ICU Cornestone: a lecture that changed my practice. (41/698)

In 1982, the author attended a lecture by Professor Joseph Civetta dealing with the concept that, at times, the goal of care should be comfort rather than cure, and that inappropriate care prolonged dying and suffering. Efforts to improve end-of-life care subsequent to this had effects on care at a local level and at a state level. Intensive care providers should be leaders in the provision of appropriate and compassionate care at the end of life.  (+info)

Stroke medicine-ethical and legal considerations. (42/698)

In this short paper we set out to demonstrate common ground between Medical Ethics and Jurisprudence. We delineate the scope of the debate entailing juristic and medical ethical issues in stroke medicine. The article refers to joint legal and ethical issues pertaining to withholding and withdrawing life-sustaining treatment and advance directives. A key concern is that certain essential clinical prognostic questions require to be evaluated before any justifiable discussion about their ethical implications can ensue. The pre-eminence of the principle of autonomy in medical ethics and jurisprudence is emphasised throughout the paper.  (+info)

Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study. (43/698)

OBJECTIVE: To clarify the practice of withholding the artificial administration of fluids and food from elderly patients with dementia in nursing homes. DESIGN: Qualitative, ethnographic study in two phases. SETTING: 10 wards in two nursing homes in the Netherlands. PARTICIPANTS: 35 patients with dementia, eight doctors, 43 nurses, and 32 families. RESULTS: The clinical course of dementia was considered normal and was rarely reason to begin the artificial administration of fluids and food in advanced disease. Fluids and food seemed to be given mainly when there was an acute illness or a condition that needed medical treatment and which required hydration to be effective. The medical condition of the patient, the wishes of the family, and the interpretations of the patients' quality of life by their care providers were considered more important than living wills and policy agreements. CONCLUSIONS: Doctors' decisions about withholding the artificial administration of fluids and food from elderly patients with dementia are influenced more by the clinical course of the illness, the presumed quality of life of the patient, and the patient's medical condition than they are by advanced planning of care. In an attempt to understand the wishes of the patient doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family.  (+info)

Withholding life prolonging treatment, and self deception. (44/698)

OBJECTIVES: To compare non-treatment decision making by general practitioners and geriatricians in response to vignettes. To see whether the doctors' decisions were informed by ethical or legal reasoning. DESIGN: Qualitative study in which consultant geriatricians and general practitioners (GPs) randomly selected from a list of local practitioners were interviewed. The doctors were asked whether patients described in five vignettes should be admitted to hospital for further care, and to give supporting reasons. They were asked with whom they would consult, who they believed ought to make such decisions, and whether the relatives' preferences would influence their decision making. MAIN MEASURES: To analyse the factors influencing the doctors' decisions not to admit otherwise terminally ill patients to hospital for life prolonging treatment. RESULTS: Seventeen GPs and 18 geriatricians completed the interview. All vignettes produced strong concordance in decision making between both groups. Ten per cent of the doctors would provide life prolonging treatment to patients with severe brain damage. Most would admit a surgical patient regardless of age or disability. Medical reasons were largely used to explain decision making. The wishes of relatives were influential and resource considerations were not. There was variability regarding decision making responsibility. CONCLUSIONS: Little attempt was made to link decision making with ethical or legal concepts and there may have been non-recognition, or denial, of the ethical consequences of failure to admit. The process of decision making may involve deception. This may be conscious, because of the illegality of euthanasia, or unconscious (self deception), because of deepseated medical and societal reluctance to accept that intentionally withholding life prolonging treatment may equate with intentionally causing death.  (+info)

Ethics and decision making in end stage lung disease. (45/698)

Most physicians believe they do more good than harm, and these duties of helping and not harming the patient are rooted in the Hippocratic oath, the good Samaritan tradition, and the Order of the Knight Hospitallers founded in the 11th century to care for pilgrims and those wounded in the Crusades.(1) In recent times the simple principles of beneficence and non-maleficence have been augmented and sometimes challenged by a rising awareness of patient/consumer rights, and the public expectation of greater involvement in medical, social and scientific affairs which affect them. In a publicly funded healthcare system in which rationing (explicit or otherwise) is inevitable, the additional concepts of utility and distributive justice can easily come into conflict with the individual's right to autonomy. Possible treatment options for end stage lung disease include transplantation and long term invasive ventilation which are challenging in resource terms. Other interventions such as pulmonary rehabilitation and palliative care are relatively low cost but not uniformly accessible.  (+info)

Very high cost treatment for a single individual--a case report. (46/698)

A Health Authority was requested to fund immune tolerance induction for a young haemophiliac at a potential cost of up to 2 million pounds sterling over a year. The decision-making process adopted included an external review of the case, literature review to establish the evidence base for treatment, and extensive discussions with the clinicians involved. The Health Authority agreed to fund treatment, but with continuous review of the case and explicit criteria for abandoning treatment if it was not working. After 11 months these criteria were met, and the treatment was abandoned. The decision-making process and ethical issues involved in deciding whether or not to fund extremely high cost treatment for an individual patient are discussed. Cases such as this present a stark contrast between rights-based and utilitarian ethical approaches. Primary Care Trusts (PCTs) are more vulnerable (because of their smaller populations and budgets) than Health Authorities were to the financial destabilization that high-cost cases can cause. PCTs are advised to make arrangements to enter risk-sharing arrangements to spread the cost of such high-cost treatments.  (+info)

