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J Clin Ethics [journal]
- Legal briefing: brain death and total brain failure. [Journal Article]
- J Clin Ethics 2014; 25(3):245-57.
This issue's "Legal Briefing" column covers recent legal developments involving total brain failure. Death determined by neurological criteria (DDNC) or "brain death" has been legally established for decades in the United States. But recent conflicts between families and hospitals have created some uncertainty. Clinicians are increasingly unsure about the scope of their legal and ethical treatment duties when families object to the withdrawal of physiological support after DDNC. This issue of JCE includes a thorough analysis of one institution's ethics consults illustrating this uncertainty. This experience is not unique. Hospitals across the country are seeing more DDNC disputes. Because of the similarity to medical futility disputes, some court cases on this topic were reviewed in a prior "Legal Briefing" column. But a more systematic review is now warranted. I categorize recent legal developments into the following nine categories: (1) History of Determining Death by Neurological Criteria, (2) Legal Status of Determining Death by Neurological Criteria, (3) Legal Duties to Accommodate Family Objections, (4) Protocols for Determining Death by Neurological Criteria, (5) Court Cases Seeking Physiological Support after DDNC, (6) Court Cases Seeking Damages for Intentionally Premature DDNC, (7) Court Cases Seeking Damages for Negligently Premature DDNC, (8) Court Cases Seeking Damages for Emotional Distress, (9) Pregnancy Limitations on DDNC.
- A survey of healthcare industry representatives' participation in surgery: some new ethical concerns. [Journal Article]
- J Clin Ethics 2014; 25(3):238-44.
To provide preliminary evidence of the types and amount of involvement by healthcare industry representatives (HCIRs) in surgery, as well as the ethical concerns of those representatives.A link to an anonymous, web-based survey was posted on several medical device boards of the website http://www. cafepharma.com. Additionally, members of two different medical device groups on LinkedIn were asked to participate. Respondents were self-identified HCIRs in the fields of orthopedics, cardiology, endoscopic devices, lasers, general surgery, ophthalmic surgery, oral surgery, anesthesia products, and urologic surgery.A total of 43 HCIRs replied to the survey over a period of one year: 35 men and eight women. Respondents reported attending an average of 184 surgeries in the prior year and had an average of 17 years as an HCIR and six years with their current employer. Of the respondents, 21 percent (nine of 43) had direct physical contact with a surgical team or patient during a surgery, and 88 percent (38 of 43) provided verbal instruction to a surgical team during a surgery. Additionally, 37 percent (16 of 43) had participated in a surgery in which they felt that their involvement was excessive, and 40 percent (17 of 43) had attended a surgery in which they questioned the competence of the surgeon.HCIRs play a significant role in surgery. Involvement that exceeds their defined role, however, can raise serious ethical and legal questions for surgeons and surgical teams. Surgical teams may at times be substituting the knowledge of the HCIR for their own competence with a medical device or instrument. In some cases, contact with the surgical team or patient may violate the guidelines not only of hospitals and medical device companies, but the law as well. Further study is required to determine if the patients involved have any knowledge or understanding of the role that an HCIR played in their surgery.
- Family members' requests to extend physiologic support after declaration of brain death: a case series analysis and proposed guidelines for clinical management. [Journal Article]
- J Clin Ethics 2014; 25(3):222-37.
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 ventilation was the focal intervention sought by all families. The ECS's advice and recommendations generally promoted "reasonable accommodation" of the requests, balancing compassion for grieving families with other ethical and moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finite-goal accommodation, a "reasonable accommodation" strategy proved effective in balancing stakeholders' interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the "reasonable accommodation" approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases.
- The proportionate value of proportionality in palliative sedation. [Journal Article]
- J Clin Ethics 2014; 25(3):219-21.
Proportionality, as it pertains to palliative sedation, is the notion that sedation should be induced at the lowest degree effective for symptom control, so that the patient's consciousness may be preserved. The pursuit of proportionality in palliative sedation is a widely accepted imperative advocated in position statements and guidelines on this treatment. The priority assigned to the pursuit of proportionality, and the extent to which it is relevant for patients who qualify for palliative sedation, have been overstated.
- The ethical and clinical importance of measuring consciousness in continuously sedated patients. [Journal Article]
- J Clin Ethics 2014; 25(3):207-18.
