BACKGROUND AND OBJECTIVES

National standards and guidelines call for a mechanism to address ethical concerns and conflicts in children’s hospitals. The roles, responsibilities, and reach of pediatric ethics consultation services (PECS) remain unmeasured. The purpose of this study is to quantify staffing, structure, function, scope, training, and funding of PECS.

METHODS

Cross-sectional online survey was shared with an ethics informant at 181 children’s hospitals in the United States from March to June 2022. Data were summarized descriptively and with semantic content analyses.

RESULTS

One hundred seventeen surveys were received from individual children’s hospitals in 45 states and Washington DC (response rate 65%), with 104 qualifying for survey completion. Almost one-quarter of settings received 50 or more pediatric ethics consults in the past 12 months. On average, 7.4 people at each institution have responsibility for completing ethics consults. Estimated full-time equivalent salary support for ethics is on average 0.5 (range 0–3, median 0.25). One-third (33%) of facilities do not offer any salary support for ethics and three-quarters do not have an institutional budget for the ethics program. Clinical staff primarily initiate consults. End-of-life, benefits versus burdens of treatments, and staff moral distress were the most frequently consulted themes. Almost one-quarter (21%) of children’s hospitals do not receive any consults from patients or families.

CONLUSIONS

The findings from this study reveal wide variation in PECS practices and raise concern about the lack of financial support provided for PECS despite substantial workloads.

What is Known on this Subject:

Pediatric Ethics Consultation Services (PECS) serve to clarify values, prevent ethics crisis, and mitigate conflicts. Although national guidelines and practice standards call for PECS presence in children’s hospitals, the roles, responsibilities, reach, and resources of PECS remain largely unmeasured.

What This Study Adds:

This cross-sectional study quantifies staffing, structure, function, scope, training, and funding of PECS. Pediatric ethics case consultation vol and topical consult themes are described. Additional PECS services such as ethics education and organizational ethics are characterized.

The increase in biomedical technology for children and subsequent expansion of clinical complexity raises the prevalence of values-based inquiries and the relevance of ethics engagement in clinical care.13  The American Academy of Pediatrics, American Medical Association, and The Joint Commission recommend an institutional mechanism for addressing ethics issues as a paramount priority for patient care settings.46  Pediatric Ethics Consultation Services (PECS) serve to respond to questions of values uncertainty or conflicting values from patients, their caregivers, clinicians, and the community.7  Little is known about the work of PECS in children’s hospitals. A formal assessment of the structure and function of PECS is warranted to understand how PECS address ethical needs in their institutions and the variation in support provided by their institutions.8 

Over a decade ago, a landmark survey of pediatric ethicists at freestanding children’s hospitals explored the structures and processes of consultation services.9  The 33 respondents revealed on-the-job experience as the primary source of training and a stark lack of administrative resources, financial budget, and protected time for ethics in children’s hospitals.9  In the interim, the field of ethics has engaged in professionalization through clinical fellowship programs,10,11  advanced training, and formal mentoring mechanisms,12,13  and a newly established certification process.14  The current PECS literature base has been primarily institution-specific with attentiveness to the contextual climate15  and thematic summary of pediatric case consult series.1619 

This survey was developed to explore PECS changes over the past decade, continued challenges, and consideration for the field’s future direction. The survey objective was to learn about pediatric consultative ethics; the staffing, structure, function, scope, training, and funding of the ethics service.

Pediatric inpatient care settings were identified from the Children’s Hospital Association (CHA) database and contacted by telephone or e-mail to identify the ethics point of contact. The study call protocol and contact pathway is described elsewhere.20  One identified PECS point of contact from each facility was then sent an e-mail invitation with a link to the survey. Two reminders were sent in 2-week intervals with a personalized final reminder sent to nonresponders 6 weeks after the initial invitation. The survey link remained open from March 1 to June 1, 2022. For further chain-referral sampling, the survey link was also emailed with 1 reminder message to 15 pediatrician contacts from the American Academy of Pediatrics Section of Bioethics from children’s hospitals that were not listed as CHA database members.

Survey content was designed by a collaborative, interdisciplinary study team according to the Tailored Method of Survey Design.21  Adult-based ethics consultation surveys22,23  and a landmark pediatric ethics consultation service survey from 1 decade ago9  were reviewed with incorporation of content upon permission form these prior study teams.

