The Journal of Clinical Ethics, Volume 29, Number 1, Spring 2018


At the Bedside


Slowing Down Fast Thinking to Enhance Understanding

Edmund G. Howe, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 3-14.

Stress can make the comprehension of complex information more difficult, yet patients and their family members often must receive, process, and make decisions based on new, complex information presented in unfamiliar and stressful clinical environments such the intensive care unit. Family members may be asked to make decisions regarding the donation of organs and genetic tissue soon after the death of a loved one, based on new, complex information, under tight time limits. How can we assist patients and families better process complex information while under stress, and to make better decisions for themselves or for a loved one?

Open access        Video of abstract




“Buying-In” and “Cashing-Out”: Patients’ Experience and the Refusal of Life-Prolonging Treatment

Nathan Scheiner and Joan Liaschenko, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 15-9.

Surgical “buy-in” is an “informal contract between surgeon and patient in which the patient not only consents to the operative procedure but commits to the post-operative surgical care anticipated by the surgeon.” Surgeons routinely assume that patients wish to undergo treatment for operative complications so that the overall treatment course is “successful,” as in the treatment of a post-operative infection. This article examines occasions when patients buy-in to a treatment course that carries risk of complication, yet refuse treatment when complications arise. We coin this counter-phenomenon “cashing-out.” Cashing-out may elicit negative feelings among careproviders. We question why patients or families may wish to cash-out. One reason may be the changing epistemological position of patients as they experience a complication. The shift from the hypothetical discussion of complications during the initial informed-consent process to the experience of having a complication represents new knowledge. Patients and families may use this knowledge as the basis to revoke consent for some or all of the remaining treatment course. This article seeks to understand cashing-out in terms of the patients’ experiences. We hope to prompt recognition of this phenomenon across medical contexts and to provide impetus for further work to understand why patients may wish to cash-out.

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Impact of Cognitive Load on Family Decision Makers’ Recall and Understanding of Donation Requests for the Genotype-Tissue Expression (GTEx) Project

Laura A. Siminoff, Maureen Wilson-Genderson, Maghboeba Mosavel, Laura Barker, Jennifer Trgina, Heather M. Traino, Howard M. Nathan, Richard D. Hasz, and Gary Walters, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 20-30.

Genomic research projects that collect tissues from deceased organ and tissue donors must obtain the authorization of family decision makers under difficult circumstances that may affect the authorization process. Using a quasi-experimental design, the Ethical, Legal, and Social Issues (ELSI) substudy of the Genotype-Tissue Expression (GTEx) project compared the recall and understanding of the donation authorization process of two groups: family members who had authorized donation of tissues to the GTEx project (the comparison group) and family members who had authorized organ and tissue donations in years previous, who subsequently participated in two different mock-authorization processes that mimicked the GTEx authorization process (the intervention groups). Participants in the comparison and intervention groups were matched on key demographic characteristics.

      We found that participants in the intervention groups who experienced a mock-authorization process demonstrated better recall of the tissue donation request than members of the comparison group. Our data indicate that the stress associated with the loss of a loved one limited the ability of family members to recall details about the GTEx project. However, we found a similar lack of knowledge in both the comparison and the intervention group participants, suggesting lack of knowledge may be due to the complexity and unfamiliarity of the information presented to them during the authorization process. We discuss these findings in the context of everyday clinical decision making in cognitively challenging conditions.

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An International Legal Review of the Relationship between Brain Death and Organ Transplantation

Kiarash Aramesh, Hitoshi Arima, Dale Gardiner, and Seema K. Shah, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 31-42.

The “dead-donor rule” states that, in any case of vital organ donation, the potential donor should be determined to be dead before transplantation occurs. In many countries around the world, neurological criteria can be used to legally determine death (also referred to as brain death). Nevertheless, there is considerable controversy in the bioethics literature over whether brain death is the equivalent of biological death. This international legal review demonstrates that there is considerable variability in how different jurisdictions have evolved to justify the legal status of brain death and its relationship to the dead-donor rule.

      In this article, we chose to review approaches that are representative of many different jurisdictions—the United States takes an approach similar to that of many European countries; the United Kingdom’s approach is followed by Canada, India, and influences many other Commonwealth countries; Islamic jurisprudence is applicable to several different national laws; the Israeli approach is similar to many Western countries, but incorporates noteworthy modifications; and Japan’s relatively idiosyncratic approach has received some attention in the literature. Illuminating these different justifications may help develop respectful policies regarding organ donation within countries with diverse populations and allow for more informed debate about brain death and the dead-donor rule.

