Main challenges in adoption of consultation services of hospital ethics committees: A systematic review of the literature

Abstract

Background

There are numerous challenges in the consultation services of the Hospital Ethics Committees (HEC) that can impact the means of providing healthcare. This review aimed to identify the main challenges in the application of consultation services of the HEC and propose possible solutions.

Methods

This systematic review was conducted through searching electronic databases including PubMed, Scopus, Science Direct, ProQuest, and Embase. Inclusion criteria included studies published in English language in a peer-reviewed journal, from 2000 to 2019 were identified, which clearly defined the design, method, and results of the study. Study selections, quality assessments, data extraction, and analysis were completed by two researchers, independently. The thematic analysis was used to analyze the data.

Results

The search yielded 1204 articles and 6 of these, included the analyses. Challenges were categorized into 9 themes: (a) personal views and believes in healthcare professionals, (b) sense of fear in the healthcare professionals, (c) medical culture, (d) environmental factors, (e) managerial and structural factors, (f) characteristics of the HEC members, (g) factors related to the HEC, (h) problematic process for HEC consultations, and (i) weakness of knowledge about HEC. Accordingly, proposed solutions were organized according to five themes: reforming the HEC executive processes, creating the appropriate communications, developing awareness about HEC, improving the competencies of HEC members, and (e) receiving support from HEC consultations.

Conclusions

This review highlights that proposed solutions serve as examples of strategies, which attempt to solve challenges related to the application of the consultation services of HEC by healthcare professionals.

Keywords

Consultation ethics committee medical ethics clinical ethics healthcare professionals hospital

Background

During the 21st century, with advanced technology and the appearance of religious values in modern societies, conflict of values are arising and decision-making processes associated with healthcare professionals (physicians, nurses, social workers, etc.) are becoming more and more complicated.^1,2 Further, some ethical issues can be related to conﬂicting interests between healthcare professionals and patients or their families.^3,4 In hospitals, clinical practice faces a wide variety of ethical dilemmas and complex issues with patients, which can be difficult for healthcare professionals to resolve individually.^3,5 Healthcare professionals likely experience distress as a result of ethical issues.^6,7 To respond to the need and support of patients’ values, in 2004, the Ethox Centre (University of Oxford) was disseminated guidance on the structure, composition, and function for establishing and developing the Hospital Ethics Committee (HEC).^8,9

The HEC were created to address ethical situations and provide a major arena for multidisciplinary discussions of complex clinical ethics challenges.¹⁰ Recently HEC is becoming more common for two reasons: 1) with the increased worldwide awareness of the importance of ethical issues in healthcare and 2) by healthcare professionals encountering an increasing number of ethical issues in clinical practice.^11–14 Traditionally, the HECs focus on three functions of providing ethics input into trust policy and guidelines around patient care, facilitating ethics education for health professionals along with trust, and providing ethics advice to clinicians on individual cases.^9,15

The HEC presented consultation services offered in response to problems from patients, families, healthcare professionals, or other involved uncertainty or conflict, regarding value-laden concerns that emerge in hospitals.¹⁶ The American Society for Bioethics and Humanities clarify the goal of ethics consultation ‘‘to improve the quality of health care through the identification, analysis, and resolution of ethical questions and concerns’’.¹ When a consultation service is requested, members of the HEC appraise the clinical situation and resolve the problems through interviews with healthcare professionals, patients, and their families.¹⁶ After a clinical care recommendation has been reached, the HEC representatives evaluate the outcomes of the consultation.¹⁷

There is some evidence that when physicians and nurses confront an ethical problem, instead of using HEC consultation, prefer to consult their colleagues.¹⁸ Several studies have looked at why physicians or other healthcare professionals may or may not use HEC consultation services.^19–22 A survey by DuVal et al. assessed the reasons that physicians seek consultation from ethics committees, showing that the most common event leading to request consultation was the need for help in resolving a conflict, interacting with a difficult patient or family, decision-making or planning for care, as well as for emotional reasons such as disappointment or fear.²⁰ Gaudine et al. conducted a qualitative study to investigate the barriers and facilitators perceived by nurses and physicians to use the advice of the HEC. In this study, data related to the identification of barriers and facilitators of the application of HEC consulting were categorized into nine classes of barriers and nine classes of facilitators.²³

However, to our knowledge, there is a lack of systematic review regarding the main challenges in the adoption of the consultation services of HEC and proposed possible solutions by healthcare professionals. Healthcare professionals in the context of this study refer to physicians and nurses. Therefore, in this review, we aimed to identify the main challenges in the adoption of the consultation services of HEC and proposed possible solutions.