The survey was independently reviewed, piloted, revised, and repiloted by an interdisciplinary team before administration. The final survey instrument consisted of 44 base questions with maximum potential of 56 questions based on conditional responses.

Recognizing that different institutions use different nomenclature, the term ethics consultant was defined in the survey as “reference to whichever entity does pediatric ethics consultations in the care setting (whether an ethics committee, an individual ethicist, or some other model).” Only 1 survey response was accepted per children’s hospital.

The Institutional Review Board at the Children’s Hospital of Philadelphia determined that the survey format and content qualified as exempt from full Institutional Review Board review. A Research Electric Data Capture (REDCap©) questionnaire format was used for online data collection with the first survey page serving as written consent for participation.

Bed size was obtained from the CHA database for CHA members or was directly asked of the ethics informant for those which were not CHA members. All other data points were obtained from the survey responses. The analyses were descriptive and univariate in nature. The study team used counts for categorical variable responses. For missing responses caused by skip patterns in the survey, the number of responders was used as the denominator (actual n). PC SAS version 9.4 was used for all summaries and analyses.

After obtaining contact information for an ethics representative at 160 out of 190 children’s hospitals on the CHA membership roster20  plus 21 children’s hospitals not on the roster, those 181 ethics informants received surveys with 117 responses received (65%). Completed surveys were from 45 states and the District of Columbia. Personal respondent demographics, such as age, gender, or professional role were not obtained to protect the identity of the ethics point of contact with the focus being institutional-level data.

Out of 117 responding children’s hospitals, 104 settings (89%) identified having access to an ethics consultation service.

Over half (55%) of pediatric ethics consultations are addressed by general hospital ethics consultants who also cover adult hospitals or adult health-systems. Pediatric-specific consultation committees exist in 45% of responding settings. No children’s hospital depicted use of a third-party consulting ethics group or external contracting with ethics advisors as the means for addressing pediatric ethic consults.

A median number of 5 people (range 1–20, average 7.4) at each institution have responsibility for completing pediatric ethics consults. Only 1 or 2 people do pediatric ethics consults in 20% of settings. Estimated total number of full-time equivalent salary support for ethics is 0.52 average (range 0–3, median 0.25). One-third of facilities did not offer any salary support for ethics. Pediatricians, nurses, social workers, and chaplains represent the most common consultant disciplines (Table 1). Half (48%) reported the presence of palliative care team members on the ethics consult team including: palliative care physicians (38%), advance practice providers (12%), palliative social workers (12%), palliative nurses (10%), palliative chaplains (6%), and 1 palliative care music therapist represented.

TABLE 1

Patterns in Pediatric Ethics Consultations (n = 104 Facilities)

CategoryResponsen (%)
Consult volume in past 12 months (n = 103 responses)   
 0 (0) 
 1–5 18 (17) 
 6–10 25 (24) 
 11–15 11 (11) 
 16–25 13 (13) 
 26–50 14 (14) 
 > 50 22 (21) 
Duration of most experienced consultant’s service time (n = 97 responses)   
 Less than 1 y 0 (0) 
 1–3 y 1 (1) 
 4–10 y 21 (22) 
 >10 y 71 (73) 
Disciplines or roles represented as consultants (n = 104 responses)   
 Pediatrician 78 (75) 
 Nursing 71 (68) 
 Social work 59 (57) 
 Chaplaincy 53 (51) 
 Administration 33 (32) 
 Community member 33 (32) 
 Legal 31 (30) 
 Medical resident or house officer 28 (27) 
 Risk management 18 (17) 
 Patient advocate 16 (15) 
 Philosopher 7 (7) 
 Trained conflict mediator 6 (6) 
 Human resources 3 (3) 
 Compliance officer 2 (2) 
Annual budget for pediatric ethics program (n = 99 responses)   
 No 73 (73) 
 Less than $24 999 9 (9) 
 $25 000–$49 999 3 (3) 
 $50 000–$74 999 0 (0) 
 $75 000–$99 999 0 (0) 
 $100 000 or more 7 (7) 
 Not sure 7 (7) 
CategoryResponsen (%)
Consult volume in past 12 months (n = 103 responses)   
 0 (0) 
 1–5 18 (17) 
 6–10 25 (24) 
 11–15 11 (11) 
 16–25 13 (13) 
 26–50 14 (14) 
 > 50 22 (21) 
Duration of most experienced consultant’s service time (n = 97 responses)   
 Less than 1 y 0 (0) 
 1–3 y 1 (1) 
 4–10 y 21 (22) 
 >10 y 71 (73) 
Disciplines or roles represented as consultants (n = 104 responses)   
 Pediatrician 78 (75) 
 Nursing 71 (68) 
 Social work 59 (57) 
 Chaplaincy 53 (51) 
 Administration 33 (32) 
 Community member 33 (32) 
 Legal 31 (30) 
 Medical resident or house officer 28 (27) 
 Risk management 18 (17) 
 Patient advocate 16 (15) 
 Philosopher 7 (7) 
 Trained conflict mediator 6 (6) 
 Human resources 3 (3) 
 Compliance officer 2 (2) 
Annual budget for pediatric ethics program (n = 99 responses)   
 No 73 (73) 
 Less than $24 999 9 (9) 
 $25 000–$49 999 3 (3) 
 $50 000–$74 999 0 (0) 
 $75 000–$99 999 0 (0) 
 $100 000 or more 7 (7) 
 Not sure 7 (7) 

