BACKGROUND:While surgeon burnout is extensively documented, the medical community has limited corresponding data regarding what it might mean to thrive in the profession as captured by robust measures of "flourishing." STUDY DESIGN:We conducted a cross-sectional survey measuring flourishing in a sample of 1,000 practicing US surgeons from the American Medical Association Masterfile between September and December 2025, including the Harvard Flourish Index (FI) and Secure Flourish Index (SFI). We used multivariable regression to assess personal and professional correlates of flourishing. RESULTS:Of 959 eligible surgeons in our sample, 283 (30%) responded. Mean flourishing (SFI) score was 7.98 (± 1.21) on a 0-10 scale (higher score=higher flourishing). Surgeons reported the highest flourishing in "Financial and Material Stability" (8.57 ± 2.11) and "Meaning and Purpose" (8.50 ± 1.39), while "Close Social Relationships" (7.41 ± 2.08) was the lowest-ranked domain. In multivariate linear regression, working fewer hours (adjusted β (each additional hour), -0.02; p<0.001), having children (adjusted β, 0.43; p=0.05) and viewing surgery as a calling (adjusted β, 0.28; p=0.006) were associated with higher flourishing. A majority (88%) of surgeons view the profession as a calling. CONCLUSION:Practicing surgeons report high levels of flourishing, with scores surpassing several historical medical and non-medical cohorts. Most surgeons reported comparatively high scores in meaning and purpose concurrent with deficits in social connectivity. Burnout and well-being conversations in the surgical professions may benefit from a flourishing framework. Naming meaning and purpose exemplars while being able to identify key deficits like social connectivity may be crucial for helping surgeons thrive.

Video telehealth visits (VTV) have emerged as a critical tool for oncology care delivery, with potential to address longstanding access disparities. We examined the association between broadband internet availability, individual digital literacy factors, and VTV utilization among patients with cancer. In a retrospective cohort of 13,897 patients across a multi-site practice, VTV utilization was significantly lower in areas with ≤1 internet service provider (ISP) offering download speeds ≥25 Mbps (p = 0.0009). Validation in a regional cohort (n = 6665) confirmed lower VTV utilization in low-broadband areas. Among 1134 surveyed patients, higher digital literacy was the strongest predictor of VTV use (OR 2.5; p < 0.001), even where broadband was limited. This study demonstrates that while both broadband availability and digital literacy independently influence VTV utilization, individual digital skills can partially offset structural limitations, underscoring the need for concurrent investment in broadband infrastructure and targeted digital literacy initiatives to advance access to care.

IntroductionThe unproven stem cell intervention (SCI) industry markets stem cell products to patients navigating chronic and serious conditions who seek alternative options when conventional treatments no longer offer relief or improvement. This market is often characterized by providers using deceptive advertising to misinform potential consumers to seek stem cells that have not been shown to be safe and/or effective through clinical studies.ObjectiveThis study examines how patients describe interpersonal and institutional trust in relation to their interest in and decisions about unproven SCIs among two distinct and divergent chronic disease patient groups: patients with little or no interest in unproven SCIs (low seekers) and those with high interest or have undertaken an unproven SCI (high seekers).MethodsA semi-structured interview guide was developed deductively and modified inductively based on the Unified Theory of Health Behavior. Qualitative interviews among 36 patients and carers were conduct and transcripts were analyzed using constant comparison based on the principles of grounded theory.ResultsTrust varies across social contexts as low seekers expressed strong reservations about the commercialization elements of the SCI industry placing greater confidence in conventional medicine. In contrast, high seekers questioned the advice of conventional providers and motives of medical regulators. Across both, personal relationships were commonly described as influential in how participants evaluated unproven SCIs.ConclusionThese findings suggest that communication efforts in clinical settings should account for the relational and emotional dimensions of trust. Interventions aimed at countering misleading information and promoting informed choices should engage trusted messengers and address the broader social and psychological contexts in which patients may seek unproven SCIs.