Experience with enoxaparin in patients with mechanical heart valves who must withhold acenocumarol. (47/698)

OBJECTIVES: To evaluate the incidence of thromboembolic and haemorrhagic events in a cohort of patients with mechanical heart valves who had to withhold acenocumarol and were treated with enoxaparin. DESIGN: Observational prospective study. SETTING: In hospital; after discharge, and follow up by telephone call. PATIENTS AND METHODS: All consecutive patients with mechanical heart valves admitted to the authors' hospital between May 1999 and January 2002 who had to interrupt treatment with acenocumarol and were treated with enoxaparin as an alternative to other methods were enrolled. In each patient, the following characteristics were prospectively determined: the reason for interrupting acenocumarol, demographic data, estimated global risk for thromboembolic events, international normalised ratio before starting enoxaparin treatment, number of days taking enoxaparin, and mean level of anti-Xa activity during treatment. All patients were followed up through clinical history during the hospitalisation and by telephone after discharge to detect thromboembolic events. MAIN OUTCOME MEASURE: Presence of thromboembolic or haemorrhagic events. RESULTS: 82 patients were identified and followed up for a mean of 2.8 months (range 1.5-3.5 months) after discharge. 61 of them (74%) had one or more associated thromboembolic risk factors. Acenocumarol was interrupted (to perform an invasive procedure in 74 patients and because of haemorrhagic complication in 8) an average of 11.2 days (range 3-40 days). Most patients received the standard enoxaparin dose (1 mg/kg at 12 hour intervals). Mean (SD) anti-Xa activity was 0.58 (0.3) IU/ml (median 0.51). There were 8 minor and 1 major bleeding events during enoxaparin treatment. No thromboembolic complications were clinically detected during hospitalisation or during follow up (95% confidence interval 0% to 3.6%). CONCLUSIONS: Enoxaparin may be an effective and relatively safe substitute anticoagulant for patients with mechanical heart valves who must withhold acenocumarol.  (+info)

Recovery of renal function and the discontinuation of dialysis in patients treated with continuous peritoneal dialysis. (48/698)

OBJECTIVE: Previous studies have shown that patients with end-stage renal disease (ESRD) treated with continuous peritoneal dialysis (CPD) have better preservation of endogenous renal function than patients treated with hemodialysis (HD). We wondered if this better preservation of endogenous renal function seen with CPD patients translates into the improved likelihood of recovery of endogenous renal function in those patients with potentially reversible causes of renal failure. METHODS: To evaluate this question, we reviewed the records of all 1200 patients that completed CPD training at a large, freestanding peritoneal dialysis center in New Haven, Connecticut, between 1979 and 1999, and the records of all patients completing CPD training in New England between 1993 and 1998. In New Haven, about half the new patients with ESRD were started on CPD compared to only 15% in New England. We then compared the chances of recovery of renal function in these two cohorts of CPD patients to the chances of recovery of renal function in two groups of HD patients. The first group consisted of all patients that started on HD in New England between 1993 and 1998. The second group consisted of all patients that started HD in our HD unit in New Haven, Connecticut, between 1993 and 1999. The data on the New England patients were provided by the ESRD Network of New England. All patients entered into the present study had to have been on dialysis for a minimum of 3 months, as in the United States Renal Data System database, and had to have recovered sufficient renal function to be able to be maintained off dialysis for a minimum of 30 days. RESULTS: 29 of 1,200 CPD patients (2.4%) trained in New Haven recovered sufficient renal function to permit the discontinuation of dialysis for a minimum of 30 days. In comparison, only 305 of 19,032 patients (1.6%) managed with HD in New England (p < 0.05 compared to New Haven CPD patients) and 3 of 430 patients (0.7%) in our HD center (p < 0.05 compared to New Haven CPD patients) recovered sufficient glomerular filtration rate (GFR) to allow the discontinuation of dialysis for at least 30 days. If only those CPD patients that initiated dialysis between 1993 and 1999 in New Haven were analyzed, 15 of 369 (4.1%) recovered sufficient GFR to allow discontinuation of dialysis for at least 30 days (p < 0.025 compared to both groups of HD patients). Of the 2,924 patients completing CPD training in New England, 60 (2.1%) recovered renal function; this percentage is not significantly different from the percent of HD patients in New England recovering renal function. CONCLUSION: Although the present study is a retrospective study and the actual criteria for selection of CPD and HD therapy are not controlled for, the data raise the question of whether there may be a therapeutic advantage to treating newly diagnosed ESRD patients, that have a potentially reversible cause of renal failure, with CPD.  (+info)