Marika Dawn Warren

During COVID-19, most intensive care units (ICUs) in Canada implemented strategies to manage a surge in demand for critical care to avoid turning people away, termed “triage-avoidant strategies.” These strategies, including redeploying non-ICU staff to the ICU to increase patient capacity, and transferring people over long distances to available beds, may have caused negative consequences for patients, healthcare staff, and equity-deserving groups. This study explores the perspectives of equity-deserving groups and organizations on triage-avoidant strategies during COVID-19, examined organization-specific responses, and identified system-level recommendations to improve equity, access, and preparedness. A qualitative descriptive study was conducted between July and December 2023 across five provinces in Canada. Participants, including staff from organizations serving equity-deserving groups, as well as government and healthcare representatives, were recruited through professional networks and snowball sampling. A semi-structured interview guide was used to elicit perspectives, which were then analyzed inductively using thematic analysis. 23 individuals from Ontario (n=12), British Columbia (n=4), Saskatchewan (n=4), Nova Scotia (n=2) and New Brunswick (n=1) participated. 15 participants (65%) identified as persons of colour or among equity-deserving groups; 13 (57%) participants worked within organizations representing decision-makers, clinicians, and/or equity-deserving groups. We identified three themes: 1) Triage-avoidant strategies were perceived to have disproportionately harmful effects on equity-deserving groups and healthcare providers; 2) organizations acted to mitigate effects of triage-avoidant strategies; and 3) various system-level actions could help mitigate the perceived effects of these strategies in future surges in demand. This study contributes to the literature by incorporating perspectives of representatives from diverse organizations and equity-deserving groups on how triage-avoidant strategies disproportionately harmed the populations they serve. Our findings can inform the development/implementation of triage-avoidant strategies that mitigate the perceived harmful effects on decision-makers, clinicians, and equity-deserving groups, while promoting equitable care. Twenty-three individuals from Ontario (n=12), British Columbia (n=4), Saskatchewan (n=4), Nova Scotia (n=2) and New Brunswick (n=1) participated. Fifteen participants (65%) identified as persons of color or from systemically marginalized groups; thirteen (57%) participants worked within organizations representing decision-makers, clinicians, and/or systemically marginalized groups, such as race, illness, disability, socioeconomic factors or health status. We identified three main themes relating to participants’ perspectives of triage-avoidant strategies: Triage-avoidant strategies had disproportionately harmful impacts on systemically marginalized populations and healthcare providers; organizations acted to mitigate effects of triage-avoidant strategies; and, various system-level actions could help mitigate the perceived effects of these strategies in the future. Findings can inform the development and implementation of triage or triage-avoidant strategies that may mitigate the perceived harmful effects of such strategies on decision-makers, clinicians, and/or systemically marginalized groups, and promote equitable care.

Pendant la COVID-19, la plupart des unités de soins intensifs (USI) au Canada ont mis en place des stratégies pour gérer une hausse de la demande en soins critiques afin d’éviter de refuser des patients, appelées stratégies d’évitement du triage. Ces stratégies, notamment la réaffectation de personnel non spécialisé en soins intensifs vers les USI pour augmenter la capacité d’accueil, ainsi que le transfert de patients sur de longues distances vers des lits disponibles, ont pu entraîner des conséquences négatives pour les patients, le personnel de santé et les groupes en quête d’équité. Cette étude explore les perspectives de ces groupes et des organisations qui les représentent concernant les stratégies d’évitement du triage durant la COVID-19, examine les réponses propres aux organisations et identifie des recommandations à l’échelle du système pour améliorer l’équité, l’accès et la préparation. Une étude qualitative descriptive a été menée entre juillet et décembre 2023 dans cinq provinces canadiennes. Les participants, incluant du personnel d’organisations au service des groupes en quête d’équité ainsi que des représentants gouvernementaux et du secteur de la santé, ont été recrutés par le biais de réseaux professionnels et d’un échantillonnage boule de neige. Un guide d’entretien semi-structuré a été utilisé pour recueillir les points de vue, qui ont ensuite été analysés de manière inductive à l’aide d’une analyse thématique. Au total, 23 personnes provenant de l’Ontario (n=12), de la Colombie-Britannique (n=4), de la Saskatchewan (n=4), de la Nouvelle-Écosse (n=2) et du Nouveau-Brunswick (n=1) ont participé. Quinze participants (65 %) se sont identifiés comme personnes racisées ou appartenant à des groupes en quête d’équité; 13 (57 %) travaillaient au sein d’organisations représentant des décideurs, des cliniciens et/ou des groupes en quête d’équité. Trois thèmes ont été identifiés : 1) les stratégies d’évitement du triage ont été perçues comme ayant des effets disproportionnellement néfastes sur les groupes en quête d’équité et les professionnels de la santé; 2) les organisations ont agi pour atténuer les effets de ces stratégies; et 3) diverses actions à l’échelle du système pourraient contribuer à atténuer les effets perçus de ces stratégies lors de futures hausses de la demande. Cette étude apporte une contribution originale à la littérature en intégrant les perspectives de représentants d’organisations diverses et de groupes en quête d’équité sur la manière dont les stratégies d’évitement du triage ont causé des préjudices disproportionnés aux populations qu’ils desservent. Nos résultats peuvent éclairer l’élaboration et la mise en œuvre de stratégies d’évitement du triage qui atténuent les effets néfastes perçus sur les décideurs, les cliniciens et les groupes en quête d’équité, tout en favorisant des soins équitables.