Mayo Clinic addresses community health needs by integrating community expertise and collaboratively identifying and responding to community health priorities. Community-engaged research (CEnR), encompassing a continuum of engagement from raising awareness to co-ownership of research efforts, helps operationalize this commitment. Mayo Clinic's CEnR efforts are guided by principles that emphasize community context, sustained partnerships, integration of community perspectives across the research process, and evaluation of community-centered outcomes. The CEnR Program at Mayo Clinic is coordinated through the Center for Clinical and Translational Science (CCaTS), an enterprise-wide hub supporting education, career development, and translational research. It is also implemented in collaboration with Community Outreach and Engagement Research Services (COERS), a shared resource coordinated by the CCaTS and the Mayo Clinic Comprehensive Cancer Center. The CCaTS supports CEnR through community advisory boards, community health needs assessments, and an awards program; COERS advances engagement through Community Engagement Studios, a Community Scientist Program, and related outreach activities. In 2023-2024, we devised and refined a strategic framework for CEnR, bringing together a multidisciplinary group of academic and community partners and informed by a multisite evaluation. The evaluation identified key facilitators of and barriers to academic-community partnerships and generated actionable recommendations. These efforts culminated in the Mayo Clinic CEnR logic model, integrating national guidelines, institutional commitments, and evaluation findings. This logic model serves as a framework for current and future CEnR initiatives within Mayo Clinic and may inform similar efforts nationally. We describe the key elements required to establish and sustain a cross-location CEnR program within a values-based health care institution.

As technological and genomic innovations continue to advance precision cancer prevention, psychosocial, ethical, and operational complexities increasingly accompany their development. Addressing these challenges will require intentional cross-disciplinary collaboration. We argue that the distinct yet complementary lenses of bioethics and implementation science will be crucial as precision cancer prevention technologies move toward clinical integration. We provide a framework for how this joint effort can be accomplished and sustained across the translational pipeline.

Background The COVID-19 pandemic presented unprecedented challenges to hospital system and critical care resources, leading to significant changes to operations and patient care. There are limited national data on these changes and instances of unsanctioned deviations from patient care, yet understanding the COVID response is key to future preparedness efforts. We sought to understand how hospitals and states navigated scarcity during COVID-19, particularly in the absence of a declaration of crisis standards of care.Methods Between February 2022 and September 2022 we conducted 34 interviews with 36 leaders of U.S. states' COVID-19 planning and response efforts. Interviews were transcribed verbatim and verified. We analyzed interviews using iterative inductive thematic analysis for descriptions of resource scarcity and changes to policies and procedures to prevent rationing lifesaving care.Results Nearly all participants described equipment and personnel scarcity in their home institution or state during COVID-19. Hospitals across regions and states developed formal and informal coordination processes for load and resource sharing in response to influxes of high-acuity patients, avoiding formal rationing of lifesaving resources in many regions. Participants also described unsanctioned patient triage, early discharge, and patients counseled to accept less aggressive care (e.g., premature transition to hospice) in states that had not declared crisis standards of care.Conclusions Extending limited resources and inter-institutional collaboration helped avoid formal rationing. Yet, patient care was unquestionably impacted due to scarcity, both real and perceived. Reports of using hospital triage protocols to deny patients lifesaving care outside of formally recognized crisis conditions and attempts to nudge patients to accept less-resource-intensive care are concerning. This may have had disproportionate effects on older adults, individuals with disabilities, and racial and ethnic minoritized groups. To avoid unsanctioned deviations from standard practice in future health emergencies, we recommend that transparent and equitable triage protocols are implemented with robust oversight.

