Abstract
Objectives
To conduct a systematic review of literature examining the establishment and operation
of clinical ethical committees (CECs) in long-term care (LTC).
Design
Systematic review.
Setting and Participants
LTC recipients/family or staff.
Methods
Five databases (Ovid Medline, Ovid Cochrane Library, Ovid PsycINFO, Ovid EMBASE, and
CINAHL via EbscoHost) were systematically searched from their inception to May 8,
2020. The initial search was conducted on August 22, 2017, and updated on May 8, 2020,
to identify peer-reviewed studies, commentaries, or editorials. The quality of studies
was assessed using the Mixed Methods Appraisal Tool.
Results
Thirty-three articles were identified for inclusion, of which 13 were primary studies.
Most articles were set in the United States. The purpose of establishing a CEC in
LTC was typically to assist in dealing with ethical issues and improve the quality
of care. The articles described the roles of CECs to include prospective case consultation,
case review, policy development, and ethics education. Articles rarely reported whether
the CEC was required by or enshrined in law. Membership of CECs was between 4 and
20 members and most commonly included nursing staff, physicians, and directors/administrators.
The rationale behind the membership was rarely described. For case consultation, articles
described that CECs were typically convened upon referral. The resident issues which
a CEC could address included end-of-life care decisions, autonomy/self-determination,
and medical treatment decisions. The staff issues addressed by CECs included medical
treatment decisions, end-of-life care decisions, and decision-making issues. The decision-making
process followed by CECs varied. The outcome of a CEC meeting was typically a recommendation,
whereas the implementation of CEC recommendations and decisions were rarely reported.
Conclusions and Implications
This systematic review identifies how CECs operate in the LTC setting. CECs have the
potential to provide valuable support in addressing complex ethical issues in LTC;
however, empirical research is required to determine their efficacy in the LTC setting.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of the American Medical Directors AssociationAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Need for comprehensive health care quality measures for older adults.Popul Health Manag. 2018; 21: 296-302
- The Health of Aging Populations.in: Preparing for an Aging World: The Case for Cross-National Research. National Academies Press (US), Washington (DC)2001
- Moral distress: A call to action.AMA J Ethics. 2017; 19: 533-536
- A Systematic review of sexual assaults in nursing homes.Gerontologist. 2018; 58: e369-e383
- Sexual aggression between residents in nursing homes: Literature synthesis of an underrecognized Problem.J Am Geriatri Soc. 2010; 58: 1970-1979
- The criminal justice response to elder abuse in nursing homes: A routine activities perspective.West Crim Rev. 2006; 7: 67-81
- Physical restraint deaths in a 13-year national cohort of nursing home residents.Age Ageing. 2017; 46: 688-693
- Regulating restraint use in mental health and aged care settings: Lessons from the Oakden scandal.Alternative Law Journal. 2019; 44: 29-36
- Psychotropic medication use among nursing home residents in Austria: A cross-sectional study.BMC Geriatr. 2009; 9: 18
- American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity, Guiding principles for the care of older adults with multimorbidity: An approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity.J Am Geriatr Soc. 2012; 60: e1-e25
- A risk-benefit assessment of dementia medications: Systematic review of the evidence.Drugs Aging. 2015; 32: 453-467
- Deaths due to thermal injury from cigarette smoking in a 13-year national cohort of nursing home residents.Int J Older People Nurs. 2019; 14: e12233
- Impediments to applying the ‘dignity of risk’ principle in residential aged care services.Australas J Ageing. 2013; 32: 188-193
- Quality of advance care planning policy and practice in residential aged care facilities in Australia.BMJ Support Palliat Care. 2013; 3: 349
- Epidemiology of falls in older sge.Can J Aging. 2011; 30: 7-19
- Falls in older people: Epidemiology, risk factors and strategies for prevention.Age Ageing. 2006; 35: ii37-ii41
- Incidence of falls and fall-related outcomes among people in aged-care facilities in the Lower Hunter region, NSW.NSW Public Health Bull. 2008; 19: 166
