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PubMed1999

Unilateral do-not-attempt-resuscitation orders and ethics consultation: a case series.

OBJECTIVE: To describe the role of an ethics consultation service in unilaterally withholding cardiopulmonary resuscitation. DESIGN: Retrospective case series of 31 ethics consultations regarding unilateral do-not-attempt-resuscitation orders between 1992 and 1996. SETTING: A large, urban, academic medical center. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, physicians' rationale for withholding cardiopulmonary resuscitation, ethics consultants' recommendations, and patient outcomes were measured. The consultation service agreed with the medical team's intent to withhold cardiopulmonary resuscitation in 25 cases, but a unilateral do-not-attempt-resuscitation order was written in only seven of these. In 17 cases, the disagreement between the physician and the patient or surrogate over code status was resolved in a conference organized by the ethics service. CONCLUSIONS: The process of ethics consultation is useful in resolving disagreements over withholding cardiopulmonary resuscitation and other treatment and can frequently result in a consensus. Hospital policies that permit unilateral treatment limitation should be based on a model that is process-based and that encourages interdisciplinary participation in decision-making, such as that recently proposed by the Houston Task Force.

Academic Medical Centers↗
PubMed1998

Making consultation work.

In the current rapidly changing healthcare environment, nurse executives are likely to find themselves seeking and hiring consultants, as well as working with consultants who have been hired by others. Because working with a consultant entails a certain amount of risk and involves a commitment of both personal and organizational resources, nurse executives need to know how to be effective buyers and users of consultation services. The author presents guidelines for developing effective working relationships with consultants.

Consultants↗
PubMed2005

The number of consultant clinical chemists in the 15-nation European Union.

The number of consultant clinical chemists (NCCC) in the 15-nation European Union (EU) (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, The Netherlands, Portugal, Spain, Sweden, United Kingdom) has been ascertained. These data were analysed in relation to several established national parameters, including demographics, gross domestic product (GDP), cost of healthcare, cost of in vitro diagnostic (IVD) testing and the number of physicians and pharmacists. Large differences in the population-corrected costs of IVD testing (range approximately 2.4-fold) and NCCC (range approximately 30-fold) were observed between the countries, which could not be satisfactorily explained by any of the parameters assessed. The differences in IVD testing and NCCC might reflect different practices in laboratory medicine across the EU, but could not be estimated independently. In recognition of the different scope of laboratory medicine practised under the title of clinical chemistry, a simple staffing model was derived in an attempt to give a better estimate of the appropriate number of consultant laboratory medicine specialists. This model allocated a fixed number of laboratory specialists per million inhabitants for the five disciplines: clinical chemistry, 10; haematology, 10; serology, 7.5; microbiology, 12.5; and blood banking, 2. The staffing model also allowed for the contribution of the primary care sector by including one full-time consultant laboratory medicine specialist for each small private laboratory and two extra consultant laboratory specialists per million inhabitants where there are not large numbers of private laboratories. Application of the model to the available data helped to reduce the variation observed in the primary analysis of NCCC (range approximately 9-fold) but still revealed important differences between countries. These differences could arise from the poor quality of published data as much as from true differences in laboratory medicine practice. We conclude that a more sophisticated analysis of laboratory practice and of all professionals working in laboratory medicine disciplines would be required before any conclusions could be drawn about relative staffing, efficiency or cost effectiveness. The staffing model derived is a first step towards objective estimation of the number of consultant laboratory specialists in the EU.

Chemistry, Clinical↗
PubMed1992

The design and use of the bioethics consultation form.

The emergence of the ethics consultation as a means to resolve moral crises in clinical medicine has revealed the need for a worksheet that would facilitate intake and analysis. The author developed the "Bioethics Consultation Form" as an attempt to remedy this need. The form is arranged in an outline format and is a useful asset to ethics committee discussions and record keeping. The first section covers basic intake data concerning the patient's medical and personal information, advance directives, and values, as well as the values of the physician and family. After the intake section is completed with the above data, the ethics consultant then turns to the analysis section. This second section allows for (1) the discussion of conflicting values, (2) the identification of priorities, and (3) the elucidation of ethical norms relevant to the case. The Bioethics Consultation Form was adopted by the Patient Care Advisory Committee of the Franklin Square Hospital Center in Baltimore, Maryland in 1986. The methodology in the use of the form will be discussed. Further, the potential spectrum of consultative cases that can be analyzed using the form will be highlighted.