Objectives: Community voices highlight opportunities to improve understanding and access to prostate cancer genomic testing; however, uptake remains limited, particularly among racially and geographically diverse populations. This study explored community perceptions of prostate cancer genomic testing and identified barriers, facilitators, and communication priorities to inform culturally responsive, literacy-sensitive education strategies. In this study, we focus specifically on tissue-based genomic testing used to inform treatment decision-making, rather than cancer screening or inherited genetic risk assessment. Methods: We conducted a qualitative, phenomenological study using a community-based participatory research approach with multi-site Community Advisory Boards (CABs) in Florida, Arizona, and Minnesota (June 2023-March 2024). Across eight focus groups, 31 participants, including prostate cancer survivors, caregivers, clinicians, and community advocates, shared perspectives on genomic testing and preferences for educational materials. Discussions were conducted in English, audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis guided by Braun and Clarke's six-phase approach. Results: Participants demonstrated limited awareness of genomic testing and frequently conflated it with ancestry or hereditary testing. Engagement was shaped by fear, stigma, masculine identity norms, and structural barriers, including cost and healthcare access. Caregivers were described as central to decision-making, while trust in information sources strongly influenced receptivity to genomic testing. Participants emphasized the need for clear, culturally relevant communication delivered by trusted community messengers and supported by family-inclusive approaches. Conclusions: Community perspectives suggest that improving access to prostate cancer genomic testing requires more than increasing availability; it requires addressing gaps in understanding, trust, and structural access. Community-informed, culturally grounded strategies may support more equitable implementation of precision oncology.

Many older adults with advanced cancer never communicate goals of care or treatment preferences to their clinicians, raising the risk that care received will not match their values. Scalable models of care may help surmount this barrier. To test whether a combined patient and clinician intervention increased the rate of advance care planning (ACP) documentation in large health care systems. This stepped-wedge cluster randomized clinical trial using an open cohort design included patients aged 65 years or older with advanced cancer seen at oncology clinics in 3 health care systems located in the US South, Midwest, and Mid-Atlantic regions from April 1, 2020, to November 30, 2022. Data collection ended in 2024. The intervention involved delivering brief evidence-based patient-facing video decision aids available in 25 languages as well as goals-of-care communication training to oncology clinicians. Patients in the control period received usual care. The primary outcome was ACP documentation, which included any electronic health record documentation of a goals-of-care conversation, palliative care, hospice, or limitation of life-sustaining treatments, identified via a validated natural language processing program. Analysis was performed on an intention-to-treat basis. Twenty-nine practices, comprising 13 800 unique eligible patients with a total of 29 357 repeated measurements, were included (mean [SD] age, 74.5 [6.6] years; 52.3% men [15 344 of 29 357 measurements]). The proportion of patients with ACP documentation was greater in the intervention phase compared with the usual care phase (adjusted rate difference, 6.8% [95% CI, 2.8%-10.8%]; P < .001). ACP documentation in the intervention phase occurred among 3980 of 15 754 patients (25.3%) (goals-of-care conversation, 21.4% [3377 of 15 754]; palliative care, 9.6% [1517 of 15 754]; hospice, 5.4% [847 of 15 754]; and limitation of life-sustaining treatments, 7.2% [1128 of 15 754]). In comparison, ACP documentation in the usual care phase occurred among 2834 of 13 603 patients (20.8%) (goals-of-care conversation, 16.8% [2281 of 13 603]; palliative care, 9.5% [1287 of 13 603]; hospice, 5.3% [724 of 13 603]; and limitation of life-sustaining treatments, 8.4% [1149 of 13 603]). In this stepped-wedge cluster randomized clinical trial for older adults with advanced cancer, a bundled evidence-based decision aid and communication training intervention increased the proportion of older patients with ACP documentation. This approach offers an innovative paradigm with a clinically meaningful increase in ACP documentation, a widely used quality metric that reflects high-quality patient-centered care delivery. ClinicalTrials.gov Identifier: NCT03609177

