Clinical ethics consultation as “shared document”. Emerging ethical and medico-legal issues: Sacchini D., Corsano B., Refolo P., Minacori R., Spagnolo A.G.the experience of IBioMedH-UCSC CEC Service (2005-2016)

Background The clinical ethics consultation (CEC) aims to help patients, relatives, caregivers and healthcare professionals to cope with ethical issues arising in patient care. CEC can be drafted in two different ways: 1. CEC provided by clinical ethics consultant requested by clinical wards; 2. CEC as “shared decision-making document” (SDM-D) among different “bedside” stakeholders (patient, relatives, healthcare professionals, health managers) aimed at an agreed advanced clinical planning, namely in dilemmatic/uncertain settings. In fact, SDM is “an approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences” (Elwyn et al., 2010) Aim Assessing rising ethical/medico-legal issues in clinical cases requested for CEC and addressed through SDM-D. Methods We examined retrospectively SDM-Ds provided by IBioMedH-UCSC CEC Service and requested from different clinical Departments of “A. Gemelli” University Hospital Foundation (starting from January 2005 to December 2016), examining clinical indication, patient’s preferences, quality of life; context, in the light of personalist bioethical approach (Sgreccia, 1986).. Results 53 SDM-Ds out of 173 CECs were setup from 2005 to 2016. Clinical Departments that requested clinical ethics consultation were: Reproductive and maternal-Foetal Diseases (15, 28%); Internal Medicine & Infectious Diseases (12, 23%); Pediatrics and Neonatal care (11, 22%); Neurology (9, 15%); Hospice (3, 6%); Intensive Care Unit (2, 4%); Surgery (1, 2%). The following main ethical issues were recognized: cardiopulmonary resuscitation; tracheostomy, ectopic pregnancies; inducing childbirth; mechanical ventilation; palliative sedation. Possible ethical/medico-legal issues were identified: problems of communication and understanding between the parties; patients/family difficulties to identify benefits/burdens of treatments proposed by physicians and the patient’s best interest; incomplete patient’s understanding of physician’s clinical goals; the patient/family request to join the discussion and to share the decisions concerning treatments; the fear of family that the doctors are not doing enough for the patient; for end-of-life patients, the fear that doctors will do unnecessary treatments that produce suffering; the patients/family perception to have distant and seemingly irreconcilable positions with those of the doctors. The different reasons for dissatisfaction of patients/family seems related not to physicians’ technical skills, but to relationship issues. We observed that relationship difficulties could complicate other issues. In all cases examined, SDM helped to overcome potential conflicts, incomplete understandings or misunderstandings. The consequence of SDM was that no complaints has subsequently developed from these cases, some of which were particularly sensitive. Conclusion In our experience, the CEC provided through SDM-D can help: the optimization of the choice of proportionate treatments; to strengthen patients/family-doctors relationship and, at the same time, reduce the risk of complaints/disagreement; to analyse from the ethical point of view, for all the parties, the most problematic aspects of clinical situations and the possible solutions for a really SDM. The CEC-SDM-D can also clarify the goals of care for patient’s best interest.