Health care professionals (HCPs) are regularly exposed to moral problems arising in patient care that may compromise quality of care. An understanding of risk factors and early indicators may help practitioners to address these problems early on. This study aims to provide an overview of moral risk factors in patient care. Risk factors known from the literature and those that have led to moral problems discussed in clinical ethics consultations (CECs) are examined. Characteristics, ethical issues and outcomes of CEC are also presented.
Scoping review on moral risk factors in patient care; CEC case series with semi-structured analysis of documentation (consultation reports, feedback forms, electronic patient records) from 204 CECs held between 2012 and 2020 at a somatic (USB) and a psychiatric (UPK) university hospital in Basel, Switzerland.
Ninety-nine moral risk factors were identified from the literature referring to four risk areas: patient (41), family (12), health care professional (29) and system (17). Eighty-seven of these were documented at least once in CEC. The most prevalent factors were patient vulnerability (100%), absent or unclear hospital policies (97.1%), shift work (83.3%), inadequate understanding between patient and HCPs (73.5%), inadequate communication (66.2%), disagreement between patient and HCPs about care (58.8%), and multiple care teams (53.4%). The prevalence differs significantly depending on the medical specialty. CECs are requested as often in psychiatry as in somatic medicine. In the USB, ethical questions about life-sustaining treatment (27.8%), maternal-foetal conflicts (18.8%) and assisted reproductive technology (10.5%) are the most prevalent; in the UPK, questions about coercive measures (41.8%), risk and opportunity assessment (14.9%) and child welfare endangerment (13.4%) predominate. Overall, a consensus was almost always reached among the participants (98.5%) and the results implemented (93.9%). CECs were rated as helpful (95.0%) or partly helpful (5.0%).
CEC is useful in both somatic medicine and psychiatry to find consensual and helpful solutions to moral conflicts. There are highly prevalent and potent moral risk factors in all dimensions relevant in clinical care that can be used to prevent moral problems. Further empirical research is needed to create different risk profiles specific to the medical specialities.