Can ethical case interventions improve healthcare?

What was the aim of this review?

The aim of this review was to find out whether ethical case interventions could improve care for patients. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. A typical example for situations in which ethical conflicts can arise are cases in which it is uncertain whether provision or limitation of treatment is in line with patients' will or patient welfare (or both). Ethical case interventions involve ethical experts discussing ethical challenges of patient care (specific patient situations) with different health professionals responsible for the care of the patient as well as the patient and his family. The aim of ethical case interventions is to support decision-making in clinical practice. Researchers in Cochrane collected and analysed all relevant studies to determine whether ethical case interventions improve patient care and found four relevant studies published in six articles.

Key messages

It was uncertain whether ethical case intervention reduced the decisional conflict of those who need to make decisions about treatment, because the certainty of evidence was very low. We found no studies reporting effects of ethical case interventions on moral distress, patient involvement in decision-making, patients' quality of life or ethical competency. It was uncertain whether ethical case intervention increased satisfaction with care, because the certainty of evidence was very low. We need more high-quality studies to evaluate ethical case intervention.

What was studied in this review ?

We chose the decisional conflict of participants affected by the decision, reduction of moral distress, patient involvement in decision-making and quality of life of patients as main outcome criteria to assess whether ethical case interventions improve health care.

What were the main results of this review?

The review authors found four relevant studies with results published in six articles. All studies compared ethical case interventions with usual care in intensive care units. The studies used two different models of ethical case interventions – proactive and request-based ethics consultation. In proactive ethics consultation, the ethicist himself/herself identifies potential ethical conflicts without being requested or ethics consultation is offered in response to latent conflicts. In request-based ethics consultation, professionals, patients or their families specifically ask for an ethics consultation to resolve a specific ethical conflict. All studies received public funding and one received additional funding from private sources.

Three studies reported on proactive ethics consultation. We found no data on decisional conflict, moral distress, patient involvement in decision-making, quality of life of patients or ethical competency. One study assessed satisfaction with care. It was uncertain whether proactive ethics consultation increased satisfaction with care, because the certainty of the evidence was very low.

One study reported on request-based ethics consultation. The study assessed the level of consensus regarding decisions about the care of patients as an indirect criterion for the reduction of decisional conflict. It was uncertain whether request-based ethics consultation increased consensus and, thus, reduced decisional conflict, because the certainty of the evidence was very low. We found no data on moral distress, patient involvement in decision-making, quality of life of patients or ethical competency.

How up to date is this review?

The review authors searched for studies that were published up to September 2018.

Authors' conclusions: 

It is not possible to determine the effectiveness of ethical case interventions with certainty due to the low certainty of the evidence of included studies in this review. The effectiveness of ethical case interventions should be investigated in light of the outcomes reported in this systematic review. In addition, there is need for further research to identify and measure outcomes which reflect the goals of different types of ethical case intervention.

Read the full abstract...
Background: 

Decisions in clinical medicine can be associated with ethical challenges. Ethical case interventions (e.g. ethics committee, moral case deliberation) identify and analyse ethical conflicts which occur within the context of care for patients. Ethical case interventions involve ethical experts, different health professionals as well as the patient and his/her family. The aim is to support decision-making in clinical practice. This systematic review gathered and critically appraised the available evidence of controlled studies on the effectiveness of ethical case interventions.

Objectives: 

To determine whether ethical case interventions result in reduced decisional conflict or moral distress of those affected by an ethical conflict in clinical practice; improved patient involvement in decision-making and a higher quality of life in adult patients. To determine the most effective models of ethical case interventions and to analyse the use and appropriateness of the outcomes in experimental studies.

Search strategy: 

We searched the following electronic databases for primary studies to September 2018: CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched CDSR and DARE for related reviews. Furthermore, we searched Clinicaltrials.gov, International Clinical Trials Registry Platform Search Portal and conducted a cited reference search for all included studies in ISI WEB of Science. We also searched the references of the included studies.

Selection criteria: 

We included randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies which compared ethical case interventions with usual care or an active control in any language. The included population were adult patients. However, studies with mixed populations consisting of adults and children were included, if a subgroup or sensitivity analysis (or both) was performed for the adult population.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care review group. We used meta-analysis based on a random-effects model for treatment costs and structured analysis for the remaining outcomes, because these were heterogeneously reported. We used the GRADE approach to assess the certainty of the evidence.

Main results: 

We included four randomised trials published in six articles. The publication dates ranged from 2000 to 2014. Three studies were conducted in the USA, and one study in Taiwan. All studies were conducted on intensive care units and included 1165 patients. We judged the included studies to be of moderate or high risk of bias. It was not possible to compare different models of the intervention regarding effectiveness due to the diverse character of the interventions and the small number of studies. Included studies did not directly measure the main outcomes. All studies received public funding and one received additional funding from private sources.

We identified two models of ethical case interventions: proactive and request-based ethics consultation. Three studies evaluated proactive ethics consultation (n = 1103) of which one study reported findings on one key outcome criterion. The studies did not report data on decisional conflict, moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life or ethical competency for proactive ethics consultation. One study assessed satisfaction with care on a 5-point Likert scale (1 = lowest rating, 5 = highest rating). The healthcare providers (nurses and physicians, n = 365) scored a value of 4 or 5 for 81.4% in the control group and 86.1% in the intervention group (P > 0.05). The patients or their surrogates (n = 275) scored a value of 4 or 5 for 83.6% in the control group and for 74.8% in the intervention group (P > 0.05). It was uncertain whether proactive ethics consultation led to high satisfaction with care, because the certainty of evidence was very low.

One study evaluated request-based ethics consultation (n = 62). The study indirectly measured decisional conflict by assessing consensus regarding patient care. The risk (increase in consensus, reduction in decisional conflict) increased by 80% as a result of the intervention. The risk ratio was 0.20 (95% confidence interval 0.09 to 0.46; P < 0.01). It was uncertain whether request-based ethics consultation reduced decisional conflict, because the certainty of evidence was very low. The study did not report data on moral distress of participants of ethical case interventions, patient involvement in decision-making, quality of life, or ethical competency or satisfaction with care for request-based ethics consultation.

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