Publications by authors named "Anita Tarzian"

46 Publications

Ethics Consultation in United States Hospitals: Assessment of Training Needs.

J Clin Ethics 2021 ;32(3):247-255

Altarum Institute, Ann Arbor, Michigan USA.

Background: To help inform the development of more accessible, acceptable, and effective ethics consultation (EC) training programs, we conducted an EC training needs assessment, exploring ethics practitioners' opinions on: the relative importance of various EC practitioner competencies; the potential market for EC training (that is, how many individuals would benefit and how much individuals and hospitals would be willing to pay); and the preferred content, format, and characteristics of EC training.

Methods: As part of a multipart study, we surveyed "best informants" who self-identified as the person most actively involved in EC or healthcare ethics in a random sample of 600 U.S. general hospitals, stratified for bed size.

Results: The competency that was ranked most important for a lead or solo ethics consultant was knowledge of ethics, while common sense was ranked least important. The median estimated number of individuals at each hospital who would benefit from EC training was six at the basic level, three at the advanced level, and two for EC management training. In 19.1 percent of hospitals, respondents thought their hospital would not be willing to pay anything for EC training within the next two years. Respondents thought potential trainees would be likely to participate in EC training on multiple different topics. Opinions varied widely on preferred formats. Most respondents thought it very important to be able to interact with instructors and with other trainees, practice EC skills, receive a certificate for completing EC training, and complete EC training during work hours.

Conclusions: These findings provide U.S. population data that may be useful to healthcare educators and bioethics leaders in their efforts to develop EC training programs and products that match trainees' preferences and needs.
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August 2021

Health care ethics programs in U.S. Hospitals: results from a National Survey.

BMC Med Ethics 2021 07 29;22(1):107. Epub 2021 Jul 29.

Altarum Institute, 3520 Green Ct., Suite 300, Ann Arbor, MI, 48105, USA.

Background: As hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.

Methods: Based on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.

Results: Among 372 hospitals whose informants responded to an online survey, 97% of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents' strategies for managing challenges include staff training and additional funds.

Conclusions: While this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs.
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http://dx.doi.org/10.1186/s12910-021-00673-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320092PMC
July 2021

Do You Follow Me? Limits to Posting on PICU Patient's Blog.

Authors:
Anita Tarzian

Am J Bioeth 2021 07;21(7):71-72

National Center for Ethics in Health Care.

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http://dx.doi.org/10.1080/15265161.2021.1926161DOI Listing
July 2021

Ethics Consultation in U.S. Hospitals: Opinions of Ethics Practitioners.

Am J Bioeth 2021 Mar 26:1-19. Epub 2021 Mar 26.

Altarum Institute.

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners' opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted.
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http://dx.doi.org/10.1080/15265161.2021.1893550DOI Listing
March 2021

Ethics Consultation in U.S. Hospitals: A National Follow-Up Study.

Am J Bioeth 2021 Mar 26:1-14. Epub 2021 Mar 26.

Altarum Institute.

A 1999-2000 national study of U.S. hospitals raised concerns about ethics consultation (EC) practices and catalyzed improvement efforts. To assess how practices have changed since 2000, we administered a 105-item survey to "best informants" in a stratified random sample of 600 U.S. general hospitals. This primary article details the methods for the entire study, then focuses on the 16 items from the prior study. Compared with 2000, the estimated number of case consultations performed annually rose by 94% to 68,000. The median number of consults per hospital was unchanged at 3, but more than doubled for hospitals with 400+ beds. The level of education of EC practitioners was unchanged, while the percentage of hospitals formally evaluating their ECS decreased from 28.0% to 19.1%. The gap between large, teaching hospitals and small, nonteaching hospitals widened since the prior study. We suggest targeting future improvement efforts to hospitals where needs are not being met by current approaches to EC.
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http://dx.doi.org/10.1080/15265161.2021.1893547DOI Listing
March 2021

The Veterans Health Administration Approach to COVID-19 Vaccine Allocation-Balancing Utility and Equity.

Fed Pract 2021 Feb;38(2):52-54

is Deputy Executive Director of the US Department Veterans Affairs National Center for Ethics in Health Care. is Editor-in-Chief; Chief, Consultation Psychiatry and Ethics, New Mexico VA Health Care System; and Professor and Director of Ethics Education at the University of New Mexico School of Medicine in Albuquerque.

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http://dx.doi.org/10.12788/fp.0093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953856PMC
February 2021

Getting Real: The Maryland Healthcare Ethics Committee Network's COVID-19 Working Group Debriefs Lessons Learned.

HEC Forum 2021 Jun 13;33(1-2):91-107. Epub 2021 Feb 13.