Ethics consultants do not represent the patient population served in terms of racial and ethnic diversity in 65% of settings. Despite this lack of diverse representation among ethics consultants, two-thirds of respondents stated that there are not initiatives in place to increase the diversity of consultants. The one-third of respondents with diversity initiatives in place described active recruitment, partnership with Diversity Equity and Inclusion institutional leads, network outreach programs, mentorship and shadowing programs for students, and strategic planning or workgroups. Recognizing the lack of human diversity, 70% of respondents report having mechanisms consistently in place to ensure the ethics process includes an open range of diverse viewpoints, opinions, and perspectives to try to overcome groupthink.

Over three-fourths (77%) of respondents have someone on the consult service who has been doing pediatric consults for over a decade (Table 1). Almost half of settings (47%) do not have anyone on staff who has obtained Healthcare-Ethics Consultation Certification, an optional certification for clinical ethicists, and 30% of settings do not have anyone on staff who has completed a fellowship or graduate degree program in bioethics. Twenty-three responding sites (22%) do not have a staff member with either Healthcare-Ethics Consultation Certification or formal ethics training performing ethics consults.

Continuing ethics education is not required for pediatric ethics consultants in 77% of settings. For those with an ethics-specific continuing medical education annual requirement for physician consultants (11%), an average 13.6 (range 2–40, median 10) hours are required. Respondents described ethics didactics, grand rounds, consortium trainings, staff development, and case reviews as the primary education modalities.

All PECS received consults over the past year with 21% of settings having received over 50 consults in the past 12 months (Table 1). As depicted in Fig 1, the most common ethics consult topics were: end-of-life issues, benefits versus burdens of treatments, staff moral distress, and care team conflict with parents. The least common ethics topics were patient safety, privacy or confidentiality, professional boundaries (including relationships and gift giving), distribution of scarce resources, and equity and discrimination.

FIGURE 1

Consult topic frequency.

FIGURE 1

Consult topic frequency.

Close modal

Thirteen respondents (13%) depict having “trigger” scenarios which result in an automatic PECS consult, whether certain duration of days in intensive care setting or a procedure or intervention-based referral to PECS.

Team response to ethics consultations could include more than 1 approach in 91% of institutions: completion by a small team (87%), a single individual (72%), or a full ethics committee (61%). Twenty percent of pediatric ethics services do not use curbside conversations and instead require a full ethics consultation process when an ethics question is raised. Ethics consults are staffed during weekend hours in 70% of responding children’s hospitals and only staffed during weekday business hours in 30% of settings.

Three-fourths of respondents do not join in clinical care team or patient rounds. For those PECS that do join clinical teams, ethics representatives round at scheduled times with the intensive care team (8%), other hospital rounds (4%), or both intensive care and other hospital rounds (13%).

Ethics consultants obtain the perspective of the patient and/or patient’s proxy in ethics consults in all consults (23%), more than half of consults (44%), between one-quarter to one half of consults (19%), or less than one-quarter of consults (14%).

The majority of respondents (87%) affirmed that their hospital maintained a formal guidance document addressing pediatric ethics consultation. This policy document covers: who may request a consult (69%), roles and responsibilities of PECS members (60%), steps involved in consult completion (52%), expected documentation of PECS cases (49%), identification of personnel accountable for the quality of PECS work (27%), the process for notifying a patient’s guardian of a PEC request specific to the child’s case (23%), and role clarity regarding which requests are appropriate for PECS review (20%).