Advance Directives↗
PubMed2006

[Telemedicine consultations in Iceland].

OBJECTIVE: A Telemedicine project was initiated to evaluate the usefulness of medical teleconsultations in Iceland and to gain experience for further planning of Telemedicine in the country. MATERIAL AND METHODS: The consultations were based on videoconference and store and forward method. Electronic stethoscope, spirometry, otoendoscope and digital pictures were used along with conventional videoconsultations. Doctors in six specialties in Landspitali University Hospital and one in private practice and Primary Care Physicians from five Health Care Centers in Iceland participated in the project. RESULTS: The results show that the Telemedicine consultations is practical and can be very useful. The doctors were content with the use of Telemedicine and the patients were pleased with the technique and the consults in general. All patients for example said that the consultation was just as or even better as if the specialist was in the room in person. The use of Telemedicine was helpful in almost all of the cases. Attention must be paid to organization of the consultations, payment, technical details and knowledge. CONCLUSION: Telemedicine have a role for Icelandic healthcare and may prove to be very useful. There are a number of factors who need preparation before the implementation of a Telemedicine service.

Humans↗
PubMed1979

Psychiatric nursing consultation: the use of an inservice model to assist nurses in the grief process.

This paper proposes that death is a situation which nurses face on a daily basis. Anxiety, depression, and hostility are defined as feelings common to nurses in working with dying patients. Anxiety and depression were significantly lowered in nurses who attended at least three of the five inservice sessions. Hostility levels did not significantly change. This paper also examines the role of the psychiatric nruse consultant in assisting staff nurses to improve the quality of care provided by examining their own emotional system. The consultant can act as faciltator of the group process so that nurses can continue to function independent of the consultant after the consulting process has ended. The psychiatric nurse consultant can utilize inservice curricula such as the one described above to produce affective change in nurses who work with dying patients, which has the potential to improve the quality of care given to the dying.

Adult↗
PubMed1990

Neonatal ethics: development of a consultative group.

Experience of a neonatal ethics advisory group in a tertiary care setting was reviewed to identify which aspects of the experience have been most valuable in the development of a consultative group. Consultations were requested for 31 patients seen from August 1984 through December 1988. Review of these patients indicated that 21 of 31 infants were born after full-term gestations, 11 of 31 infants were seen beyond the neonatal period, and some type of congenital anomaly was the principal diagnosis for 64.7% of the patients. The reasons for seeking consultation primarily involved decisions regarding withdrawal or withholding of treatment. For 22 of the 31 patients, the consensus of the group supported the decision of the health care team. In the remaining consultations, the recommendation of the group was that more information and/or communication was needed. In the analysis of the neonatal ethics advisory group's experience with consultations the characteristics of neonatal patients were identified and the value of having a forum for discussing the difficult ethical issues facing members of the health care team were validated.

Abnormalities, Multiple↗
PubMed1987

Psychiatric consultations in short-term general hospitals.

We investigated the use of psychiatric consultations in short-term general hospitals using a national sample of 327 hospitals and examining the hospital experience of approximately 263,000 patients discharged from these hospitals. We found that the demographic characteristics of patients receiving psychiatric consultations in the national sample were roughly similar to those reported for patients receiving consultations in earlier, single-hospital studies. Rates of consultation were considerably lower, however: 0.9%, compared with a median rate of 3.3% reported in the literature. We also found that patients receiving psychiatric consultations used more hospital resources than other patients.

Adult↗
PubMed1987

Psychiatric consultation to inpatients with 'early-onset' type I diabetes mellitus in a university hospital.

With the use of medical records and the Consultation-Liaison Outcome Evaluation System, we studied psychiatric consultation to 52 hospitalized patients with type I diabetes mellitus having onset of disease by age 25 years. The distribution of psychiatric diagnoses assigned to this sample of patients with "early-onset" diabetes did not differ from those of patients with other medical and surgical illnesses. Three features did distinguish consultation to patients having type I diabetes: the diabetics were referred unusually early in the hospital course; psychotropics were seldom utilized; and consultants' recommendations for diagnostic studies were not followed in more than 90% of cases. The study indicates that the primary medical diagnosis is a critical variable governing consultees' use of and responses to psychiatric consultation.