Maryland Healthcare Ethics Committee Network, University of Maryland Carey School of Law, Baltimore, MD, USA.

Responding to a major pandemic and planning for allocation of scarce resources (ASR) under crisis standards of care requires coordination and cooperation across federal, state and local governments in tandem with the larger societal infrastructure. Maryland remains one of the few states with no state-endorsed ASR plan, despite having a plan published in 2017 that was informed by public forums across the state. In this article, we review strengths and weaknesses of Maryland's response to COVID-19 and the role of the Maryland Healthcare Ethics Committee Network (MHECN) in bridging gaps in the state's response to prepare health care facilities for potential implementation of ASR plans. Identified "lessons learned" include: Deliberative Democracy Provided a Strong Foundation for Maryland's ASR Framework; Community Consensus is Informative, Not Normative; Hearing Community Voices Has Inherent Value; Lack of Transparency & Political Leadership Gaps Generate a Fragmented Response; Pandemic Politics Requires Diplomacy & Persistence; Strong Leadership is Needed to Avoid Implementing ASR … And to Plan for ASR; An Effective Pandemic Response Requires Coordination and Information-Sharing Beyond the Acute Care Hospital; and The Ability to Correct Course is Crucial: Reconsidering No-visitor Policies.
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http://dx.doi.org/10.1007/s10730-021-09442-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882050PMC
June 2021

Relational Autonomy in an Era of Limited Visitation: What's a Son, Mother, and Medical Team to Do?

Authors:
Anita Tarzian

Am J Bioeth 2021 01;21(1):78-79

University of Maryland Francis King Carey School of Law.

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http://dx.doi.org/10.1080/15265161.2021.1850050DOI Listing
January 2021

Surprise Billing in the Emergency Department: What's a Clinical Ethics Consultant to Do?

Authors:
Anita Tarzian

Am J Bioeth 2020 08;20(8):110-111

University of Maryland.

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http://dx.doi.org/10.1080/15265161.2020.1782119DOI Listing
August 2020

Disability Rights as a Necessary Framework for Crisis Standards of Care and the Future of Health Care.

Hastings Cent Rep 2020 May;50(3):28-32

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) "Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations," which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both distributive and recognitive justice. The disability rights movement's demand "Nothing about us, without us" requires substantive inclusion of disabled people in decision-making related to their interests, including in crisis planning before, during, and after a pandemic like Covid-19.
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http://dx.doi.org/10.1002/hast.1128DOI Listing
May 2020

Patient and Family Descriptions of Ethical Concerns.

Am J Bioeth 2020 06;20(6):52-64

National Institutes of Health.

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants ( = 196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.
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http://dx.doi.org/10.1080/15265161.2020.1754500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673656PMC
June 2020

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement.

Am J Respir Crit Care Med 2020 05;201(10):1182-1192

: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as "unrepresented." There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice.: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.: The committee designed its policy recommendations to promote five ethical goals: ) to protect highly vulnerable patients, ) to demonstrate respect for persons, ) to provide appropriate medical care, ) to safeguard against unacceptable discrimination, and ) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: ) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; ) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; ) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than by treating clinicians; ) institutions should use all available information on the patient's preferences and values to guide treatment decisions; ) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; ) institutions should employ this fair process even when state law authorizes procedures with less oversight.: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.
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http://dx.doi.org/10.1164/rccm.202003-0512STDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7233335PMC
May 2020

Vaginal Microbiota Transplantation: The Next Frontier.

J Law Med Ethics 2019 12;47(4):555-567

Kevin DeLong, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Fareeha Zulfiqar, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine. Diane E. Hoffmann, J.D., is at the University of Maryland Francis King Carey School of Law. Anita J. Tarzian, Ph.D., R.N., is at the University of Maryland Francis King Carey School of Law and the School of Nursing. Laura M. Ensign, Ph.D., is at the Center for Nanomedicine, Department of Ophthalmology, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Departments of Gynecology and Obstetrics, Infectious Diseases, Pharmacology and Molecular Sciences, and Oncology, Johns Hopkins University School of Medicine, and the Departments of Chemical & Biomolecular Engineering and Biomedical Engineering, Johns Hopkins University.

The success of fecal microbiota transplantation (FMT) as a treatment for Clostrioides difficile infection (CDI) has stirred excitement about the potential for microbiota transplantation as a therapy for a wide range of diseases and conditions. In this article, we discuss vaginal microbiota transplantation (VMT) as "the next frontier" in microbiota transplantation and identify the medical, regulatory, and ethical challenges related to this nascent field. We further discuss what we anticipate will be the first context for testing VMT in clinical trials, prevention of the recurrence of a condition referred to as bacterial vaginosis (BV). We also compare clinical aspects of VMT with FMT and comment on how VMT may be similar to or different from FMT in ways that may affect research design and regulatory decisions.
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http://dx.doi.org/10.1177/1073110519897731DOI Listing
December 2019

Re-envisioning "Doing Everything" for an Infant with Trisomy 18.

