The purposes of this study were to assess reasons for consultation of the Ethics Consultation Service for trauma patients and how consultations impacted care. We conducted a review of ethics consultations at a Level I trauma center from 2001 to 2010. Data included patient demographics, etiology of injury, and timing/type of the consult, categorized as: shared decision-making, end-of-life, privacy and confidentiality, resource allocation, and professionalism. Consultations were requested on 108 patients (age mean, 46.5 ± 20 years; Injury Severity Score mean, 23 ± 14; length of stay [LOS] mean, 44 ± 44 days), 0.50 per cent of all trauma admissions. Seventy-seven per cent of consultations occurred in the intensive care unit. End of life was the most common consultation (44%) followed by shared decision-making (41%). Average time to consultation was 25 days. Shared decision-making consults occurred much earlier than end-of-life consults as evidenced by a lower consult day/LOS ratio (consult day/LOS = 0.36 ± 0.3 vs 0.77 ± 0.3, P = 0.0001). Conclusions consisted of: 1) ethics consultation on trauma patients are most commonly for end-of-life and shared decision-making issues; 2) most ethics consultations occur while patients are in the intensive care unit; and 3) earlier ethics consultations are likely to be for shared decision-making issues.

SummaryEach year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.Clin J Am Soc A left heart catheterization with percutaneous intervention to an occluded coronary artery is performed. Anuric renal failure occurs from acute tubular necrosis soon after and dialysis is initiated. He also has complications of postanoxic encephalopathic seizures, lower gastrointestinal bleeding, and laboratory values consistent with shock-liver. He remains intubated without sedation. At both 24 and 72 hours-off sedation-the patient lacks corneal reflexes and has only extensor motor responses to pain. The neurology consultants diagnose him with severe anoxic brain injury and state in the medical record that the patient has a "poor prognosis." Two weeks after arrest, the patient is transferred from the initial hospital to a second hospital at the family's request. At the new hospital, the pulmonary and critical care team consults the neurology, renal, and palliative care teams to discuss the patient's care plan. Dialysis and ventilator support are continued. The primary team schedules a family meeting for the next day with palliative care, patient advocacy, social services, and the patient's wife and two grown children. The meeting centers on discussing the patient as a person, and the medical providers learn that Mr. A. was...

234decisionmaking and the danger of a surrogate making paternalistic or possibly harmful decisions. 7 A shared decisionmaking model 8 that involves members of the care team, members of an ethics committee, and other members of the patient's family or the patient's friends, as well as the surrogate, would help in this case. There is a good chance that Ed's mother is in denial and is still suffering immense grief over her son's predicament and needs both time and support to help her address the reality of his condition. Through a shared decisionmaking model, her burden of making decisions on Ed's behalf could be lessened, and she could become more open to acknowledging her son's desire to die peacefully and come to be at peace with this decision, knowing that she did not give up on her son. As with most ethical dilemmas, compassion, trust, patience, and good communication strategies can go a long way to helping resolve seemingly intractable disagreements.

Assisted living (AL) communities are long-term care settings where people live, work, and visit, and where social relationships and care, including end-of-life care, are negotiated. Assisted living is fraught with uncertainty and conflict about values, especially given residents’ cognitive and physical frailty. These value-laden issues have implications for both resident and care partners’ experiences. Yet, almost no research has examined ethics in this complex care environment. In this article, we draw on and synthesize existing theory, research, and practice knowledge to offer a conceptual model and discuss case examples that highlight everyday ethical issues in AL. We conceptualize the moral decision-making process and hence the moral landscape of AL, as influenced by a myriad of multi-level factors that shape interpersonal encounters and decision-making involving residents and their care partners, which ultimately shape individuals’ actions and experiences in the setting. We conclude by discussing implications for research, policy, and practice.