Adult↗
PubMed1995

A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients.

BACKGROUND: Patients who somatize but who do not meet criteria for somatization disorder are common in the community. Virtually no research has been conducted to determine how to treat these patients. METHODS: We conducted a randomized controlled clinical trial of a psychiatric consultation intervention we had previously shown to improve the management of somatization disorder. The study population included 51 physicians treating 56 somatizing patients who had a history of seeking help for six to 12 lifetime unexplained physical symptoms. At the onset of the experiment, physicians randomized to the treatment condition received a consultation letter recommending a specific management approach; physicians randomized to the control/crossover condition received the consultation letter after 12 months. Data on health outcomes and charges were collected every 4 months for 2 years after randomization for 96% of subjects who entered the study. RESULTS: Patients of physicians who received the intervention reported significantly increased physical functioning, an improvement that remained stable during the year after the intervention. The intervention reduced annual medical care charges by $289 (95% confidence interval, $40 to $464) in 1990 constant dollars, which equates to a 32.9% reduction in the annual median cost of their medical care. CONCLUSIONS: Somatizing patients with a lifetime history of six to 12 unexplained physical symptoms reported better physical functioning after their primary care physician was provided appropriate treatment recommendations via a psychiatric consultation. Such a consultation is cost-effective because it reduces subsequent charges for medical care, while improving health outcomes in a chronically impaired population.

Adult↗
PubMed1993

The use of mental health professional consultants to police hostage negotiation teams.

Three hundred law enforcement agencies in the United States that employ a negotiator in hostage incidents responded to a survey regarding the use of mental health professionals as consultants to the negotiation team. Thirty-nine percent of the agencies with a negotiator use a mental health professional consultant to the negotiation team. Police agencies that use a mental health professional as a consultant on negotiation techniques reported more hostage incidents ending by negotiated surrender and fewer hostage incidents ending by tactical team assault and arrest of the perpetrator. Also, police agencies that use a mental health professional as a consultant on the assessment of the perpetrator reported fewer hostage incidents resulting in the serious injury or death of a hostage. Although these results are only correlational, they raise the possibility that the use of mental health professionals as consultants to police hostage negotiation teams may decrease the risk of hostage injury and death.

Chi-Square Distribution↗
PubMed1975

A conceptual overview of selected consultation models.

Because of their current popularity and utility 4 consultation models have been selected for analysis: consultee centered, group process, social action, and ecological (exemplified by Gerald Caplan, Ronald Lippitt, Saul Alinsky, and James Kelly, respectively). The process of consultation as outlined by these models is described along the following dimensions: definitions of consultation, self-perceptions of the consultant, target populations, motivation of the client system, entry, goals, diagnosis, techniques, termination, and evaluation. The discussion focuses on criteria for selecting an appropriate consultation model.

Goals↗
PubMed1978

The effects of consultation style on consultee productivity.

This study examined the effectiveness of three different consultation styles adapted from Bindman's typology. Consultees were nurses on eight wards in a state hospital for the retarded, who were assigned to Expert, Resource, and Process consultation groups plus a no-treatment control. Data on the number of new programs independently initiated by consultees were collected during a 6-week base line, 12-week consultation, and 6-week follow-up period. Results showed a general increase in number of programs initiated during the second half of the consultation period, with trends established there continued through the follow-up. Degree of change was directly related to the style of consultation: the Expert role proved no better than the control condition; the Resource and Process roles generated significant consultee activity, with the Process model generating the most programs in both experimental and follow-up periods.

Behavior Therapy↗
PubMed1977

Consultation as a political process.