Authors:
Anita Tarzian

Am J Bioeth 2020 Jan;20(1):62-63

University of Maryland Baltimore.

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http://dx.doi.org/10.1080/15265161.2020.1689033DOI Listing
January 2020

Unanswered Questions About Clinical Ethics Expertise.

Am J Bioeth 2019 11;19(11):91-94

University of Maryland, Baltimore.

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http://dx.doi.org/10.1080/15265161.2019.1669733DOI Listing
November 2019

What Is the Minimal Competency for a Clinical Ethics Consult Simulation? Setting a Standard for Use of the Assessing Clinical Ethics Skills (ACES) Tool.

AJOB Empir Bioeth 2019 Jul-Sep;10(3):164-172. Epub 2019 Jul 11.

j Law & Health Care Program, Maryland Carey Law, Maryland Health Care Ethics Committee Network (MHECN) , Baltimore , Maryland , USA.

The field of clinical ethics is examining ways of determining competency. The Assessing Clinical Ethics Skills (ACES) tool offers a new approach that identifies a range of skills necessary in the conduct of clinical ethics consultation and provides a consistent framework for evaluating these skills. Through a training website, users learn to apply the ACES tool to clinical ethics consultants (CECs) in simulated ethics consultation videos. The aim is to recognize competent and incompetent clinical ethics consultation skills by watching and evaluating a videotaped CEC performance. We report how we set a criterion cut score (i.e., minimally acceptable score) for judging the ability of users of the ACES tool to evaluate simulated CEC performances. A modified Angoff standard-setting procedure was used to establish the cut score for an end-of-life case included on the ACES training website. The standard-setting committee viewed the Futility Case and estimated the probability that a minimally competent CEC would correctly answer each item on the ACES tool. The committee further adjusted these estimates by reviewing data from 31 pilot users of the Futility Case before determining the cut score. Averaging over all 31 items, the proposed proportion correct score for minimal competency was 80%, corresponding to a cut score that is between 24 and 25 points out of 31 possible points. The standard-setting committee subsequently set the minimal competency cut score to 24 points. The cut score for the ACES tool identifies the number of correct responses a user of the ACES tool training website must attain to "pass" and reach minimal competency in recognizing competent and incompetent skills of the CECs in the simulated ethics consultation videos. The application of the cut score to live training of CECs and other areas of practice requires further investigation.
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http://dx.doi.org/10.1080/23294515.2019.1634653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6921700PMC
May 2020

A Call to Justice in Serving Hospitalized Prisoners.

Authors:
Anita Tarzian

Am J Bioeth 2019 07;19(7):56-57

a University of Maryland School of Nursing.

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http://dx.doi.org/10.1080/15265161.2019.1619347DOI Listing
July 2019

Foregoing Spoon Feeding in End-Stage Dementia.

Authors:
Anita Tarzian

Am J Bioeth 2019 Jan;19(1):88-89

a University of Maryland School of Nursing.

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http://dx.doi.org/10.1080/15265161.2019.1545506DOI Listing
January 2019

Is There a Duty to Warn Parents of a Cancer-Causing Genetic Mutation?

Authors:
Anita J Tarzian

Am J Bioeth 2018 Jul;18(7):73-74

a University of Maryland School of Nursing.

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http://dx.doi.org/10.1080/15265161.2018.1478502DOI Listing
July 2018

Challenges of Dealing with Financial Concerns during Life-Threatening Illness: Perspectives of Health Care Practitioners.

J Soc Work End Life Palliat Care 2018 Jan-Mar;14(1):28-43. Epub 2018 Mar 5.

a University of Maryland, Baltimore, School of Social Work , Baltimore , Maryland , USA.

The costs of serious medical illness and end of life care are often a heavy burden for patients and families (Collins, Stepanczuk, Williams, & Rich, 2016 ; Kim, 2007 ; May et al., 2014 ; Zarit, 2004 ). Twenty-six practitioners, including social workers, managers/administrators, supervisors, and case managers from five health care settings, participated in qualitative semistructured interviews about financial challenges patients encountered. Seven practitioners took part in a focus group. Practitioners were recruited from hospice (n = 5), long-term care (n = 5), intensive care (n = 5), dialysis (n = 6), and oncology (n = 5). Interview and focus group questions focused on financial challenges patients encountered when facing life-threatening illness. Interview data were transcribed and thematically coded and trustworthiness of data was established with peer debriefing, member checking, and agreement on themes among the authors. Practitioners described interacting micro, meso, and macroinfluences on the financial well-being and challenges patients encountered. Microlevel influences involved patient characteristics, such as their demographic profile and/or health status that set them up for financial aptitude or challenges. Macrolevel influences involved the larger health care/safety net system, which provided valuable resources for some patients but not others. Practitioners also discussed the mesolevel of influence, the local setting where they worked to match available resources with patients' individual needs given the constraints emerging from the micro and macrolevels. Practitioners described how they navigated the interplay of these three areas to meet patients' needs and cope with financial challenges. Implications for practice point to directly addressing the kind of financial concerns that patients and families facing financial burden from serious medical illness have, and identifying ways to bridge knowledge and resource access gaps at the individual, organizational, and societal levels.
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http://dx.doi.org/10.1080/15524256.2018.1432008DOI Listing
September 2018

Withdrawing Life Support in Pregnancy: State Laws and Implications for Ethics.

Authors:
Anita J Tarzian

Am J Bioeth 2017 Jul;17(7):75-76

a University of Maryland.

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http://dx.doi.org/10.1080/15265161.2017.1314708DOI Listing
July 2017

Maryland's Medical Orders for Life-Sustaining Treatment Form Use: Reports of a Statewide Survey.

J Palliat Med 2017 09 4;20(9):939-945. Epub 2017 Apr 4.

3 Law and Health Care Program, University of Maryland Francis King Carey School of Law , Baltimore, Maryland.

Background: Advance directives (ADs) and Physicians Orders for Life-Sustaining Treatment (POLST) orders perform different but complementary functions in documenting a patient's treatment preferences and translating them into actionable orders that change in keeping with the patient's evolving clinical picture. Maryland's Medical Orders for Life-Sustaining Treatment (MOLST) form developed through a stakeholder-driven process that deviates from other POLST forms. While a patient or surrogate can decline discussing MOLST orders with a clinician, clinicians must write MOLST orders for certain patients (e.g., those admitted to a nursing home (NH), assisted living facility (ALF), hospice, home health (HH) agency, or dialysis center, discharged from a hospital to any of these facilities, or transferred between hospitals).

Objective: To gather data on Maryland MOLST form use to evaluate performance and inform future research and practice.

Design: Chart reviews (CRs).

Setting/subjects: MOLST forms and patient data collected from Maryland hospitals (adult nonpsych, nontrauma, nonobstetric patients), NHs, ALFs, hospices, HH agencies, and dialysis centers.

Measurements: Facility demographic tool and CR tools.

Results: A total of 1959 CRs were received from 137 facilities, including 2064 MOLST forms. Most patients required to have MOLST orders had them (84%); fewer had ADs (47%). Few patients or surrogates declined discussing MOLST orders (1%). Few MOLST orders were written based on medical ineffectiveness criteria defined in Maryland law (<1%). MOLST form completion error rates ranged from 1% to 3%. Non-white patients were about twice as likely to have a MOLST "Attempt CPR" order (62%) as white patients (32%).

Conclusions: MOLST error rates are relatively low and consistent with other research. Areas for improvement include selecting one order option where required, avoiding contradictions between Page 1 and 2 orders, offering MOLST Page 2 options if relevant, and documenting in the medical record a summary of the discussion informing MOLST orders.
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http://dx.doi.org/10.1089/jpm.2016.0440DOI Listing
September 2017

Comfort Care Request for Preterm Infant.

Am J Bioeth 2017 Jan;17(1):82-83

b University of Maryland.

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http://dx.doi.org/10.1080/15265161.2016.1251772DOI Listing
January 2017

Preemptive C-Section Refusal Based on Religious Beliefs.

Am J Bioeth 2017 Jan;17(1):92-93

b University of Texas-Houston.

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http://dx.doi.org/10.1080/15265161.2016.1251774DOI Listing
January 2017

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants.

Am J Bioeth 2016 ;16(3):15-24

j Case Western Reserve University.

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.
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http://dx.doi.org/10.1080/15265161.2015.1134705DOI Listing
January 2017

Alone and Saying No.

Am J Bioeth 2016 ;16(2):76-7

b University of Maryland.

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http://dx.doi.org/10.1080/15265161.2015.1132050DOI Listing
September 2016

Parental Neglect or Appropriate End-of-Life Care?

Am J Bioeth 2016 ;16(2):68-9

b University of Maryland.

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http://dx.doi.org/10.1080/15265161.2015.1132038DOI Listing
September 2016
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