Methods

Design

This systematic review was carried out to identify challenges in the application of the consultation services of HEC and proposed possible solutions. This systematic review was conducted based on the preferred reporting items for systematic reviews and meta-analyses’ (PRISMA) guidelines.²⁴

Search strategy

A comprehensive systematic search of online databases, including PubMed, Scopus, Science Direct, ProQuest, and Embase was performed. These databases were selected due to their broad scope of publications and multi-disciplinary contents. The final search was performed on 11 September 2019. According to Boolean logic, the corresponding search formulas were formulated according to the characteristics and the requirements of each database. The key terms and final searching syntax in databases was as the following: (“Ethics* committee” OR “clinical ethics*” OR “medical ethics*”OR “counsel* ethics*” OR “advise ethics*” OR “advice ethics*” OR “consult ethics*”) AND (“Hospital”). After excluding irrelevant articles, to ensure that any relevant articles are not missed, we conducted searches of the reference lists of relevant articles (reference by reference). Finally, to identify and cover more articles, a manual search of some reliable key journals also was performed.

Eligibility criteria

The different inclusion and exclusion criteria were used to select the articles for this review. Inclusion and exclusion criteria are listed in Table 1.

Table 1.

Inclusion and exclusion criteria.

Inclusion criteria

• Article related to the purpose of the review• Publish to English language• Were published in a peer-reviewed journal• Years limited to 2000–2019• Design, method and results of study clearly defined

Exclusion criteria

• Duplicate publications• Letters to the editors • Presentations at conferences (Conferences abstract)• Commentaries• Book review• Case reports• Protocol• Assessment results fall within the scope of low quality research after using the checklist quality assessment tool

Study selection

After removing duplicates, the articles were screened in two phases: First, the title and abstract, and second the full-text versions of all remaining records were assessed for eligibility. Authors documented the inclusion and exclusion criteria for each article and discussed disagreements until consensus was reached.

Quality assessment

The final articles that met the inclusion criteria were independently assessed for quality. The tool for assessment of included studies was MMAT (Mixed Methods Appraisal Tool) checklist version 2018. The MMAT is intended to be used as a checklist for concomitantly appraising and/or describing studies included in systematic mixed studies’ reviews (reviews including original qualitative, quantitative, and mixed-method studies).²⁵ Based on the scores achieved from the assessment, the quality of articles was classified into strong, medium, and weak.

Data extraction

To extract data, we used a researcher-made data extraction table form in Microsoft Word. The data extraction content mainly included: first author’s name, year of publication, aim, country, study design, participants, sample sizes, and quality score.

Data analysis

After the selection of final articles, to identify challenges and proposed solutions in included articles, the collected research data were analyzed. We used thematic analysis for categorizing the results, following both chronological phases of realization and emerging themes. All the steps, including searching, screening, quality assessment, and data extraction, were independently reviewed by two authors (AH and RKZ), and the discrepancies were resolved by a third researcher (SM).

Results

Search results

From the electronic online search in databases, a total of 1204 records were found, of which 405 duplicate records were identified and removed. The titles and abstracts of all articles were read and 763 irrelevant articles were excluded. Then, 36 articles underwent full-text review. Among these, 5 articles according to the inclusion criteria were chosen. One study was identiﬁed via a reference by reference search and finally, 6 articles were selected (Figure 1).

Figure 1.

Articles ﬂow diagram.

Publication characteristics

All 6 articles were published between 2004 and 2013 in different journals. The method of conducting the included articles was a qualitative study (n = 4) and a quantitative study (n = 2). Most included articles were conducted in the context of the hospital. The results of the quality assessment showed 5(83.33%) articles had good quality, and 1(16.66%) had medium quality. Characteristics of the included articles are detailed in Table 2. Thematic analysis was categorized into the following factors: 9 main theme challenges (Table 3) and 5 main theme solutions (Table 4).

Table 2.

Detailed characteristics of the included articles.