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Clinical Practice


The Bedside Capacity Assessment Tool: Further Development of a Clinical Tool to Assist with a Growing Aging Population with Increased Healthcare Complexities

Maria Torrroella Carney, Brian Emmert, and Brian Keefe, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 43-51.

      Background: As the population of the United States ages, chronic diseases increase and treatment options become technologically more complicated. As such, patients’ autonomy, or the right of patients to accept or refuse a medical treatment, may become a more pressing and complicated issue. This autonomy rests upon a patient’s capacity to make a decision. As more older, cognitively and functionally impaired individuals enter healthcare systems, quality assessments of decision-making capacity must be made. These assessments should be done in a time-efficient manner at a patient’s bedside by the patient’s own physician. Thus, a clinically practical tool to assist in decision-making capacity assessments could help guide physicians in making more accurate judgments.

      Objectives: To create a clinically relevant Bedside Capacity Assessment Tool (BCAT) to help physicians make timely and accurate clinical assessments of a patient’s decision-making capacity for a specific decision.

      Setting: The Department of Medicine, Division of Geriatrics and Palliative Medicine, Zucker School of Medicine at Hofstra/Northwell .

      Participants: Geriatric medicine fellows, palliative medicine fellows, and internal medicine residents (n = 30).

      Measurements: Subjects used the BCAT to assess the decision-making capacity of patients described in 10 written, clinically complex capacity assessment vignettes. Subjects’ conclusions were compared to those of experts.

      Results: The subjects’ and experts’ assessments of capacity had a 76.1 percent rate of agreement, with a range of 50 percent to 100 percent. With removal of three complex outlier vignettes, the agreement rate reached 83.2 percent.

      Conclusion: The strong correlation between the two groups—one of physicians in training utilizing the BCAT and the other of specialists in this area—suggests that the BCAT may be a useful adjunct for clinicians who assess decision-making capacity in routine practice. The range indicates that further refinement and testing of this tool is necessary. The potential exists for this tool to improve capacity assessment skills for physicians in clinical practice.

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Meaningful Use of Electronic Health Records for Quality Assessment and Review of Clinical Ethics Consultation

Susan Sanelli-Russo, Kelly McBride Folkers, William Sakolsky, Joseph J. Fins, and Nancy Neveloff Dubler, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 52-61.

Evolving practice requires peer review of clinical ethics (CE) consultation for quality assessment and improvement. Many institutions have identified the chart note as the basis for this process, but to our knowledge, electronic health record (EHR) systems are not necessarily designed to easily include CE consultation notes. This article provides a framework for the inclusion of CE consultation notes into the formal EHR, describing a developed system in the Epic EHR that allows for the elaborated electronic notation of the CE chart note. The implementation of the “meaningful use” criteria for EHR, mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, requires that health professionals meet certain standards for quality, efficiency, and safety, all of which overlap with the goals of standardization, peer review, and quality improvement within CE consultation.

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The Ethics of Bundled Payments in Total Joint Replacement: ”Cherry Picking” and “Lemon Dropping”

Casey Jo Humbyrd, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 62-8.

The Centers for Medicare & Medicaid Services has initiated bundled payments for hip and knee total joint replacement in an effort to decrease healthcare costs and increase quality of care. The ethical implications of this program have not been studied. This article considers the ethics of patient selection to improve outcomes; specifically, screening patients by body mass index to determine eligibility for total joint replacement. I argue that this type of screening is not ethically defensible, and that the bundled payment program as structured is likely to lead to unfair restrictions on who receives total joint replacements.

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Colorado’s New Proxy Law: Moving from Statute to Guidelines

Jacqueline J. Glover, Deb Bennett-Woods, and Jean Abbott, The Journal of Clinical Ethics 29, no. 1 (Spring 2018): 69-71.

In 2016, the Colorado legislature passed an amendment to Colorado’s medical proxy law that established a process for the appointment of a physician to act as proxy decision maker of last resort for an unrepresented patient (Colorado HB 16-1101: Medical Decisions For Unrepresented Patients). The legislative process brought together a diverse set of stakeholders, not all of whom supported the legislation. Following passage of the statutory amendment, the Colorado Collaborative for Unrepresented Patients (CCUP), a group of advocates responsible for initiating the legislative process, coordinated a unique effort to engage these stakeholders in the creation of a set of voluntary guidelines to assist facilities and individual careproviders in the implementation of policies and procedures enabled by the statute. This article delineates the questions and concerns of stakeholders, describes how those issues were addressed within the guidelines, and proposes additional opportunities for research to assess the impact of the legislation in Colorado.

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Slowing Down Fast Thinking to Enhance Understanding

Edmund G. Howe

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