Continuous sedation at the end of life is a practice that has attracted a great deal of attention. An increasing number of guidelines on the proposed correct performance of the practice have been drafted. All of the guidelines stress the importance of using sedation in proportion to the severity of the patient's symptoms, thus to reduce the patient's consciousness no more than is absolutely necessary. As different patients can have different experiences of suffering, the amount of suffering should, ideally, be assessed subjectively; that is, via communication with the patient. Continuously sedated patients are often unable to communicate, however, making subjective methods of pain assessment unusable. For these patients, the degree of consciousness is the sole available measure. It therefore seems important to adequately measure how deeply the patient is sedated, thereby allowing sedation to be increased when it is too light and decreased when it is too heavy. This is in accordance with the idea that reducing consciousness is not an ethically neutral act. Although consciousness measuring techniques are a hot topic in anesthesiology, almost no research exists on the use of such techniques in the context of continuous sedation at the end of life. This article aims to review existing techniques to measure consciousness and to evaluate their applicability, efficiency, and invasiveness for patients who are continuously sedated until death. Techniques commonly used to assess the depth of sedation in continuously sedated patients are basic clinical assessment and sedation scales, as they are often considered reliable and non-invasive. These techniques might not be very reliable, however, since it is known that some patients are nonresponsive and yet aware. Moreover, sedation scales require stimulation of the patient (for example prodding, shaking, or providing painful stimuli), and can thus be considered invasive of one's bodily integrity or dignity. Other techniques, such as EEG (electroencephalography) derivatives, may score better on reliability and invasiveness. Yet these have so far never been compared to sedation scale scores for patients receiving continuous sedation at the end of life. Therefore, we conclude that, for both clinical and ethical reasons, research into the efficiency and applicability of other techniques, such as derivatives of EEG, are urgently needed.
- When Should We Not Respect a Patient's Wish? [Journal Article]
- J Clin Ethics 2014; 25(3):196-206.
Patients who face making a high-stakes decision-whether or not to accept a lifesaving intervention-may make a decision that their careproviders believe is deeply and dangerously mistaken. How can careproviders best help patients in such situations? If a determination of competency exam seems to be in the patients' best interests, how can careproviders refer their patients without betraying their patients' trust, given that the trust between patients and careproviders is one of the most powerful tools careproviders have in working with patients? Ethically, is it possible for careproviders to participate in determinations of competency for their own patients? I will present approaches that careproviders can adopt to help patients who "won't budge" when making what appear to be dangerously erroneous choices regarding lifesaving interventions.
- Power and jurisdiction. [Journal Article]
- J Clin Ethics 2014; 25(3):194-5.
In response to Flamm and Kodish, I argue that our misunderstanding or disagreement is primarily the result of different definitions of power. I also disagree with them and claim that they are indeed using the public's ethics. Finally, I argue that there is no reason to think that bioethicists cannot have the same sort of influence in the boardroom that they have in the clinic.
- Empirical Bioethics Research is a Winner, But Bioethics Mission Creep Is a False Alarm. [Journal Article]
- J Clin Ethics 2014; 25(3):189-93.
While we do not share Evans's view that social science research is needed to shield bioethics from competitive threat, we incorporate and engage in social science research to inform our knowledge base, our clinical practice, and our contributions to the ongoing development of the field.
- What Should Careproviders Do When a Patient "Won't Budge"? [Journal Article]
- J Clin Ethics 2014; 25(3):179-88.
Patients who face making a high-stakes decision--whether or not to accept a lifesaving intervention--may make a decision that their careproviders believe is deeply and dangerously mistaken. How can careproviders best help patients in such situations? If a determination of competency exam seems to be in the patients' best interests, how can careproviders refer their patients without betraying their patients' trust, given that the trust between patients and careproviders is one of the most powerful tools careproviders have in working with patients? Ethically, is it possible for careproviders to participate in determinations of competency for their own patients? I will present approaches that careproviders can adopt to help patients who "won't budge" when making what appear to be dangerously erroneous choices regarding lifesaving interventions.
- Letter: Improving Patient-Doctor Communication about Risk and Choice in Obstetrics and Gynecology through Medical Education: A Call for Action. [JOURNAL ARTICLE]
- J Clin Ethics 2014; 25(2):176.
The authors suggest that three articles published in the Fall 2013 issue of The Journal of Clinical Ethics could be used in graduate medical education to help students be more prepared to address differences in professional opinion and improve their skills in patient-doctor communication.