Rationale: The US prison population carries a high burden of chronic disease and disability, with older adults constituting the fastest growing subpopulation. When medical needs exceed a prison's healthcare service capabilities, incarcerated patients are transported to clinics and hospitals in surrounding communities. The influence of prison policies on off-site medical care of incarcerated patients is poorly understood. This study aims to identify and classify correctional policies regulating the care of incarcerated patients in community hospitals. Methods: Between 6/2024-10/2024 we searched the Internet for policies from states’ Departments of Corrections (DOC) pertaining to healthcare of incarcerated patients. We compiled, reconciled and organized those policies according to date, jurisdiction and relevance to hospital care. We then developed a preliminary thematic coding scheme and, using mixed inductive and deductive content analysis, two coders independently applied our codebook to each policy. Any coding discrepancies were resolved by consensus, and when necessary, with adjudication by a third team member. Results: Forty-eight state DOCs and the District of Columbia (totaling 49 “states”) have publicly available policies pertaining to healthcare. Among these, 20/49 (41%) have policies pertaining to the protection of bodily privacy during healthcare encounters. Separately, 31 (63%) have policies regarding the confidentiality of incarcerated patients’ medical encounters and records. Thirty-four (69%) maintain policies regarding incarcerated individuals’ right to select and consent to treatment. Thirty-three (67%) include language about the right to refuse treatment. Twenty-six states (53%) direct that incarcerated individuals be informed of their right to access healthcare either in writing (22/49; 45%), verbally (20/49; 41%), or through posted signage (5/49; 10%). Twenty-one states (43%) address shackling during off-site medical care, but only 15 (31%) address responding to requests from off-site clinicians to minimize or remove patients’ restraints. Just 4/49 states (8%) use person-centered language (avoiding terms like “offender” and “inmate”). Policy excerpts addressing key domains are depicted in the Table. Conclusions: Correctional policies regarding the care of incarcerated patients in community hospitals vary significantly in scope and content across states. While incarcerated people have a Constitutionally protected right to accept or refuse healthcare, including making their own treatment decisions, many state policies do not explicitly mandate how these disclosures must be communicated to patients or their healthcare providers. These silences, when combined with security measures like shackling and the ubiquitous presence of officers, countermand person-centered care and undermine the ability of hospital healthcare professionals to uphold the rights and dignity of incarcerated patients.

Objective:To explore barriers and facilitators experienced by therapists (physical therapists/assistants and occupational therapists/assistants) supporting the implementation of the electronic health record (EHR)-based Healing After Surgery (HAS) initiative, which used clinical decision support (CDS) elements to support therapists in providing perioperative education and support to patients for the use of evidence-based nonpharmacological pain care (NPPC) techniques as part of a health system-wide clinical trial. Design:A cross-sectional web-based survey. Setting:Three academic and 3 community-based hospitals from the same health system. Participants:Therapists (N=236) who delivered the EHR-based HAS initiative. Interventions:Not applicable. Main Outcome Measures:Barriers and facilitators that therapists experienced implementing the EHR-based HAS initiative. Results:We received survey responses from therapists (34.6% response rate). Using a numerical rating scale (1=not at all, 10=a great deal), therapists reported the highest agreement to questions regarding understanding the goal of the initiative (mean ± SD, 7.3±2.4) and alignment of the initiative with therapy practice (mean ± SD, 7.2±2.4), followed by alignment with patient needs (mean ± SD, 6.7±2.4). Ratings were slightly lower for understanding of their role (mean ± SD, 6.5±2.3), leadership support (mean ± SD, 6.3±2.4), and adequacy of training (mean ± SD, 6.2±2.4). Therapists rated the helpfulness of CDS elements at the midpoint of the scale, with mean ratings ranging from 5.0 to 5.1. Only 27% of therapists felt equipped to educate patients on all NPPC techniques. Conclusions:The EHR-based HAS initiative was perceived to align with standard therapy care. However, many therapists did not feel equipped to support all NPPC techniques. Similar future efforts should address additional training needs and CDS refinement.