Consultation may be viewed as a political-bargaining process in which actors seek to maximize at minimal cost expertise, organizational position, and organizational reputation. A view of consultation as political process allows for a shift in language in discussions of consultation. Such a language shift suggests shifts in the social meaning of the consulation process. Emphasis was placed on four suggested functions of consultation: definition and legitimation of a situation or of facts as "problematic"; raising the priority of an i5sue on the agenda of action in a consultee's agency; legitimation of deviant administrative behavior, and creation and sustenance of interagency linkages. A perspective is proposed that looks at the consequences as well as the intents of the process. This view of consultation can be studied emprically.

Humans↗
PubMed1998

Effectiveness of pediatric practice consultation on missed opportunities for immunization.

OBJECTIVE: To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines. DESIGN: The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed. RESULTS: The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions. CONCLUSIONS: There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities.

Baltimore↗
PubMed1993

Practice patterns and the adequacy of residency training in consultation medicine.

OBJECTIVE: To describe consultation practice patterns of graduates of an internal medicine residency program and to determine whether they consider themselves to be adequately trained to practice in the area of internal medicine consultations. DESIGN: The authors surveyed graduates of the internal medicine residency program at the University of California, San Diego, School of Medicine from 1980 to 1989. Respondents described their practice types and the mechanics of consultations they currently perform, as well as the adequacy of their training in and frequency of encountering 74 clinical problems in the area of internal medicine consultation. Topics were categorized as Group I: excessive training; Group II: adequate training, frequently encountered; Group III: adequate training, infrequently encountered; Group IV: inadequate training, frequently encountered; and Group V: inadequate training, infrequently encountered. SETTING: University teaching hospital. PARTICIPANTS: Of 214 graduates, 91 returned surveys adequate for analysis. RESULTS: Internists prefer verbal communication with their colleagues and seeing surgical patients in the office prior to admission. Residents perceive that they have been excessively trained in preoperative evaluations of the asymptomatic and chronically ill adult and in several postoperative complications. Topics seen frequently in clinical practice but inadequately taught include: issues in convalescence and rehabilitation from surgical procedures, use of psychotropic medications, and management of eating disorders. CONCLUSIONS: To prepare residents for practice, program directors in consultation medicine might consider incorporating outpatient preoperative evaluation assessments, encouraging a liaison between surgeons and internists, and modeling verbal communication among colleagues. Consideration should be given for more didactic training for Group IV topics.

Adult↗
PubMed2006

Need and utilization of psychiatric consultation services among general hospital inpatients.

OBJECTIVE: The aim of the present study was to estimate the need for psychiatric consultation services and psychiatric inpatient referral among inpatients of non-psychiatric hospital departments, and to assess the actual utilization of these services. METHODS: The study was carried out among 728 inpatients of physical rehabilitation wards, medical, surgical, and gynecological wards in Austrian hospitals. Psychiatric case identification was performed by research psychiatrists using the Clinical Interview Schedule (CIS). Diagnoses were given according to DSM-III-R. The assessment of need for consultation and inpatient referral was based on the clinical judgments of research psychiatrists. RESULTS: Overall, 34.2% of the inpatients were cases according to the CIS-criteria, 51.8% of them needing either psychiatric consultation or inpatient referral according to research psychiatrists. In 66.7% of those for whom research psychiatrists had stated a need, this need was not met ("unmet need"), while only 33.3% of them had their need met. In contrast, a psychiatric consultation was performed among 5% of those patients not needing psychiatric services according to the research psychiatrists ("overprovision"). Variables of the health care system (i.e. department type and catchment area of the hospital) were among the predictors for "met needs". CONCLUSION: The rate of actual psychiatric consultations and admissions to psychiatric wards was markedly lower than the need according to research psychiatrists' judgment.

Austria↗
PubMed2005

Making the case for ethics consults in community mental health centers.

Practitioners in community mental health center (CMHC) settings face an environment of vast and ever-increasing ethical complexities, in which there are both emergent dilemmas and ongoing ethical tensions created through competing treatment paradigms. CMHCs clients are a highly vulnerable population due to lower socio-economic status, possibly compromised mental functioning, and societal stigmatization. While many healthcare institutions serving vulnerable individuals offer access to clinical ethics consultations, consults are not routinely available at CMHCs. In this article, we explore the need for ethics consults in CMHCs, propose possible benefits and costs of ethics consultations, and offer suggestions for incorporating consults at CMHCs.

Community Mental Health Services↗