethics consultations related to limiting treatment, and (2) if such differences were found, to identify factors associated with that difference and the role, if any, of ethics consultants in mitigating them. METHODS: The study was a mixed methods retrospective study of consultation summaries and hospital and ethics center data on 56 age-and gender-matched Caucasian and African American Medicare patients who received ethics consultations related to issues around limiting medical treatment in the period 2011 to 2014. The average age of patients was 70.9. RESULTS: Consultation requests for females were made significantly earlier in their stays in the hospital (6.57 days) than were consultation requests made for males (16.07 days). For African American patients, the differences in admission-to-request intervals for female patients (5.93 days) and male patients (18.64 days) were greater than for Caucasian male and female patients. Differences in the timing of a consultation were not significantly correlated with the presence of an advance directive, the specialty of the attending physician, or the reasons for the consult request. Ethics consultants may have mitigated problems that developed during the lag in request times for African American males by spending more time, on average, on those consultations (316 minutes), especially more time, on average, than on consultations with Caucasian females (195 minutes). Most consultations (40 of 56) did result in movement toward limiting treatment, but no statistically significant differences were found among the groups studied in the movement toward limiting treatment. The average number of days from consult to discharge or death were strongly correlated with the intervals between admission to the hospital and request for an ethics consultation. CONCLUSION: Our findings suggest race and gender disparities in the timing of ethics consultations that consultants may have partially mitigated.

Can I trust them to do everything? The role of distrust in ethics committee consultations for conflict over life-sustaining treatment among Afro-Caribbean patients.

BACKGROUND: Distrust in the American healthcare system is common among Afro-Caribbeans but the role of this distrust in conflict over life-sustaining treatment is not well described. OBJECTIVE: To identify the ways that distrust manifests in ethics committee consultation for conflict over life-sustaining treatment among Afro-Caribbean patients. METHODS: This was a retrospective cohort study at a large academic hospital of all ethics committee consultations for life-sustaining treatment among Afro-Caribbean patients and their surrogates. We reviewed medical records and identified cases in which ethics consultants described distrust as playing a role in the conflict over life-sustaining treatment. RESULTS: Of the 169 ethics committee consultation cases for conflict over life-sustaining treatment, 11 (6.5%) involved patients who self-identified as Afro-Caribbean. Distrust played a role in several of these cases, with surrogates of three patients, in particular, illustrating the way that perceived heath disparities, past labelling and concerns about continued maltreatment generated distrust leading to conflict over life-sustaining treatment. CONCLUSIONS: Exploring issues of distrust may help ethics consultants identify the source of conflict over life-sustaining treatment among Afro-Caribbean patients.

Not just little adults: a review of 102 paediatric ethics consultations.

AIM: The American Academy of Pediatrics statement on institutional ethics committees highlights the importance of paediatric ethics consultation. However, little has been published on actual experience with ethics consultation in paediatrics. The objective of this study was to review and describe topics covered by a large retrospective sample of clinical ethics consultations in paediatric medicine. METHODS: We reviewed ethics consultations involving patients of <18 years of age from January 2005 to July 2013 at one institution. Descriptive statistics of the patient population, the reason for the ethics consultation and the consultant's perceived contribution to the case were generated. Subgroups of patients were compared based on demographic and clinical characteristics using Wilcoxon's rank sum tests, chi-square tests and logistic regression models. RESULTS: Most of the 102 eligible consultations originated from intensive care units and were requested by attending physicians. The most frequent topic leading to consultation was end-of-life issues. Both younger age and male sex were associated with consults for end-of-life issues (p < 0.001 and p = 0.010). CONCLUSION: This analysis provides important information describing the type of consults requested in paediatric medicine, which is necessary given the movement towards professionalising clinical ethics consultation. Further empirical research is needed on ethics consultation in paediatrics.

Characteristics and Outcomes of Ethics Consultations in an Oncologic Intensive Care Unit.

OBJECTIVE: To evaluate the frequency, characteristics, and outcomes of ethics consultations in critically ill patients with cancer. DESIGN, SETTING, AND METHODS: This is a retrospective analysis of all adult patients with cancer who were admitted to the intensive care unit (ICU) of a comprehensive cancer center and had an ethics consultation between September 2007 and December 2011. Demographic and clinical variables were abstracted along with the details and contexts of the ethics consultations. MAIN RESULTS: Ethics consultations were obtained on 53 patients (representing 1% of all ICU admissions). The majority (90%) of patients had advanced-stage malignancies, had received oncologic therapies within the past 12 months, and required mechanical ventilation and/or vasopressor therapy for respiratory failure and/or severe sepsis. Two-thirds of the patients lacked decision-making capacity and nearly all had surrogates. The most common reasons for ethics consultations were disagreements between the patients/surrogates and the ICU team regarding end-of-life care. After ethics consultations, the surrogates agreed with the recommendations made by the ICU team on the goals of care in 85% of patients. Moreover, ethics consultations facilitated the provision of palliative medicine and chaplaincy services to several patients who did not have these services offered to them prior to the ethics consultations. CONCLUSION: Our study showed that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients' surrogates in the majority of cases. Additionally, these consultations identified the need for an increased provision of palliative care and chaplaincy visits for patients and their surrogates at the end of life.