BACKGROUND:Peri-operative pain management guidelines recommend multimodal strategies, but education on non-pharmacological pain care (NPPC) is lacking. The present study explored patients' experiences participating in the Healing After Surgery (HAS) initiative as part of a pragmatic clinical trial, designed to provide patients with peri-operative education and support for using NPPC. METHODS:We sought to interview two patients from each of the 31 surgical practices participating in the trial. Interviews were semi-structured, audio-recorded, and transcribed verbatim. We used a rapid analytic approach to summarize interview transcripts. Summaries were uploaded to NVivo and two researchers independently reviewed queries and produced analytic memos with key themes organized according to the Theoretical Framework of Acceptability's seven constructs. RESULTS:We analyzed interview transcripts for 71 patients. Findings revealed that patients (1) generally liked the HAS initiative (affective attitude), (2) it aligned with patients' beliefs about wellness techniques and concerns about opioids (ethicality), and (3) many patients had experience using NPPC (self-efficacy). However, (4) care team education and provision of NPPC was inconsistent (intervention coherence), (5) patients varied on their thoughts about the effectiveness of NPPC and the role of NPPC and medication (perceived effectiveness), (6) some patients found resources repetitive and encountered logistical challenges engaging with resources or using NPPC (burden), and (7) patients cited completing tasks ahead of surgery and competing demands post-operatively (e.g., caring for a spouse or young children) as barriers (opportunity costs). An additional theme, the invisible and individualistic nature of pain, also emerged. CONCLUSIONS:Peri-operative initiatives that educate patients about NPPC may be well-received and remind patients of "wellness techniques" and alert them to their role in pain management. Familiarity with NPPC may contribute to patients' self-efficacy using these techniques. However, some patients may require additional support to feel comfortable using NPPC in a post-operative context. Emphasizing the care team's role of directing patients to existing educational recourse or interactive supportive resources may be a low burden way of providing this support. Adding a health coach role to the intervention may also be an option for providing extra support without increasing care teams' workload. TRIAL REGISTRATION:This study was registered on ClinicalTrials.gov, NCT05166356, https://clinicaltrials.gov/study/NCT05166356?term=%20NCT05166356&rank=1 Patient enrollment began on 3/01/2022.

BACKGROUND:Despite the plausible role for community health workers (CHWs) in supporting historically disenfranchised patients experiencing cancer-related pain, few survivorship care models currently include CHWs. The purpose of our study was to learn from existing CHWs regarding the feasibility of working with rural dwelling and/or Hispanic/Latino patients and their cancer care teams; as well as assessing their anticipated barriers and facilitators of delivering a proposed collaborative care pain intervention [Achieving Equity through SocioCulturally-informed, Digitally-Enabled Cancer Pain managemeNT (ASCENT)]. METHODS:Guided by the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework, we recruited experienced CHWs to a mixed-methods feasibility study, including survey, interview and/or focus group. The survey assessed CHWs' comfort level with proposed intervention-related tasks (e.g., working with patients diagnosed with cancer). Interviews and focus groups explored potential training needs, as well as perceived intervention implementation barriers and facilitators. We summarized results using descriptive statistics and a rapid qualitative analytic approach. RESULTS:In total, 12 CHWs participated. Data included surveys (n=12), interviews (n=8), and a focus group with 4 participants. Overall, participant-CHWs felt confident they could participate in healthcare teams and remotely engage rural-dwelling and/or Hispanic/Latino patients diagnosed with cancer. Implementation barriers and facilitators included: working remotely in an unfamiliar geographic area, resource availability, technology, implementation-specific challenges, and patient level factors (e.g., loss of motivation). CONCLUSIONS:Participant-CHWs viewed serving on a multidisciplinary healthcare team to support Hispanic/Latino and rural-dwelling cancer patients experiencing pain as feasible but identified training and resourcing needs.

Chronic disease patients seeking information about unproven stem cell interventions (SCIs) routinely encounter misinformation. Identifying differences among patients with little interest in unproven SCIs (low seekers) from those with high interest (high seekers) would help in developing patient communication interventions. This study characterizes patient knowledge, information sources, attitudes, and emotion of 36 patients and carers through in-depth interviews and reports three themes: knowledge; attitudes about safety, efficacy and expectations; and desperation. Both cohorts had low health and science literacy on stem cells and clinical translation. Low seekers reported significant risks whereas high seekers tended to be unaware or dismissive of risks of unproven SCIs and expressed modest to high benefits. Stress, abandonment, and hopelessness were the emotions expressed by patients who were desperate for an unproven SCI. Knowing the factors that influence diverse attitudes surrounding the intent to undergo unproven SCIs will inform the design of behavioral interventions.

