Martin L Smith's research while affiliated with Cleveland Clinic and other places

Publications (39)

Article
Background: How caregivers contribute to positive or negative outcomes for left ventricular assist device (LVAD) patients remains unclear. Our primary study objectives were to (1) identify caregiver support attributes through a retrospective chart review of social workers' psychosocial assessments for LVAD patients and (2) determine how these attr...
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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 reasonabl...
Article
A greater understanding of how beliefs and perceptions inform LVAD-placement refusals can help ensure that standards for informed decision-making are met. Here, we report on the factors that influence declination and what accounts for changes in decliners' decision-making process, when and if that occurs. We identified candidates (8 bridge-to-trans...
Article
Standardizing consultation processes is increasingly important as clinical ethics consultation (CEC) becomes more utilized in and vital to medical practice. Solid organ transplant represents a relatively nascent field replete with complex ethical issues that, while explored, have not been systematically classified. In this paper, we offer a propose...
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Full-text available
Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of th...
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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 e...
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We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients' ages ranged from 14 to 85. Continued mechanical ventil...
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Background: Little has been written about models for clinical ethics consultation. By “model” we mean the way in which the engagement between the clinical ethics consultant, hospital staff, and other stakeholders is structured, with a key variable being the degree of integration with stakeholders within the institution or segments of the institutio...
Article
The clinical ethicist met with Ms. H to clarify what information she wants and does not want to know. First, she wants to receive any treatment that could prolong her life, regardless of how the treatment affects her ability to engage in activities of daily living. Second, she wants to be included in the decision-making process as much as possible,...
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It is generally accepted that appropriate documentation of activities and recommendations of ethics consultants in patients' medical records is critical. Despite this acceptance, the bioethics literature is largely devoid of guidance on key elements of an ethics chart note, the degree of specificity that it should contain, and its stylistic tenor....
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Clinical ethics consultation is largely outside the scope of regulation and oversight, despite its importance. For decades, the bioethics community has been unable to reach a consensus on whether there should be accountability in this work, as there is for other clinical activities that influence the care of patients. The American Society for Bioet...
Article
Living donor liver transplantation (LDLT) is associated with a low but finite and well documented risk of donor morbidity and mortality, therefore organizations and individuals involved in this activity must accept the fact that donor death is as a question of "when, not if". Studies in the field of crisis management show that "preparing for the in...
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Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.
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Most solid-organ transplants performed in the Western world are from deceased donors. In the last decade, deceased donation rates have reached a plateau as the number of patients with end-stage organ disease has steadily increased, resulting in a large discrepancy between organ supply and demand. Living donor transplantation is one way to decrease...
Article
We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed.To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple...
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Full-text available
Conflicts of interest. None to report. Despite widespread acceptance in the United States of neurological criteria to determine death, clinicians encounter families who object, often on religious grounds, to the categorization of their loved ones as “brain dead.” The concept of “reasonable accommodation” of objections to brain death, promulgated i...
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While consensus exists among many practitioners of ethics consultation about the need for and identification of core competencies and standards, there has been virtually no attempt to determine how these competencies and standards are best taught and assessed. We believe that clinical ethics consultation has reached a state of sufficient maturity t...
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In 1998 the authors of Core Competencies for Health Care Ethics Consultation declined to endorse certification of individuals or groups who do ethics consultation, judging it was, "at best, premature." The "professionalization" of clinical ethics consultants has long been a subject of heated debate, with questions raised about accreditation of trai...
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For a variety of reasons, the most commonly used advance directive documents (eg, the living will) may not be very useful in many situations that older adults encounter. The durable power of attorney for health care is a more versatile document. We advocate focusing less on "signing away" certain interventions and more on clarifying the goals of ca...
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The ethical imperative for quality improvement in health care requires that all health care personnel engage in attentive observation, reflection, innovative thinking, and action. A core QI question for everyone working in a clinical setting is this: How can the delivery and service systems I participate in be improved to enhance and improve qualit...
Article
Determining resuscitation status (RS) for inpatients with advanced cancer is emotionally charged and often conflictual. Available data suggest that clinicians have inconsistent practices when establishing and documenting do-not-resuscitate (DNR) orders. Lack of standardization may contribute to ineffective and unclear discussions regarding RS. To i...
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The Texas Advance Directives Act (TADA) provides legal immunity for physicians who discontinue life-sustaining treatment judged to be medically inappropriate. The process includes review and affirmation of physicians' judgments by an ethics or medical committee. This study was undertaken to determine awareness of and experience with the medical app...
Article
Palliative care services provide symptom control and psychosocial support for dying patients and their families. These services are not available in many cancer centers and tertiary hospitals. The purpose of this study was to review the impact of a palliative care program, established in 1999, on overall in-hospital mortality. We reviewed the M. D....
Article
Payment to subjects for participation in research is reportedly common, but no published data documents the nature of this practice. Institutional review boards (IRBs) are responsible for ensuring both the safety and voluntary participation of research subjects, yet guidance from federal and expert pediatric sources regarding appropriate payment ap...