Variables que condicionan la utilización de la consulta de enfermería en centros de salud de la Comunidad de Madrid / Differences in the nursing consultation utilization in primary care, Spain

Fundamentos: Diferentes condiciones de utilización de servicios sanitarios pueden originar situaciones de falta de equidad. El objetivo del trabajo es conocer si existen diferencias en el uso de la consulta de enfermería en atención primaria. Métodos: Estudio multicéntrico transversal en 23 centros de salud de la Comunidad de Madrid. Se incluyó a 662 sujetos. Se recogieron variables relativas al centro de salud, de la consulta de enfermería, características sociodemograficas y de necesidad en salud. Se estudiaron la calidad de vida y la satisfacción de los sujetos. Las variables se clasificaron, según el modelo «conductual», en predisponentes, facilitadoras o de necesidad. Se construyeron modelos multivariantes explicativos. Resultados: Vivir en zonas de renta alta y la edad se asociaron con aumentos del 17% (IC95%: 0,4-36,9%) y del 11,0% por cada década (IC95%: 6,2-16,2) de las consultas/año de enfermería. De los factores facilitadores, cada minuto añadido de duración de la consulta se asoció con un aumento del 2,0% (IC95%: 1,2-2,9%) en las consultas/año, cada nueva consulta médica se asociaba con un aumento del 2,7% (IC95%: 2,1-3,2%) y la demora en conseguir cita superior a un día supuso una disminución del 32,8% (IC95%: 19,3-44,1%) del número de consultas. Cada condición crónica, que expresa necesidad en salud, se asoció con un incremento del número de consultas del 4,8% (IC 95%: 1,7-8,0%). La mejor percepción de la calidad de vida se asoció con una reducción de las consultas de un 5,4% (IC95%: 1,0-8,7%). Conclusión: Las diferencias en el uso de la consulta de enfermería responde a criterios de necesidad, pero también está influenciada por condiciones de accesibilidad(AU)

Background: Different conditions in health services utilization may create situations of inequity. The objective was analyze the differences of nurse consultation utilization in primary care. Methods: Cross-sectional study, in 23 health centres in Madrid. Environmental variables, consultation characteristics, socio-demographic and health need characteristics were collected. The quality of life and satisfaction were also studied. The variables were classified according to the «behavioral model» in predisposing, enabling or need variables. Explanatory multivariate models were constructed (Generalized-Estimating-Equations). Results: The higher income areas and aging, predisposing factors, were associated with increases of 17% (95% CI: 0.4 to 36.9%) and 11.0% per decade (95% CI: 6.2 - 16.2) in nursing consultations per year. Among enabling factors, each additional minute of consultation length was associated with an increase of 2.0% (95% CI :1.2-2, 9%) in number of nurse consultations, each new medical consultation was associated with a increase of 2.7% (95% CI: 2.1-3.2%) and the delay in getting appointment over a day, represented a decrease of 32.8% (95% CI: 19.3 to 44.1%) in the total nursing consultations. Each chronic condition, which expresses the need health, was associated with an increase in the number of visits of 4.8% (95% CI: 1.7 to 8.0%). The improved perception of quality of life was associated with a reduction of 5.4% (95% CI 1.0 to 8.7%) of the consultations. Conclusion: The difference of the use of primary care nurse consultations is based on health need criteria, but is also influenced by accessibility conditions(AU)

Report of the ethics committee, 2012.

In accordance with the bylaws of the American Psychological Association (APA), the Ethics Committee reports regularly to the membership regarding the number and types of ethics matters investigated and the major programs undertaken. In 2012, ethics adjudication, ethics education and consultation, and special projects were activities of the Ethics Committee. Issues, activities, and programs regarding diversity and minority group outreach are also discussed.

The establishment of research ethics consultation services (RECS): an emerging research resource.

Emphasis on translational research to facilitate progression from the laboratory into the community also creates a dynamic in which ethics and social policy questions and solutions are ever pressing. In response, academic institutions are creating Research Ethics Consultation Services (RECS). All Clinical Translational Science Award institutions were surveyed in early 2010 to determine which institutions have a RECS in operation and what is their composition and function. Of the 46 institutions surveyed, 33 (70%) have a RECS. Only 15 RECS have received any consult requests in the last year. Issues that are common among these relatively nascent services include relationships with institutional oversight committees, balancing requestor concerns about confidentiality with research integrity and human subjects protection priorities, tracking consult data and outcomes, and developing systems for internal evaluation. There is variability in how these issues are approached. It will be important to be attentive to the institutional context to develop an appropriate approach. Further data about the issues raised by requestors and the recommendations provided are necessary to build a community of scholars who can navigate and resolve ethical issues encountered along the translational research pathway.

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study.

BACKGROUND: To evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting. METHODS: A pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression. RESULTS: Structured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of "personal information overheard by others", being "seen by irrelevant persons", having "unintentionally heard inappropriate conversations from healthcare providers", and experiencing "providers' respect for my privacy". There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis. CONCLUSIONS: Significant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.