Background/Objectives: Multi-cancer detection (MCD) tests have emerged as a promising tool to redefine the landscape of early cancer detection. Implementation of this novel technology will likely fall to primary care clinicians (PCC). The purpose of this study is to characterize and explore differences in PCCs perceptions and preferences towards MCD testing. Methods: Between March and May of 2023, this cross-sectional survey was administered to 281 PCCs, including physicians and advanced care providers practicing within an integrated healthcare system spanning five states. The survey collected data on self-reported characteristics, perceptions of MCD testing, and preferences for learning about MCD testing. Analysis was limited to those with no prior experience with MCD testing (N = 181, response rate 22.8%). Descriptive statistics summarized key variables and chi-square tests assessed differences in perceptions and preferences by key characteristics. Results: Most PCCs were interested in MCD testing (66.3%), but limited knowledge/awareness of MCD testing and confidence to manage patients with a positive test were observed, along with concerns around cost (76.7%) and misuse/poor implementation. The primary preferences for learning about MCD testing were online courses or classroom instruction (64.5%). Significant differences in perceptions and preferences for learning were observed by location, degree, and years in practice. Conclusions: PCCs in our study held positive views towards MCD testing, but gaps and variation in knowledge and confidence towards MCD testing and concerns around the cost and misuse/poor implementation were observed. While efforts to train and educate all PCCs on MCD testing is a critical first step, more research is needed to understand how best to support implementation tailored to individual and system-level needs and characteristics.

Background:Best practice guidelines recommend educating surgical patients about non-pharmacological pain care (NPPC) techniques that can be used in addition to pain medication for perioperative pain management, given the risks for opioid misuse following surgery. As part of the parent non-pharmacologic options in postoperative hospital-based and rehabilitation pain management (NOHARM) clinical trial, we implemented the Healing After Surgery initiative, which leveraged the Epic electronic health record (EHR) to provide patients with education on NPPC techniques perioperatively. We disseminated educational materials directly to patients via the EHR patient portal and prompted patients to select the techniques they were most interested in using, which auto-populated the EHR so that their care team could view their preferences. We also built clinical decision support elements in the EHR to prompt and support inpatient nurses in providing patients with education and reinforcement for using their preferred NPPC techniques. Print materials, a website, a DVD, videos on hospital televisions, a toll-free number, and Zoom-based group calls provided additional education on NPPC techniques. Objective:This study evaluated nurses' perceptions of barriers and facilitators to implementing the EHR-based Healing After Surgery initiative. Methods:We invited inpatient nursing leaders and bedside nurses to participate in a semistructured interview. Inpatient nursing leaders were invited to complete a brief survey that asked them to rate their agreement with 7 items using a numeric rating scale (1=not at all, 10=a great deal). Results:Interview findings from 29 nurses revealed: (1) nurses gravitated towards providing NPPC techniques they were familiar with, (2) the initiative was patient-centric with opportunities to better engage patients, and (3) nurses experienced challenges implementing and prioritizing the intervention in the inpatient setting due to competing demands in a pandemic and postpandemic environment. Interviews revealed mixed effectiveness of implementation strategies. We received survey responses from 47 nursing leaders who indicated that their staff knew about the Healing After Surgery initiative (mean=7.53, SD=1.77) and what they were expected to do (mean=7, SD=1.88). They thought the Healing After Surgery initiative supported patients' pain management needs (mean=6.76, SD=2.24), endorsed it as a priority (mean=7.02, SD=2.56), and encouraged staff to support it (mean=5.98, SD=2.78). They indicated staff experienced some burden supporting the initiative (mean=3.93, SD=2.47), but supported some variation of the initiative continuing once the parent trial ended (mean=7.72, SD=2.62). Conclusions:Nurses understood the intervention's benefit but struggled to implement unfamiliar NPPC techniques and prioritize the initiative due to other clinical demands. Additional implementation strategies may be needed to better engage patients and facilitate intervention delivery.