Any staff member can request a PECS at every responding hospital. Ethics consultations are requested by doctors or advanced practice practitioners in over half of cases (54%), nursing staff (26%), other staff (7%), hospital administration (6%), or patients and families (6%).

Almost one-quarter (21%) of children’s hospitals do not receive any consults from patients or families. One-third of respondents shared that patients and families are informed about the existence of the PECS through written materials routinely given at time of admission and another one-third reported these materials are available upon request from the family. These written materials are available in English in all settings, Spanish in 37% of settings, and 1 setting provides content in Somali, whereas 2 offer PECS written materials in Hmong. Under half (46%) of respondents host information about the PECS on the hospital’s public Web site and 11% display posters about the PECS in public areas of the hospital. The PECS may be reached through a call to the hospital operator in 38% of settings. Word of mouth is the sole source of sharing the PECS with patients and their families in 15% of settings. Twenty percent of settings report that patients and families are not informed about PECS function or availability.

The scope of the ethics programs includes organizational ethics (40%), research ethics (34%), regulatory and compliance functions (13%), and community outreach related to ethics (13%).

Aside from PECS work focused on healthcare ethics consults, additional engagement for ethics includes an ethics education series (38%), an ethics center or department (36%), an ethics training program (20%), and an ethics academic conference (16%). In a typical year, pediatric ethics program staff engage in an average 29 (range 0–200, median 7) formal teaching engagements relevant to ethical issues (eg, lectures, case-based discussions, grand rounds, didactics, and/or morning reports).

Most ethics programs have responsibility within the institution for leading or supporting development of new policies and review of policies relevant to ethical issues (90%). PECS respondents emphasized a commitment to engaging in equity work by embedding equity within hospital policies, serving on committees with an eye for equity, and developing ethics curricula attentive to issues of equity.

Almost three-quarters of respondents (74%) do not have an institutional budget for the ethics program (Table 1).

The survey results suggest that although pediatric ethics case consultation volume, educational initiatives, and service to the organization in terms of policy review and ethics outreach have increased in the last decade, ethics programs remain largely unfunded and under-resourced. PECS members primarily engage in ethics work via volunteer service time or collateral duty. Interdisciplinary PECS members lack formal ethics education and rely primarily on on-the-job training.

Consult volume increased compared with a pediatric ethics survey completed in 2010, at which time half of responding ethics consultants at children’s hospitals reported that their services conducted 6 to 10 formal ethics consultations in the previous 12 months.9  Despite this increase in consult volume, the number of individuals responsible for leading ethics consults only increased from an average 5.6 per facility reported in the 2010 study to 7.4 reported in this study. Further research is warranted to explore the ideal staffing model and optimal volume of pediatric ethics consults to maintain professional competencies and meet patient needs.24 

In 2010, one-third of ethics consultants reported receiving any salary support for ethics.9  Although two-thirds of ethics consultants in this study reported receiving salary support for their ethics role, protected time for ethics remains low. The limited full-time equivalent reported by respondents may result in PECS limited to responding to escalated conflicts or mitigating crises as noted in the frequency of ethics consults occurring at end-of-life or in settings of high staff moral distress.25  Ethics may be underutilized in children’s hospitals, as Watt et al’s comparison of staff survey on encountered ethical issues versus actual ethics consult occurrence noted although 63 staff surveys logged an encountered ethics issue in a 15 month period; this correlated with only 5 ethics consult requests in the same timeframe.25  Upstream efforts toward earlier engagement of ethics, such as corounding in the ICU26,27  or hospital unit, occur in less than one-quarter of settings and yet these proactive mechanisms may be important steps toward ethics integration. Protected time for ethics work could help shift the focus from responding to ethics concerns to earlier integration and a more preventive ethics approach.28 

Ethics consultants described extensive ethics education initiatives, preventive ethics efforts, policy writing and policy development, staff moral distress programs, and institutional service as part of their larger programmatic ethics work. However, the actual programmatic budget for this ethics work is dismal considering three-fourths of children’s hospitals do not budget any dollars toward ethics programs.

