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Characterisation of organisational issues in paediatric clinical ethics consultation: a qualitative study
  1. D J Opel1,2,
  2. B S Wilfond1,2,
  3. D Brownstein2,
  4. D S Diekema1,2,
  5. R A Pearlman3,4
  1. 1
    Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington, USA
  2. 2
    Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
  3. 3
    Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
  4. 4
    Geriatric Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
  1. Dr D J Opel, Metropolitan Park West, M/S: MPW 8-2, 1100 Olive Way, Suite 800, Seattle, WA 98101, USA; djopel{at}


Background: The traditional approach to resolving ethics concerns may not address underlying organisational issues involved in the evolution of these concerns. This represents a missed opportunity to improve quality of care “upstream”. The purpose of this study was to understand better which organisational issues may contribute to ethics concerns.

Methods: Directed content analysis was used to review ethics consultation notes from an academic children’s hospital from 1996 to 2006 (N  =  71). The analysis utilised 18 categories of organisational issues derived and modified from published quality improvement protocols.

Results: Organisational issues were identified in 68 of the 71 (96%) ethics consult notes across a range of patient settings and reasons for consultation. Thirteen of the 18 categories of organisational issues were identified and there was a median of two organisational issues per consult note. The most frequently identified organisational issues were informal organisational culture (eg, collective practices and approaches to situations with ethical dimensions that are not guided by policy), policies and procedures (eg, staff knows policy and/or procedural guidelines for an ethical concern but do not follow it) and communication (eg, communication about critical information, orders, or hand-offs repeatedly does not occur among services).

Conclusions: Organisational issues contribute to ethical concerns that result in clinical ethics consults. Identifying and addressing organisational issues such as informal culture and communication may help decrease the recurrence of future similar ethics concerns.

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  • Competing interests: None.

  • Ethics approval: This study was examined and approved by the Seattle Children’s Hospital’s Institutional Review Board.

  • A version of this paper was presented at the 10th Annual Meeting of the American Society for Bioethics and Humanities, Cleveland, Ohio, USA, in 2008.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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