Context. Pain is a prevalent symptom in patients with serious illness and often requires interventional approaches for adequate treatment. Little is known about referral patterns and collaborative attitudes of palliative physicians regarding pain management specialists. Objectives. To evaluate referral rates, co-management strategies, and beliefs of palliative physicians about the value of Pain Medicine specialists in patients with serious illness. Methods. A 30-question survey with demographic, referral/practice, and attitudes/belief questions was mailed to 1000 AAHPM physician members. Responses were characterized with descriptive statistics and further analyzed for associations between training experiences, practice environment, and educational activities with collaborative practice patterns and beliefs. Results. The response rate was 52.6%. Most survey respondents had initial board certification primarily in internal medicine (n = 286, 56%) or family medicine (n = 144, 28%). A minority of respondents had completed a formal ABMS Hospice and Palliative Medicine fellowship (n = 178, 34%). Respondents had been in practice for a median of nine years, (range 1-38 years) primarily in community hospitals (n = 249, 47%) or academic hospitals (n = 202, 38%). The variables best associated with collaborative practices and attitudes was practice in an academic hospital setting and participation in regular joint academic conferences with pain medicine clinicians. Conclusion. This study shows that Palliative Care physicians have highly positive attitudes toward Pain Medicine specialists, but referrals remain low. Facilitating professional collaboration via joint educational/clinical sessions is one possible solution to drive ongoing interprofessional care in patients with complex pain.

Normothermic Regional Perfusion, or NRP, is a method of donated organ reperfusion using cardiopulmonary bypass or a modified extracorporeal membrane oxygenation (ECMO) circuit after circulatory death while leaving organs in the dead donor's corpse. Despite its potential, several key ethical issues remain unaddressed by this technology.

BACKGROUND:In response to COVID-19, many states revised, developed, or attempted to develop plans to allocate scarce critical care resources in the event that crisis standards of care were triggered. To our knowledge, no prior analysis has assessed this plan development process, including whether plans were successfully adopted. RESEARCH QUESTION:How did states develop or revise scarce resource allocation plans during the COVID-19 pandemic, and what were the barriers and facilitators to their development and adoption at the state level? STUDY DESIGN AND METHODS:Plan authors and state leaders completed a semistructured interview February to September 2022. Interview transcripts were qualitatively analyzed for themes related to plan development and adoption according to the principles of grounded theory. RESULTS:Thirty-six participants from 34 states completed an interview, from states distributed across all US regions. Among participants' states with plans that existed prior to 2020 (n = 24), 17 were revised and adopted in response to COVID-19. Six states wrote a plan de novo, with the remaining states failing to develop or adopt a plan. Thirteen states continued to revise their plans in response to disability or aging bias complaints or to respond to evolving needs. Many participants expressed that urgency in the early days of the pandemic prevented an ideal development process. Facilitators of successful plan development and adoption include: coordination or support from the state department of health and existing relationships with key community partners, including aging and disability rights groups and minoritized communities. Barriers include: lack of perceived political will to adopt a plan and development during a public health emergency. INTERPRETATION:To avoid repeating mistakes from the early days of the COVID-19 response, states should develop or revise plans with community engagement and consider maintaining a standing committee with diverse membership and content expertise to periodically review plans and advise state officials on pandemic preparedness.

Teaching ethics is crucial to health sciences education. Doing it well requires a willingness to engage contentious social issues. Those issues introduce conflict and risk, but avoiding them ignores moral diversity and renders the work of ethics education irrelevant. Therefore, when (not if) contentious issues and moral differences arise, they must be acknowledged and can be addressed with humility, collegiality, and openness to support learning. Faculty must risk moments when not everyone will “feel safe,” so the candor implied in psychological safety can emerge. The deliberative and social work of ethics education involves generous listening, wading into difference, and wondering together if our beliefs and arguments are as sound as we once thought. By forecasting the need for candid engagement with contentious issues and moral difference, establishing ground rules , and bolstering due process structures for faculty and students, a riskier and more relevant ethics pedagogy can emerge. Doing so will prepare everyone for the moral diversity they can expect in our common life and in practice.