The American Academy of Pediatrics,5  the American Medical Association,4  and the American Society of Bioethics and Humanities29  each endorse use of a written ethics consultation policy to guide practice standards in the care setting. Sixty percent of ethics consultants endorsed the presence of a written policy guiding ethics practices in the pediatric setting in 2010, whereas the majority of this survey’s respondents (87%) affirmed use of a local ethics policy to guide ethics practices. The increase in ethics policy guidance may help children’s hospitals foster fairness in their values-based provisions and consistency in their consultation practices.30,31 

Although PECS report mechanisms to foster diversity of opinions within their teams, ethics consultants do not represent the children’s hospital workforce or patient population in terms of human diversity. Whereas some efforts to increase diversity, such as mentorship programs and partnerships, were described, the findings from this survey should leverage not just conversation but action to target a more diverse ethics workforce.

Low PEC request rate by families is consistent with historical data, if not inflated.1517  Low request rates may be explained by both the lack of family guidance on PECS and the difficulty finding a PECS contact.20  Additional research is warranted to determine whether the lack of family-initiated consults is because families are not allowed to or informed about how to initiate an ethics consultation. It is important to address these gaps, especially since PEC for inequality and discrimination32,33  are quite rare, and this type of consult likely comes from families. Institutional models, which ensure pamphlet distribution, posters, public-facing websites, and staff education,7,9  are integral for increasing access to families.

The majority of ethics consultants bring practical experience and yet lack formal training. Although many ethics consultants in pediatric settings bring longevity through years of practice, one-fourth of responding settings did not have a staff member with either certification or formal ethics training performing ethics consults. The idea of staff members engaging in other specialized work in children’s hospitals without formalization of their professional competencies and rigorous education with mentorship would be concerning. With the advent of ethics fellowship programs, certificate programs, and coursework; ethicists and their host hospitals will need to consider further investment in professionalization as part of upholding strong practice standards.3436 

As per survey methodology, limitations of this study include potential for recall bias in self-reporting ethics activities. Report of most frequently consulted themes is at particular risk of subjective decision about the typology of the consult theme. The survey relied on self-report rather than program investigation and thus there could be an inherent bias in over- or under-reporting programmatic reach, role, or support (to include whether ethics may be incorporated into staff job duties). Respondents may not have had full access to institutional budget to sufficiently inform their report of programmatic financial support. Practice of nonresponders may vary from that of responders.37  Study strengths include reporting at the institutional level with noted diversity in programmatic size and setting and response pattern representative of geographic regions throughout the United States. Although, focusing on institutional-level data without incorporating respondent’s personal demographics such as age, gender, race, or profession is a missed opportunity to further define the field’s diversity.

This study updates our knowledge on the state of PECS and the scope of their work, revealing wide variety in staffing, structure, function, training, and funding within children’s hospitals. Clearly values uncertainty and conflict exist within settings caring for children. Additional research is warranted to guide future directions for PECS models, funding, and maximized impact contextualized to diverse pediatric care settings. Quantitative analyses of the staffing and time invested in ethics consultancy and program work would help inform health systems wanting to implement and resource PECS. Specifically, knowing what disciplines (whether an intensive care physician, philosopher, social worker, etc.) receive protected time for ethics work and the number of hours of ethics work occurring per week by members of those disciplines would likely help advance and balance the interdisciplinary field. PECS must be competent, resourced, responsive to institutional needs, and positioned to promote just health care.7  This survey raises concern regarding whether children’s hospitals are investing in ethics personnel and ethics programs in a manner that adequately leverages the patient care, institutional, and community benefits of PECS.

We thank Dr Connie Ulrich, Ms Marie Neumann, Mr Jacob Robinson, Dr Malachia Trout for initial review of the survey. The study team thanks Dr Ellen Fox and Dr Jennifer Kesselheim sharing their ethics survey instruments and contact protocols.

Drs Weaver and Walter conceptualized and designed the study and drafted the initial manuscript; Mr Sharma helped to coordinate data analyses; and all authors reviewed and revised the manuscript for intellectual content, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

COMPANION PAPER: A companion to this article can be found online at http://www.pediatrics.org/cgi/doi/10.1542/peds.2022-058947.

FUNDING: Dr Walter was supported by the National Heart, Lung, And Blood Institute of the National Institutes of Health under Award Number K23HL141700.

CONFLICT OF INTEREST DISCLOSURES: Dr Weaver participated in this study in a private capacity. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, Veterans Affairs, the National Center for Ethics in Healthcare, or the federal government. The other authors have indicated they have no conflicts of interest to disclose.

PECS

Pediatric Ethics Consultation Services

1
Zawacki
BE
.
Contemporary biomedical ethics
.
N Engl J Med
.
1980
;
303
(
16
):
947
2
Siegler
M
.
Clinical medical ethics: its history and contributions to American medicine
.
J Clin Ethics
.
2019
;
30
(
1
):
17
26
3
Berger
JT
.
Stumbled, fumbled, bumbled, grumbled, and humbled: looking back at the future history of clinical ethics
.
J Clin Ethics
.
2014
;
25
(
2
):
96
101
4
Chaet
DH
.
AMA code of medical ethics’ opinions on ethics committees and consultations
.
AMA J Ethics
.
2016
;
18
(
5
):
499
500
5
Moon
M
;
Committee on Bioethics
.
Institutional ethics committees
.
Pediatrics
.
2019
;
143
(
5
):
e20190659
6
The Joint Commission
.
2022 Comprehensive Accreditation Manual
.
Oakbrook Terrace, IL
:
The Joint Commission
;
2022
7
American Society of Bioethics and Humanities
.
Core Competencies for Healthcare Ethics Consultants
, 2nd ed.
Chicago, IL
:
ASBH
;
2011
8
Carter
B
,
Brockman
M
,
Garrett
J
,
Knackstedt
A
,
Lantos
J
.
Why are there so few ethics consults in children’s hospitals?
HEC Forum
.
2018
;
30
(
2
):
91
102
9
Kesselheim
JC
,
Johnson
J
,
Joffe
S
.
Ethics consultation in children’s hospitals: results from a survey of pediatric clinical ethicists
.
Pediatrics
.
2010
;
125
(
4
):
742
746
10
Feder
KJ
,
Chao
SK
,
Vercler
CJ
,
Shuman
AG
,
Firn
JI
.
A pre-doctoral clinical ethics fellowship for medical students
.
J Clin Ethics
.
2021
;
32
(
2
):
165
172
11
Chidwick
P
,
Faith
K
,
Godkin
D
,
Hardingham
L
.
Clinical education of ethicists: the role of a clinical ethics fellowship
.
BMC Med Ethics
.
2004
;
5
:
E6
12
Thomas
HC
,
Meador
K
,
Payne
K
,
Drolet
BC
.
Interdisciplinary ethics certificate program for graduate medical education trainees
.
J Grad Med Educ
.
2021
;
13
(
6
):
863
867
13
Doukas
DJ
,
Ozar
DT
,
Darragh
M
,
de Groot
JM
,
Carter
BS
,
Stout
N
.
Virtue and care ethics & humanism in medical education: a scoping review
.
BMC Med Educ
.
2022
;
22
(
1
):
131
14
Antommaria
AHM
,
Feudtner
C
,
Benner
MB
,
Cohn
F
;
Healthcare Ethics Consultant Certification Commission
.
The healthcare ethics consultant-certified program: fair, feasible, and defensible, but neither definitive nor finished
.
Am J Bioeth
.
2020
;
20
(
3
):
1
5
15
Nathanson
PG
,
Walter
JK
,
McKlindon
DD
,
Feudtner
C
.
Relational, emotional, and pragmatic attributes of ethics consultations at a children’s hospital
.
Pediatrics
.
2021
;
147
(
4
):
e20201087
16
Johnson
LM
,
Church
CL
,
Metzger
M
,
Baker
JN
.
Ethics consultation in pediatrics: long-term experience from a pediatric oncology center
.
Am J Bioeth
.
2015
;
15
(
5
):
3
17
17
Winter
MC
,
Friedman
DN
,
McCabe
MS
,
Voigt
LP
.
Content review of pediatric ethics consultations at a cancer center
.
Pediatr Blood Cancer
.
2019
;
66
(
5
):
e27617
18
Larcher
VF
,
Lask
B
,
McCarthy
JM
.
Paediatrics at the cutting edge: do we need clinical ethics committees?
J Med Ethics
.
1997
;
23
(
4
):
245
249
19
Leland
BD
,
Wocial
LD
,
Drury
K
,
Rowan
CM
,
Helft
PR
,
Torke
AM
.
Development and retrospective review of a pediatric ethics consultation service at a large academic center
.
HEC Forum
.
2020
;
32
(
3
):
269
281
20
Sharma
S
,
Weaver
MS
,
Walter
JK
.
The accessibility of inpatient pediatric ethics consultation services to patient caregivers
.
Hosp Pediatr
.
2022
;
12
(
9
):
e291
e294
21
Dillman
DSJ
,
Christian
L
.
Internet, Mail, and Mixed-Mode Surveys: The Tailored Design Method
.
Hoboken, NJ
:
John Wiley & Sons, Inc
;
2009
22
Fox
E
,
Danis
M
,
Tarzian
AJ
,
Duke
CC
.
Ethics consultation in U.S. hospitals: a national follow-up study
.
Am J Bioeth
.
2022
;
22
(
4
):
5
18
23
Fox
E
,
Myers
S
,
Pearlman
RA
.
Ethics consultation in United States hospitals: a national survey
.
Am J Bioeth
.
2007
;
7
(
2
):
13
25
24
Glover
AC
,
Cunningham
TV
,
Sterling
EW
,
Lesandrini
J
.
How much volume should healthcare ethics consult services have?
J Clin Ethics
.
2020
;
31
(
2
):
158
172
25
Watt
K
,
Kirschen
MP
,
Friedlander
JA
.
Evaluating the inpatient pediatric ethical consultation service
.
Hosp Pediatr
.
2018
;
8
(
3
):
157
161
26
Kana
LA
,
Feder
KJ
,
Matusko
N
,
Firn
JI
.
Pediatric interprofessional ICU ethics tounds: a single-center study
.
Hosp Pediatr
.
2021
;
11
(
4
):
411
416
27
Schneiderman
LJ
,
Gilmer
T
,
Teetzel
HD
.
Impact of ethics consultations in the intensive care setting: a randomized, controlled trial
.
Crit Care Med
.
2000
;
28
(
12
):
3920
3924
28
Forrow
L
,
Arnold
RM
,
Parker
LS
.
Preventive ethics: expanding the horizons of clinical ethics
.
J Clin Ethics
.
1993
;
4
(
4
):
287
294
29
Tarzian
A
,
Fox
E
,
Danis
M
,
Duke
CC
.
Ethics consultation in U.S. hospitals: adherence to national practice standards
.
AJOB Empir Bioeth
.
2022
;
13
(
1
):
10
21
30
Kaps
B
,
Kopf
G
.
Functions, operations and policy of a volunteer ethics committee: a quantitative and qualitative analysis of ethics consultations from 2013 to 2018
.
HEC Forum
.
2022
;
34
(
1
):
55
71
31
Neal
JB
,
Pearlman
RA
,
White
DB
, et al
.
Policies for mandatory ethics consultations at U.S. academic teaching hospitals: a multisite survey study
.
Crit Care Med
.
2020
;
48
(
6
):
847
853
32
Fanta
M
,
Ladzekpo
D
,
Unaka
N
.
Racism and pediatric health outcomes
.
Curr Probl Pediatr Adolesc Health Care
.
2021
;
51
(
10
):
101087
33
Nong
P
,
Raj
M
,
Creary
M
,
Kardia
SLR
,
Platt
JE
.
Patient-reported experiences of discrimination in the US health care system
.
JAMA Netw Open
.
2020
;
3
(
12
):
e2029650
34
Bibler
TM
,
Nelson
RH
,
Moore
B
,
Malek
J
,
Majumder
MA
.
Building effective mentoring relationships during clinical ethics fellowships: pedagogy, programs, and people
.
HEC Forum
.
Feb
26
,
2022
35
Murano
MC
,
Maglio
M
,
Spranzi
M
,
Foureur
N
.
The “Commitment Model” of clinical ethics consultation: revisiting the meaning of expertise and professionalization
.
J Clin Ethics
.
2021
;
32
(
4
):
287
298
36
Horner
C
,
Childress
A
,
Fantus
S
,
Malek
J
.
What the HEC-C? an analysis of the healthcare ethics consultant-certified program: one year in
.
Am J Bioeth
.
2020
;
20
(
3
):
9
18
37
VanGeest
JB
,
Johnson
TP
,
Welch
VL
.
Methodologies for improving response rates in surveys of physicians: a systematic review
.
Eval Health Prof
.
2007
;
30
(
4
):
303
321