Ref. ID	References	Aim	Country	Design of study	Setting	Participants (n)	Quality of article
1	DuVal et al.²⁶	To identify the ethical dilemmas that internists encounter, the strategies they use to address them, and the usefulness of ethics consultation	USA	Quantitative	Doctors’ offices	Physicians (344)	Medium
2	Orlowski et al.²¹	To determine factors that may influence doctors to request or not request ethics consultation	USA	Quantitative	University Community Hospital	Doctors (121)	Good
3	Førde et al.²⁷	The study indicates that the clinicians found the clinical ethics consultations useful and worthwhile doing	Norway	Qualitative	Hospital	Subgroup of the committee members (10)	Good
4	Pederson et al.²⁸	Explores signiﬁcant barriers confronting the ethics committees in providing such consultation services	Norway	Qualitative	Hospital	Committee members (9)	Good
5	Gaudine et al.²³	‘What are the barriers and facilitators nurses and physicians perceive in consulting their hospital ethics committee?	Canada	Qualitative	Hospital	Nurses (34), nurse managers (10) and physicians (31)	Good
6	Jansky et al.²⁹	Explore the subjective need of healthcare professionals for ethics consultation, their experience with ethical conflicts, and expectations and objections toward a clinical ethics committee	Germany	Qualitative	Hospital	Physicians (30) and nurses (71)	Good

Table 3.

Main challenges in utilization the consultations services of HEC.

Themes	Challenges for HEC consultation
Personal views and believes in healthcare professionals	✓ Consultation could hurt me legally should a lawsuit arise✓ Believes to it is my responsibility to resolve this with the patient/family✓ Consultation is confusing to the patient/family✓ Complicating patient/family communication ethics ✓ Existence sense of “moral experts” in HEC members✓ Believes to consultations make things worse ✓ Believes to consultants are unqualified ✓ Consultations are unhelpful solutions are not consistent✓ Confidentiality concerns in medical team members✓ Disbelieve in health personnel to HEC✓ Desire to use informal to deal with ethical problems✓ Willingness to use faster methods to deal with ethical problems✓ Believe to the lack of involvement of who do not know the patient✓ Believe to the lack of involvement of who do not necessary medical knowledge ✓ Haven’t time to write a submission of a case to the HEC✓ Willingness to evaluate alternatives✓ Believe that one should be able to manage clinical situations oneself✓ Believe that Advice would not be helpful✓ Referring a case to HEC may be experienced as embarrassing
Sense of fear in the healthcare professionals	✓ Fear of scrutiny and judgment by others✓ Fear of repercussions✓ Fear that others may intervene with the patient/family✓ Fear of reprisal by others✓ Fear of the likelihood of diminishing the respect of all ✓ Fear of not proficient in making or guiding patient/family✓ Fear of questioning in the ability cope with the problem
Medical culture	✓ Lack of clarity in medical culture✓ Medical culture's reluctance to facing views and potential critiques from outside✓ Tendency within the medical culture for evading conﬂicts and outsiders✓ Existence certain prejudice and cultural at work
Environmental elements	✓ Disagreement between HEC members and healthcare professionals✓ The use of HEC advice was not a priority for healthcare professionals✓ Involve outsiders when facing ethical challenges is difficult✓ Feelings of lack of resources✓ Lack of support from colleagues for bringing an ethical issue forward✓ Not knowing someone on HEC by healthcare professionals✓ HEC seen as last resort✓ Being new of consulting services and not well known in the hospital✓ Feeling the HEC was a kind of court✓ Concern of time and manpower for the HEC work✓ Lack of impact of HEC in daily practice✓ Problems in implementation of HEC✓ Misuse of ethical principles in hospital
Managerial and structural factors	✓ Unjustiﬁed interference with the HEC work✓ Lack of secretary on the chart of some hospital HEC✓ Not following chain of command✓ Non responsive chain of command✓ Lack of informal and formal supports
Characteristics of HEC members	✓ Difficult to access HEC members✓ lack of professional competence among HEC members✓ Approach too theoretical and not practice oriented in HEC members✓ Lack of expertise on HEC members✓ Lack of case-related specialized competence of HEC members✓ Inability of HEC members to grasp the full picture from the “outside”✓ Absence level of responsibility and formalization among HEC members
Factors related to HEC	✓ Existent resistance within the HEC to developing inclusive and transparent procedures✓ Lack of documentation and report about ethical challenges by HEC✓ HEC are hesitant about they should deal with or how they should handle the cases✓ Absent or leave during the meeting of HEC to attend to clinical tasks by physicians✓ Lack of professional attitude by HEC✓ Fear of institutional control of HEC✓ Inability to enforce decisions by HEC✓ Inability of HEC to deal with problems that require immediate resolution✓ Unavailability of HEC when the clinicians need it
Problematic process for HEC consultations	✓ A lengthy or untimely process✓ Lack of resource person to discuss issue with✓ Lack of simple forms to send file cases with the HEC for consultation✓ Lack of good procedures in preparing and carrying out the consultation✓ The too time consuming consultation services
Weakness in knowledge about HEC	✓ Lack of knowledge about criteria for HEC consultation✓ Lack of knowledge about procedures to bring issues to HEC✓ Lack of knowledge about hours of operation of HEC✓ Lack of experience with family meetings✓ Lack of knowledge about benefit and purpose of HEC✓ Lack of knowledge about facts of patient situation✓ Lack of knowledge about ethics expertise on HEC✓ Lack of knowledge about HEC by patients and families✓ Lack of experience or expertise in managing ethical issues to bringing issues to the HEC✓ Lack of recognition that a situation is an ethical situation✓ Misconceptions about what HEC are and how to deal with disagreement

Table 4.

Possible solutions for utilization the consultations services of HEC.

Themes	Possible solutions for HEC consultation
Reforms in the HEC executive processes	✓ Providing enough time for case-discussion by HEC✓ Transparent and accountable procedures in HEC functioning✓ Structural integration of ethics consultations✓ Provide speedy consultation by HEC✓ Improve the administrative and deliberation procedures of HEC✓ Obtain a systematic and comprehensive analysis of a difﬁcult ethical dilemma✓ Deal with the fundamental questions of a problem by HEC✓ Impact the HEC consultation over wider or more general✓ Using HEC of formula to facilitate more structured deliberations✓ Get attention all aspects of a case, such as psychosocial conditions by HEC✓ With good practice by HEC
Creating the appropriate communications	✓ Facilitate to communication with patient/family✓ Spend extra time with the patient/family by ethics HEC members✓ Easy accessibility to HEC✓ Improve to shared decisions or alternate points of view✓ Strengthening the patient/family's confidence✓ Help the HEC to clinician for see the patient’s wishes and values more clearly✓ Presence of ethicist on unit of HEC✓ Respect for patient autonomy by HEC members✓ Direct contact with HEC or HEC members✓ Recruit physicians to chair the HEC in order to achieve legitimacy
Developing awareness about HEC	✓ Knowing a HEC member by healthcare professionals✓ Expand organizational integration by the hospital management✓ Advertising HEC in seminars✓ Understand the reason of HEC existence by target groups ✓ Advertising HEC in hospital departments✓ Available information within the organization about HEC✓ Being conscious of the HEC proﬁle and area of responsibility in hospital✓ Extensive training in ethics and ethics principles by HEC members
Improving the competences of HEC members	✓ Participate of HEC members in frequent ethics education✓ Specialized and social competence of HEC members✓ Reading materials about ethics by members of HEC✓ Able of members to solve ethical issues and to assist team communication✓ Increasing expertise on HEC members✓ Building a positive self-identity for the HEC members✓ Cooperation, independency and objectivity of HEC members✓ Transparency of CEC members’ activity
Supporting from HEC consultations	✓ Support by members of the health care team✓ Develop adequate institutional support by the hospital management✓ Support by the patient advocate

Study quality

The results of the quality assessment showed that 5(83.33%) articles had good quality, and 1(16.66%) had medium quality. Also, no articles were excluded based on the level of evidence or quality assessment.

Principle findings

In the finall phase of the analysis, the challenges, and proposed solutions were organized. The authors discussed and consensus at this phase to categorize the findings. Finally the challenges were categorized into 9 themes: (a) personal views and believes in healthcare professionals, (b) sense of fear in the healthcare professionals, (c) medical culture, (d) environmental factors, (e) managerial and structural factors, (f) characteristics of the HEC members, (g) factors related to the HEC, (h) problematic process for HEC consultations, and (i) weakness of knowledge about HEC. Accordingly, proposed solutions were organized according to five themes: reforming the HEC executive processes, creating the appropriate communications, developing awareness about HEC, improving the competencies of HEC members, and (e) receiving support from HEC consultations.

Discussion

The ﬁndings of this systematic review highlighted the various challenges and proposed possible solutions in the adoption of the consultation services of HEC. From the thematic analysis of the included articles, different challenges for the adoption of the consultation services of HEC were identified. Afterward, challenges were classified in nine different themes.

The first group of challenges was related to the views and beliefs of healthcare professionals about HEC. Similar to our group, in the study of Orlowski et al., doctors who did not use ethics consultation tend to think that consultation is not helpful and it is their responsibility to resolve issues with patients, families, and they relied on their existing proficiency in ethical issues.²¹ The next themes of challenges were the existence of a sense of fear in healthcare professionals. In the study of Hurst et al., fear of repercussions, scrutiny, judgment by others, were the main issues and other issues were related to the patient/family.²³ Medical culture is effective in requiring physicians and other personnel to seek HEC consultation services.

In Norway, Førde et al. found that medical culture was reluctant to facing views and potential critiques from outsiders, and it was no complete clarity in the medical culture about the HEC.²⁷ Some of the challenges identified were related to the external environment. Pederson et al. highlighted the lack of resources, time, and manpower for the committees’ work as a major concern.²⁸

In the managerial and structural aspects, there are challenges to the HEC services. Consistent with the study of Gaudine et al., the main obstacles to HEC services were lack of support by hospital management and not following the chain of command from healthcare professionals.²³ Challenges for the process of HEC and HEC members were also identified. Lack of transparent procedures, documentation, expertise, unqualified, and difficulty to access HEC members are factors that are common in studies.^26,28 The barriers to consulting an HEC are similar to those of a previous study that looked at the reasons, the barriers, and facilitator nurses and physicians perceived in consulting their HEC.²³ In this study, Gaudine et al. noted the lack of knowledge about hours of operation of HEC, benefit, criteria, and purpose of HEC.

Also based on the analysis, solutions addressing the challenges for healthcare professionals to apply the consultation services of HEC were organized according to five themes: (a) reforming the HEC executive processes, (b) creating the appropriate communications, (c) developing awareness about HEC, (d) improving the competencies of HEC members, and (e) receiving support from HEC consultations. To facilitate the HEC consultation services, reforms in the HEC executive processes are necessary. In included studies, enough time for case-discussion and good practice by a member of HEC were also highlighted.^26,29

In hospitals, good communication creates an understanding of the consultation service and awareness about HEC. The policies of advertising HEC in seminars, the presence of ethicists on the unit, and recruiting physicians to chair the HEC can be applied in this regard.²⁸ Colleagues, hospital management, and patient advocates must support healthcare professionals to bring ethical issues to HEC.²³ The proposed solutions serve as examples of strategies that attempt to solve challenges related to healthcare professional groups. The use of these solutions, in the long run, can lead to a reduction in ethical issues and can increase the consent of patients, family, and hospital personnel to improve the productivity of the hospital. Finally, in this systematic review, the results, the initial number of identified records and included studies show that low research has been done to examine the reasons for not using the consultation of the HEC, and we urge researchers and experts around the world to conduct useful research in this field.

Conclusion

Our study provides the ﬁrst systematic review of challenges and proposes possible solutions in the application of the consultation services of HEC. Healthcare professionals in daily practice need to have a consult done speedily, every time. However, the results of this study showed a high rate of challenges for healthcare professionals to use consultation services. To overcome the challenges and to increase the application of HEC services, it is necessary that healthcare administrators and CEO members review the ethical problems with their healthcare professionals and to resolve the issues that may be particularly troublesome at their organization.

Implications for further research

Future studies can look at the challenges and possible solutions of other groups such as patients, family members, community members, pharmacists, and patient advocates. Further researches about the relationship between the characteristics of hospitals and the challenges of HEC consultation services can help to clarify the issues.

Strengths and limitations

The strengths of our study are to identify the categories of challenges and solutions that can be used to evaluate the accessibility of HEC consultation services. This study had two limitations. The first and main limitation of this study is the sole focus on a group of healthcare professionals (physicians and nurses). Secondly, related articles may have been published in other languages that are opted out of our study and not assessed.

Footnotes

Availability of data and materials

Datasets are available upon reasonable request from the corresponding author.

Authors’ contributions

RKZ, SM, and AH conceived of and designed the study. AH and RKZ contributed to the acquisition of data, analysis, and interpretation of data. AH and RKZ were involved in data extraction, quality assessment, and statistical analysis. AH drafted the manuscript. SM and RKZ revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank members of the School of Management and Medical Informatics of Tabriz University Medical.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Alireza Hajizadeh

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