Decisions related to births in the "gray zone" of periviability are particularly challenging. Despite published management guidelines, clinicians and families struggle to negotiate care management plans. Stakeholders must reconcile conflicting values in the context of evolving circumstances with a high degree of uncertainty within a short time period. Even skilled clinicians may struggle to guide the patient in making value-laden decisions without imposing their own values. Exploring the experiences of one pregnant woman and her caregivers, this case study highlights how bias may undermine caregivers' ability to meet their obligation to enhance patient autonomy and the moral distress they may experience when a patient's values do not align with their own. Management strategies to mitigate the potential impact of bias and related moral distress are identified. The authors then describe one management strategy used in this case, facilitated ethics consultation, which is focused on thoughtful consideration of the patient's perspective.
In the United States, there are a large number of incarcerated individuals, resulting in high numbers of previously incarcerated individuals out on parole-who will be referred to as parolees in this paper-undergoing reentry into society. In 2016, this translated to 2640 per 100 000 adult residents in the United States being under correctional supervision, or roughly 1 in every 38 adults. 1 An aging prison population translates to an older parolee population, which translates to increased incidence of kidney disease, dialysis, and transplant needs, and therefore overall healthcare costs for this population. This is further impacted by a large African American population in prisons and later on parole, some of whom are also disproportionately impacted by renal failure due to a long recognized increased prevalence of end-stage renal disease (ESRD) in African American and Hispanic populations. 2 This paper will discuss the access needs of the parolee (previously incarcerated) population specifically; the larger issue of overall disparities in medical treatment for minority populations, including those individuals currently incarcerated and those no longer on parole, is beyond the scope of a single article. Prisoners have a constitutional right to health care, based on the United States Supreme Court decision in Estelle v. Gamble in 1976, which held that "deliberate indifference to a prison inmate's health
While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and potential challenges in implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: (1) train-the-trainer, (2) local capacity-building, (3) circuit-riding, and (4) consolidated accountability. We note each model's benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations.
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