Clinical ethics is largely about understanding concrete moral situations and supporting meaningful discussion on these to identify appropriate resolutions. However, concepts and methods to describe cases (e.g., dilemmas, situations, stories) vary between authors and case analysis methods. We undertook a non-exhaustive literature review — inspired by McDougall’s critical interpretive review method — to identify a range of influential ideas on how to describe clinical ethics cases and the methods recommended to understand these cases. We identified nine families of case analysis methods, which vary considerably with respect to the basic description of cases, the strategies recommended to understand cases, and additional features that should be considered (e.g., contexts, social and power dynamics, emotions). As a collective of clinical ethicists and academics, we identify five main limitations of these methods and underline the importance of developing methods based on the practical knowledge of clinical ethics consultants.

L’éthique clinique consiste en grande partie à comprendre des situations morales concrètes et à favoriser des discussions constructives à leur sujet afin d’identifier des solutions appropriées. Cependant, les concepts et les méthodes utilisés pour décrire les cas (ex. : les dilemmes, les situations, les récits) varient selon les auteurs et les méthodes d’analyse des cas. Nous avons entrepris une revue non exhaustive de la littérature — inspirée de la méthode d’analyse critique interprétative de McDougall — afin d’identifier une série d’idées influentes sur la manière de décrire les cas d’éthique clinique et les méthodes recommandées pour les comprendre. Nous avons identifié neuf familles de méthodes d’analyse de cas, qui varient considérablement en ce qui concerne la description de base des cas, les stratégies recommandées pour les comprendre et les caractéristiques supplémentaires à prendre en compte (ex. : les contextes, les dynamiques sociales et de pouvoir, les émotions). En tant que collectif d’éthicien(ne)s cliniques et d’universitaires, nous identifions cinq limites principales de ces méthodes et soulignons l’importance de développer des méthodes basées sur les connaissances pratiques des consultant(e)s en éthique clinique.

Understanding moral problems in clinical settings is central to clinical ethics consultation practice. Although this process may seem straightforward, it is in fact complex, multifaceted, and ongoing throughout consultations. Oftentimes the moral aspects of a situation will be articulated vaguely by those involved based on feelings of uneasiness and discomfort. Thus, clinical ethicists play a key role in helping to characterize these tensions in more formal and explicit terms using references to values and principles. The clinical ethics consultation literature points to the importance of this task and to some recommended practices in this process, such as those referenced in ASBH’s Core Competencies. However, there is a sizable gap between these practice guidelines and the actual methods, skills, and creativity deployed by clinical ethicists to accomplish this task. In this paper, we report a co-creative effort to lay out practices for understanding moral problems and structure them into a repertoire of practices. We followed a co-creative process involving semi-structured interviews with 20 practicing clinical ethicists as well as an iterative process involving drafting the repertoire and revising it during meetings and in manuscript form. The final repertoire structure and content includes: (1) elements considered to discern the moral nature of the problem; (2) actions and approaches taken to discern the moral nature of the problem; (3) elements considered in preparation for addressing the problem; (4) actions and approaches taken in preparation for addressing the problem; (5) modulating factors, and challenges and limits. We hope this work helps further ground the value of co-creative work in clinical ethics while also offering practical resources to support ongoing improvement of understanding moral problems in clinical ethics.

Integrating large language models (LLMs) like GPT-4 into medical ethics is a novel concept, and understanding the effectiveness of these models in aiding ethicists with decision-making can have significant implications for the healthcare sector. Thus, the objective of this study was to evaluate the performance of GPT-4 in responding to complex medical ethical vignettes and to gauge its utility and limitations for aiding medical ethicists. Using a mixed-methods, cross-sectional survey approach, a panel of six ethicists assessed LLM-generated responses to eight ethical vignettes. The main outcomes measured were relevance, reasoning, depth, technical and non-technical clarity, as well as acceptability of GPT-4’s responses. The readability of the responses was also assessed. Of the six metrics evaluating the effectiveness of GPT-4’s responses, the overall mean score was 4.1/5. GPT-4 was rated highest in providing technical (4.7/5) and non-technical clarity (4.4/5), whereas the lowest rated metrics were depth (3.8/5) and acceptability (3.8/5). There was poor-to-moderate inter-rater reliability characterised by an intraclass coefficient of 0.54 (95% CI: 0.30 to 0.71). Based on panellist feedback, GPT-4 was able to identify and articulate key ethical issues but struggled to appreciate the nuanced aspects of ethical dilemmas and misapplied certain moral principles. This study reveals limitations in the ability of GPT-4 to appreciate the depth and nuanced acceptability of real-world ethical dilemmas, particularly those that require a thorough understanding of relational complexities and context-specific values. Ongoing evaluation of LLM capabilities within medical ethics remains paramount, and further refinement is needed before it can be used effectively in clinical settings.

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un- Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article, we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic.