End-of-Life Decision Making in Multidisciplinary Teams: Ethical Challenges and Solutions–A Systematic Review

Mujayri, H. et al. (2024).

jicrcr.com.

https://doi.org/10.63278/jicrcr.vi.814

Abstract

Background: To provide high quality end of life (EOL) care, multidisciplinary teams (MDTs) need to be able to proficiently navigate the intricacies of ethical dilemmas faced by EOL care; to maintain an equilibrium between patient autonomy, family involvement and cultural competence. Yet, the lack of cohesive EOL decision making currently continues to occur because of communication barriers, role ambiguity and a lack of sufficient ethics training within MDTs. As a consequence, these issues demonstrate the necessity of having structured protocols to help MDTs make ethically sound decisions in the EOL care.

Aim: The purpose of this paper is to identify and review major ethical factors that affect ethical decision-making in EOL MDTs, and explore the themes of patient autonomy, communication, cultural sensitivity, ethics training, and institutional barriers.

Method: Ten studies were reviewed systematically according to PRISMA criteria using data sources including PubMed, Scopus, Web of Science, and CINAHL databases. The analysis included studies published between the years 2020 and 2024 and the ethical decision–making challenges and solutions that MDTs face in EOL care contributing to those decisions.

Results: Four key themes were identified: Issues concerning balancing patient autonomy with family input, communication challenges in MDTs, cultural sensitivity in EOL care and the necessity of ethics training. Results indicate that MDTs are often faced with ethical dilemmas when patient’s wishes diverge from those of their family and experience communication difficulties that resulted in degradation of care quality. Simulation is an entertaining and effective way to develop cultural awareness and ethics training in EOL care practice.

Conclusion: Ethical challenges in EOL decision making must be addressed with an intervention encompassing improved ethics training, MDT role clarity, culturally aware practice, and institutional support. These strategies, if implemented will support MDTs in providing patient centered and ethically sound EOL care. Further study of ethics training, communication frameworks and cultural competence on EOL decision-making in MDTs is warranted for future research.

Here are some thoughts:

This article is critically important for practicing psychologists because it directly addresses the core ethical, communicative, and interpersonal challenges they face as integral members of multidisciplinary teams (MDTs) in end-of-life (EOL) care. The systematic review identifies key themes—such as balancing patient autonomy with family input, navigating communication breakdowns within teams, and addressing cultural and religious sensitivities—that are central to a psychologist’s role. Psychologists are often the clinicians best equipped to facilitate difficult family meetings, mediate conflicts between patient wishes and family or team concerns, and ensure that care is culturally competent and patient-centered. The article underscores a significant gap in ethics training and recommends simulation-based learning, urging psychologists to seek or advocate for such training to better handle complex moral dilemmas. Furthermore, by highlighting institutional barriers and role ambiguity, it empowers psychologists to push for clearer team protocols and systemic support, ultimately enabling them to contribute more effectively to ethically sound, compassionate, and collaborative EOL decision-making.

Oaths, Conscience, Contracts, and Laws-The Gathering Storm Confronting Medical Professionalism

Gabow, P. A., & Wynia, M. K. (2024).

JAMA, 10.1001/jama.2024.10761.

Advance online publication.

https://doi.org/10.1001/jama.2024.10761

The bond between physicians and their patients has long been considered a unique, even sacred, relationship sealed with publicly professed oaths. Historically, an essential and ubiquitous component of physicians' oaths and their related ethical codes is the promise to place patients' interests above any others, including their own. This is a high bar, but it is the bar physicians swear to meet when entering the profession. For generations, many physicians have courageously met this bar, including putting their lives on the line during pandemics like COVID-19.

Today, physicians face rising challenges in fulfilling this core professional promise not from a virus but from 3 converging fronts: personal conscience, employment contracts, and laws. How these challenges to putting patient interests first have emerged and interrelate deserves elucidation because understanding these dynamics can help shape appropriate professional responses.

Personal Conscience

The First Amendment to the US Constitution forbids the establishment of a state religion (establishment clause) and protects individual religious freedom (free exercise clause). As these paired clauses demonstrate, integral to prohibiting a state religion was establishing respect for individual conscience, and in 1809 Thomas Jefferson declared, "No provision in our constitution ought to be dearer to man than that which protects the rights of conscience...."

Formal support for a physician's conscience to override their commitment to their patient's interests, however, was not codified in federal legislation until the Church Amendments of 1973, which exempted federally funded individuals and entities with moral objections from performing or assisting in abortions or sterilization procedures. This prioritization of physician conscience over patient interests has since been extended by other federal laws and regulations, and many states have passed conscience laws ensuring that physicians can refuse without penalty to provide, or even refer, patients for care a physician deems against his or her conscience.

Here are some thoughts:

The physician-patient relationship, once considered sacred, is facing unprecedented challenges from three converging fronts: personal conscience, employment contracts, and laws. Historically, physicians have sworn oaths to prioritize patients' interests above their own, but recent developments have eroded this commitment. The prioritization of physician conscience over patient interests has been codified in federal laws and regulations, while employment contracts have introduced additional constraints on physicians' ability to put patients first.

To address these challenges, physicians must recommit to their sworn oaths and codes of ethics, examining the difference between professional responsibilities and personal beliefs. They should be aware of ethical guardrails that protect patients' trust, such as informing patients about limitations of care and making referrals when necessary. Furthermore, physicians should carefully examine employment contracts and work collectively through professional organizations to change contracts and laws that privilege institutional or state-level conscience rights over patient-centered care. By vigorously defending their authority to make medical decisions with patients' interests at heart, physicians can reclaim their profession's commitment to prioritizing patients' needs.

This Cat Sensed Death. What if Computers Could, Too?

Siddhartha Mukherjee
The New York Times
Originally published January 3, 2017

Here are two excerpts:

But what if an algorithm could predict death? In late 2016 a graduate student named Anand Avati at Stanford’s computer-science department, along with a small team from the medical school, tried to “teach” an algorithm to identify patients who were very likely to die within a defined time window. “The palliative-care team at the hospital had a challenge,” Avati told me. “How could we find patients who are within three to 12 months of dying?” This window was “the sweet spot of palliative care.” A lead time longer than 12 months can strain limited resources unnecessarily, providing too much, too soon; in contrast, if death came less than three months after the prediction, there would be no real preparatory time for dying — too little, too late. Identifying patients in the narrow, optimal time period, Avati knew, would allow doctors to use medical interventions more appropriately and more humanely. And if the algorithm worked, palliative-care teams would be relieved from having to manually scour charts, hunting for those most likely to benefit.

(cut)

So what, exactly, did the algorithm “learn” about the process of dying? And what, in turn, can it teach oncologists? Here is the strange rub of such a deep learning system: It learns, but it cannot tell us why it has learned; it assigns probabilities, but it cannot easily express the reasoning behind the assignment. Like a child who learns to ride a bicycle by trial and error and, asked to articulate the rules that enable bicycle riding, simply shrugs her shoulders and sails away, the algorithm looks vacantly at us when we ask, “Why?” It is, like death, another black box.

The article is here.

Health Care Workers & Moral Objections I: Procedures

Mike LaBossiere
Talking Philosophy
Originally published on January 18, 2018

Here is an excerpt:

But, this moral coin has another side—entering a profession, especially in the field of health, also comes with moral and professional responsibilities. These responsibilities can, like all responsibilities, can justly impose burdens. For example, doctors are not permitted to instantly abandon patients they dislike or because they want to move to a better paying position. As such, ethics of a health worker refusing to perform a procedure based on their moral or religious views requires that each procedure be reviewed to determine whether it is one that a health care worker can justly refuse or one that is a justly imposed burden.

To illustrate, consider a doctor who is asked to keep prisoners conscious and alive during torture performed by agents of the state. Most doctors, like most people, would have moral objections to being involved in torture. However, there is the question of whether this would be something they should be morally expected to do as part of their profession. On the face of it, since the purpose of the medical profession is to heal and alleviate suffering (a professional ethics that goes back to the origin of western medicine) this is not something that a doctor is obligated to do even in the face of moral objections. In fact, the ethics of the profession would dictate against engaging in this behavior.

Now, imagine a health care worker who has sincere religious or moral beliefs that when a person can no longer sustain their life on their own, they must be released to God. As such, the worker refuses to engage in procedures that violate their principles, such as keeping a patient on life support. While this could be a sincerely held belief, it seems to run counter to the ethics of the profession. As such, such a health care worker would seem to not have the right to refuse such services.

The article is here.

Go Fund Yourself

Stephen Marche

Mother Jones

Originally published January/February 2018

Here is an excerpt:

Health care in America is the wedge of inequality: It’s the luxury everyone has to have and millions can’t afford. Sites like YouCaring have stepped in to fill the gap. The total amount in donations generated by crowdfunding sites has increased eleven­fold since the appearance of Obamacare. In 2011, sites like GoFundMe and YouCaring were generating a total of $837 million. Three years later, that number had climbed to $9.5 billion. Under the Trump administration, YouCaring expects donations to jump even higher, and the company has already seen an estimated 25 percent spike since the election, which company representatives believe is partly a response to the administration’s threats to Obamacare.

Crowdfunding companies say they’re using technology to help people helping people, the miracle of interconnectedness leading to globalized compassion. But an emerging consensus is starting to suggest a darker, more fraught reality—sites like YouCaring and GoFundMe may in fact be fueling the inequities of the American health care system, not fighting them. And they are potentially exacerbating racial, economic, and educational divides. “Crowdfunding websites have helped a lot of people,” medical researcher Jeremy Snyder wrote in a 2016 article for the Hastings Center Report, a journal focused on medical ethics. But, echoing other scholars, he warned that they’re “ultimately not a solution to injustices in the health system. Indeed, they may themselves be a cause of injustices.” Crowdfunding is yet another example of tech’s best intentions generating unseen and unfortunate outcomes.

The article is here.

The GOP's risky premium pledge

Jennifer Haberkorn
Politico.com
Originally posted June 5, 2017

Senate Republicans may be all over the map on an Obamacare repeal plan, but on one fundamental point — reducing insurance premiums — they are in danger of overpromising and underdelivering.

The reality is they have only a few ways to reduce Americans’ premiums: Offer consumers bigger subsidies. Allow insurers to offer skimpier coverage. Or permit insurers to charge more — usually much more — to those with pre-existing illnesses and who are older and tend to rack up the biggest bills.

Since there’s no appetite within the GOP for throwing more taxpayer money at the problem, Republicans will need to make some hard decisions to hit their goal. But the effort to drive down premium prices will inevitably create a new set of winners and losers and complicate leadership’s path to the 50 votes they need to fulfill their seven-year promise to repeal Obamacare.

“Anyone can figure out how to reduce premiums,” said Sen. Chris Murphy (D-Conn.). “You can reduce premiums by kicking everybody that has a pre-existing condition off insurance or dramatically reducing benefits.”

Republicans say that Obamacare’s insurance regulations are responsible for making coverage prohibitively expensive and contend that premiums would fall if those rules are rolled back. They say they have multiple ideas about how to roll those back while also insulating the most vulnerable but have yet to weave those together into actual legislation.

The article is here.

Is Healthcare a Right? A Privilege? Something Entirely Different?

Brian Joondeph
The Health Care Blog
Originally published April 8, 2017

Here is an excerpt:

Most developed countries have parallel public and private healthcare systems. A public option covering everyone, with minimal or no out-of-pocket expense to patients, but with long wait times for care and limited treatment options. And a private option allowing individuals to purchase the healthcare or insurance they want and need, paying for it themselves, without subsidies, tax breaks or any government assistance. One option a right, the other a privilege.

For an analogy, think of K-12 schools. A public option available without cost to students. For most, a good and more than adequate education. And a free-market private school option for those who desire and have the means. Shop around, pay as much as you want, or default to the public option.

Each system has its pros and cons, but they are separate and distinct. Instead we are trying to combine both into a single scheme — Obamacare, Ryancare or whatever finally emerges from Congress. We get the worst of both systems – bureaucracy and high cost. And the best of neither – no universal coverage and limited freedom of choice.

The blog post is here.

Nurses Say Stress Interferes With Caring For Their Patients

By Alan Yu
NPR.org
Originally posted April 15, 2016

Here is an excerpt:

Almost 20 percent of newly registered nurses leave a hospital within the first year for the same job elsewhere, or a different job in a different organization, according to a 2014 study. Rushton says to her, that means health care organizations aren't investing enough in their nursing staff.

Nurse burnout also is linked to moral distress, Rushton says, from situations where nurses know what they should do for their patients but can't act on it. For example, nurses might have to give a patient at the end of life a treatment that causes suffering without any medical benefit. She just started a program called the Mindful Ethical Practice and Resilience Academy to try to help new nurses deal with moral distress.

It's a series of in-person workshops, some of which involve nurses using simulations to practice how to make their ethical concerns heard at work. One scenario includes a patient with a complex medical condition and a nurse has been caring for him and talking to him for days following the recommended treatment.

The article is here.

Note: There are several significant areas that apply to mental health professionals in terms of stress, moral distress, professional respect, and overwork.

Seeking better health care outcomes: the ethics of using the "nudge".

Blumenthal-Barby JS, Burroughs H.
Am J Bioeth. 2012;12(2):1-10.
doi: 10.1080/15265161.2011.634481.

Abstract

Policymakers, employers, insurance companies, researchers, and health care providers have developed an increasing interest in using principles from behavioral economics and psychology to persuade people to change their health-related behaviors, lifestyles, and habits. In this article, we examine how principles from behavioral economics and psychology are being used to nudge people (the public, patients, or health care providers) toward particular decisions or behaviors related to health or health care, and we identify the ethically relevant dimensions that should be considered for the utilization of each principle.

The article is here.

Psychological principles could explain major healthcare failings

Press Release
Bangor University
Originally released on

Here is an excerpt:

In the research paper, Dr Michelle Rydon-Grange who has just qualified as a Clinical Psychologist at the School of Psychology, applies psychological theory to find new understandings of the causes that lead to catastrophic failures in healthcare settings.  She explains that the aspect often neglected in inquiries is the role that human behaviour plays in contributing to these failures, and hopes that using psychological theories could prevent their reoccurrence in the future.

The value of psychological theory in safety-critical industries such as aviation and nuclear power has long been acknowledged and is based upon the notion that certain employee behaviours are required to maintain safety. However, the same is not yet true of healthcare.

Though there may not be obvious similarities between various healthcare scandals which have occurred in disparate areas of medicine over the last few decades, striking similarities in the conditions under which these crises occurred can be found, according to Rydon-Grange.

The entire pressor is here.

Thousands of Inmates in Illinois sign up for Obamacare for MH Treatment

By Rick Pearson
The Chicago Tribune
Originally posted August 4, 2014

Cook County Sheriff Tom Dart, attempting to cope with what he says is a growing mental health crisis among inmates at the county jail, said up to 9,000 people who have been incarcerated have signed up for health insurance under the Affordable Care Act in an attempt to get the care they need.

“Systemically, over the course of decades, we’ve sort of carved back all the mental health services to the point where there is this question, we’ve carved it back to next to nothing,” Dart said on “The Sunday Spin” on WGN AM-720.

The entire story is here.

Quebec passes landmark end-of-life-care bill

Act respecting end-of-life care, Bill 52, allows terminally ill patients to choose death

By CBC News
Originally posted June 5, 2014

Terminally ill patients in Quebec now have the right to choose to die.

The non-partisan Bill 52, also known as an act respecting end-of-life care, passed Thursday afternoon in a free vote at the National Assembly in Quebec City.

The entire story is here.

Bill 52 is here.