- Mortality in nursing home residents: A longitudinal study over three years.PLoS ONE. 2018; 13: e0203480
- The Aged Care Workforce, 2016. Canberra: Department of Health. 2017.(Available at:) (Accessed January 25, 2020)
- Interim Report: Neglect (Volume 2, Hearing Overviews and Case Studies). Australia: Royal Commission into Aged Care Quality and Safety. 2019.(Available at:) (Accessed January 25, 2020)
- Interim Report: Neglect (Volume 1). Australia: Royal Commission into Aged Care Quality and Safety. 2019.(Available at:) (Accessed January 25, 2020)
- Elder Abuse - A National Legal Response (Final Report). Sydney: Australian Law Reform Commission. 2017.(Available at:)https://www.alrc.gov.au/publication/elder-abuse-a-national-legal-response-alrc-report-131/(Accessed January 25, 2020)Date: 2017
- Quality of Care Principles 2014 (Cth).(Available at:) (Accessed January 25, 2020)
- Clinical ethics revisited.BMC Med Ethics. 2001; 2: 1
- The value of clinical ethics support in Australian health care.Med J Aust. 2015; 202: 568-569
- Complex feeding decisions: Perceptions of staff, patients, and their families in the inpatient hospital setting.Gerontol Geriatr Med. 2016; (Jan-Dec:e-collection)
- Food culture, preferences and ethics in dysphagia management.Bioethics. 2015; 29: 646-652
- Moving beyond resistance to restraint minimization: A case study of change management in aged Care.Worldviews Evid Based Nurs. 2009; 6: 210-218
- Overcoming restraint use: Examining barriers in Australian ages care facilities.J Gerontol Nurs. 2006; 32: 33-38
- Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.Ann Intern Med. 2009; 151: 264-269
- EndNote X7. New York: Thomson Reuters. 2014.(Available at:)https://endnote.com/(Accessed January 25, 2020)Date: 2014
- Covidence systematic review software. Melbourne, Australia.(Available at:) (Accessed January 25, 2020)
- Mixed Methods Appraisal Tool (MMAT) Version 2018. Canada: McGill University. 2018.(Available at:) (Accessed January 25, 2020)
- Program clarifies ethical issues in care of the dying patient.Health Prog. 1984; 65: 16-18
- Resolving ethical problems in long-term care.J Gerontol Nurs. 1996; 22: 20-26
- Decisions to withhold treatment from nursing home residents.J Am Geriatr Soc. 1983; 31: 602-606
- Choices: The ethics of dying pose new challenges for caregivers.Contemp Longterm Care. 1994; 17: 40-47
- An ethics consult team in geriatric long-term care.Camb Q Healthc Ethics. 1995; 4: 178-184
- How ethical dilemmas are resolved.J Long Term Care Adm. 1994; 22: 25-28
- The Patient Self-Determination Act (PSDA) and the incapacitated patient: Policy suggestions for healthcare ethics committees.HEC forum. 1991; 3: 309-320
- Predictors of advance directives in institutionalized elderly.J Gerontol Soc Work. 2000; 33: 67-89
- Medical decision-making for the unbefriended nursing home resident.J Ethics Law Aging. 1995; 1: 87-92
- The ethics committee in the nursing home: Results of a national survey.J Am Geriatr Soc. 1988; 36: 150-156
- Ethics committees in long-term care facilities.Geriatric Nurs (Minneap). 2004; 25: 364-369
- Medical decision-making for older adults in institutional settings: Is beneficience dead in an age of risk management?.Issues Law Med. 1995; 11: 29-46
- Long-Term Care Coalition of the Orange County Bioethics Network (California).HEC Forum. 1994; 6: 183
- Learning to pay attention: An ethics study group refocuses on issues affecting long-term care residents' daily lives.Health Prog. 1993; 74: 40-43
- Ethics rounds at the nursing home: An alternative to an ethics committee.J Am Geriatr Soc. 1992; 40: 95-97
- Implementing effective ethics decision-making programs.Ann Longterm Care. 1999; 7: 232-237
- Nursing home policies addressing the use or withdrawal of life-sustaining medical treatments.Clin Geriatr Med. 1988; 4: 681-690
- Implementation of the Patient Self-Determination Act (PSDA) in nursing homes in New York City.J Am Geriatr Soc. 1997; 45: 43-49
- When there is no ethics committee.Caring Ages. 2008; 9: 13
- Feeding tubes: Ethical decision making in theory and in practice.Ann Longterm Care. 2001; 9: 20
- Early Experiences of an Ethics Consult Team.J Am Geriatr Soc. 1994; 42: 437-441
- Ethical issues in the nursing home.Mt Sinai J Med. 1993; 60: 555-559
- New Jersey's "Granny Doe" squad: Arguments about mechanisms for protection of vulnerable patients.Law Med Health Care. 1989; 17: 255
- The evolution of a long-term care ethics committee.HEC Forum. 1996; 8: 44-51
- The NJ SEED project: Evaluation of an innovative initiative for ethics training in nursing homes.J Am Med Dir Assoc. 2005; 6: 68-75
- Integrating ethics with quality assurance in long term care.QRB Qual Rev Bull. 1988; 14: 138-143
- Clinical ethics in geriatric care settings.Generations. 1994; 18: 9-12
- Sexual Consent capacity: Ethical issues and challenges in long-term care.Clin Gerontol. 2017; 40: 43-50
- Content analysis of euthanasia policies of nursing homes in Flanders (Belgium).Med Health Care Philos. 2009; 12: 313-322
- Ethics policies on euthanasia in nursing homes: A survey in Flanders, Belgium.Soc Sci Med. 2008; 66: 376-386
- Addressing ethical issues in geriatrics and long-term care: Ethics education at the Baycrest Centre for Geriatric Care.Med Law. 2000; 19: 475
- Ethical challenges in nursing homes–staff's opinions and experiences with systematic ethics meetings with participation of residents' relatives.Scand J Caring Sci. 2015; 29: 810-823
- Evaluation and perceived results of moral case deliberation: A mixed methods study.Nurs Ethics. 2015; 22: 870-880
- AHEC consensus statement on clinical ethics. Australia: NHMRC. 2015.(Available at:) (Accessed January 25, 2020)
- Long-term care providers and services users in the United States 2015–16. Vital Health Statistics. USA: National Center for Health Statistics. 2019.(Available at:) (Accessed January 25, 2020)
- Care homes market study (final report). London: Competition and Markets Authority. 2017.(Available at:) (Accessed January 25, 2020)
- 2017-18 Report on the Operation of the Aged Care Act 1997. Canberra: Department of Health. 2018.(Available at:) (Accessed January 25, 2020)
- Diagnosis of dementia in residential aged care settings in Australia: An opportunity for improvements in quality of care?.Australas J Ageing. 2018; 37: e155-e158
- Exploring the prevalence and variance of cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency among persons living in nursing homes: A cross-sectional study.BMC Geriatr. 2016; 16: 154
- Dementia prevalence and care in assisted living.Health Aff. 2014; 33: 658-666
- Research ethics committees: Basic concepts for capacity-building. Switzerland: World Health Organization. 2009.(Available at:) (Accessed January 25, 2020)
- Putting patients on research ethics committees.J R Soc Med. 2014; 107: 304-307
- What and who are clinical ethics committees for?.J Med Ethics. 2007; 33: 497-500
- Speaking out and being heard residents’ committees in Quebec’s residential long-term care centre.Health Care Anal. 2017; 25: 308-322
- The changing ethics of health care.Caring Ages. 2016; 17: 12
- Evolutionary ethics: Can values change.J Med Ethics. 2004; 30: 366
- Clinical ethics committees–Pros and cons.J Med Ethics. 1997; 23: 203-204
- Health care ethics consultation. Individual consultant or committee model?: Pros and cons.Am J Bioeth. 2013; 13: 25-27
- Limitation of care orders in patients with a diagnosis of dementia.Resuscitation. 2016; 98: 118-124
- More than capacity: Alternatives for sexual decision making for individuals with dementia.Gerontologist. 2015; 55: 716-723
- The potential for inadvertent adverse consequences of open disclosure in Australia: When good intentions cause further harm.Med Sci Law. 2019; 59: 265-274
Article info
Publication history
Published online: July 28, 2020
Footnotes
This work was supported by the Department of Health and Human Services, Seniors, Aging and Aged Care Branch, Health and Well-Being Division, Victoria, Australia and the Department of Forensic Medicine, Monash University. None of the funders influenced the design, methods, subject recruitment, data collection, analysis or preparation of the article.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any agency or departments of the Australian Federal Government, the State Government of Victoria, Monash University, the Victorian Institute of Forensic Medicine, or the Coroners Court of Victoria.
The authors are affiliated with or employed by the Department of Forensic Medicine, Monash University, which is also a funding source. The authors have no other potential financial or personal interests that may constitute a source of bias.
Identification
Copyright
© 2020 Published by Elsevier Inc. on behalf of AMDA - The Society for Post-Acute and Long-Term Care Medicine.