Citations

... In paper II we discuss both the professional autonomy of the GPs and the autonomy of the patients. Generally, autonomy refers to the human capacity for making independent choice (153,154). One could argue that absolute autonomy does not exist, as this requires the actor to be fully informed and free from external influence, which of course is unrealistic. ...
... Social support was the second most important element to assess by respondents. Less social support is associated with a higher risk for re-hospitalization 27 and mortality 28 in the LVAD population, however an accurate understanding of the importance, quality, or quantity of the support necessary is not well understood. 3 Those with a strong support system could theoretically offset other negative PS factors (such as cognitive impairment), thus influencing the healthcare team's decision to implant a LVAD for individuals. ...
... Here, learning portfolios will allow seamless integration between ethics training in undergraduate and postgraduate training [51,83,97,98] and would be in keeping with the notion of ethics training being part of a longitudinal training experience [4,135] that nurtures PIF [131,134]. Portfolios not only serve as a valuable assessment modality for longitudinal evaluation of ethical competency but also promotes continuous self-learning through the recognition of knowledge deficits while reinforcing good behaviour [63,[136][137][138][139][140][141][142][143]. ...
... The US literature refers to the embedded approach, and the Dutch to the integrative approach. Both the embedded and integrative models function as part of a broader CES service [9]. In these models, rather than providing ad hoc advice on challenging cases when consulted, ethicists work regularly and collaboratively with transgender care teams to provide specialized CES through a variety of activities, discussed below. ...
... These and related questions should guide the assessment process during direct patient interview (rather than curbside consults). Similar to their role on solid organ transplant teams (40,41), clinical ethicists commonly assist VCA teams with various aspects of the VCA program, including the assessment of recipient candidates. The ethicist does not work in isolation of the team psychologist, psychiatrist or social worker; however, the ethics assessment is additional to the psychosocial assessment performed by social workers. ...
... Die Frage der Beratungsmethodik gerät bislang jedoch kaum in den Blick der wissenschaftlichen Beschäftigung mit Themen der Klinischen Ethik. Zwar werden formale und die Struktur betreffende Fragen von Ethikberatung aufgegriffen (Agich 2001;Steinkamp und Gordijn 2010;May 2013;Flicker et al. 2014;Vollmann 2021) und Moderationsgeschick wird angemahnt (AEM 2019). Beratungsmethoden im engeren Sinne bleiben dagegen unberücksichtigt oder werden nur allgemein benannt (Orr und Shelton 2009;Simon 2021;Vollmann 2021). ...
... While the field of clinical ethics consultation is almost 30 years old and has achieved some maturity, there is by no means an accepted consensus about a number of aspects of the process or those individuals who engage in ethics consultation. Unlike other areas of medical specialization that have established fields of praxis and expertise, such as cardiology and oncology, in which standards of knowledge and practical application are accepted and for which measurements of professional accomplishment have been established (such as specialty board examinations), a similar foundation does not yet exist for the practice of ethics consultation (Kodish et al. 2013;Bruce et al. 2015;Tarzian, Wocial, and Committee 2015). There are ongoing attempts to regulate and professionalize the practice by setting both individual and institutional standards, but these efforts have not yet achieved fruition and there remains a large degree of inter-institutional variability (Fins et al. 2016;Prince et al. 2017). ...
... In the current study, recurrent CTAs cause loss of time, increase in costs, and loss of patient and organ and are similar to the results of this study. Ongoing unnecessary treatment is regarded in some societies as the violation of body integrity and abuse of the corpse [20]. Conversely, a heart that continued to beat and blood that continued to flow created an expectation that the patient in the current study might be able to recover. ...
... Hier wird in der Literatur allerdings eine oft unzureichende Aufklärung mit ungenügender Transparenz einerseits und mangelhaftem Verständnis patientenseitig beklagt, zumal die ursprüngliche Indikationsgruppe "brigde to transplant" und die ohnehin seltene "bridge to recovery" zahlenmäßig immer kleiner werden in Relation zu "destination therapy" und der in letzter Zeit häufiger genutzten "brigde to decision" [189]. Mit der verbesserten notfall-und intensivmedizinischen Versorgung mehren sich in kardiologischen Zentren jedoch auch die Fälle, in denen Patienten zum fraglichen Zeitpunkt ihre Entscheidung nicht kommunizieren können, sodass "Ersatzentscheider" (Familienangehörige, durch Patientenverfügung oder behördlich bestellte Personen) befragt werden, die allerdings mindestens in 1/3 der Fälle anders entscheiden, als es der Betroffene getan hätte [190,191]. ...