Frédérique Claudot

Elective non-therapeutic intensive care and the four principles of medical ethics

The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies is essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patients autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented.

Oral information in orthopaedics: How should the patient's understanding be assessed?

INTRODUCTION Patient information is governed by recommendations of best practices required from any healthcare professional. The aim of this study was to design a tool to measure patient comprehension of the information provided during a surgical consultation before a scheduled surgery. MATERIAL AND METHODS This was a single-center prospective study of 21 patients using a rating scale-type visual analog scale. Each patient was interviewed and asked to score his or her understanding of the information provided. The investigator checked the external validity of the tool using questions to assess patients understanding level. RESULTS The results show that there is a tendency to overvalue some information (reasons for the intervention and alternatives to surgery) and that certain information is not understood (risks and complications) or not provided (postoperative follow-up). CONCLUSION This study confirms that a rating scale can measure the understanding of information and there is a variation between perceived and actual understanding.

Talking about patient's values and posthumous organ donation

Dear Editor, In a recent paper Erwin Kompanje [1] stressed the critical importance of complying with the patient’s values when considering the possibility of post-mortem organ donation when no advance choice is available. At a time when many countries consider instituting the presumed consent rule or reinforcing it by doing so without the possibility for the family to testify of the potential donor’s reluctance, Kompanje’s words sound of paramount pertinence. Conversing with many colleagues, it emerges indeed that even under a regimen of presumed consent many families feel naturally entitled to defend their dying or dead loved one’s physical and spiritual interests and speak on his or her behalf. Certainly, posthumous harm could occur when the patient’s own wishes or values are not looked for, are disregarded or not respected [2]. Moreover, families also can be harmed, especially by overlooking the affective or family bond by denying them the right to express, honour and put into practice the values of their departed beloved. So, presumed consent is often viewed by families with much suspicion and the discussion often turns around the question of the most probable opinion of the patient. But this question of substituted judgment as such entails substantial psychological, emotional and cognitive burdens, is morally complex and is often impossible to answer [3]. Having no idea of their loved one’s opinion, many families prefer to oppose organ harvesting. So it is ethically imperative to join with them in seeking the patient’s values and help them to honour values regarding organ donation. In these circumstances, the same approach used for the determination of values previously held by patients when their decision autonomy has definitely and permanently vanished could be very helpful. For Scheunemann et al. [3], the goal is to make authentic decisions, i.e. decisions informed by the knowledge of the patient’s life story and values, always motivated by the respect of who the person was and fitting with his or her history. However, there is little guidance for clinicians to assist families in seeking an authentic depiction of the dead patient’s values. According to the contemporary law philosopher Ronald Dworkin, besides mere immediate experiential interests most individuals have critical interests: they attach importance to do in their life things that they consider as good ones, and to avoid the things they consider as bad, irrespective of the type of experience resulting from the realization of these interests. For Dworkin, it is especially in the pursuit of these critical interests—e.g. values—that an individual reveals his or her personality and makes a judgment on the kind of life he or she wants to have lived [4]. According to Agnieszka Jaworska [5], another philosopher, it is attaching importance to some ideals, something that extends beyond us, things that are greater than only our personal benefit and are included in a broader normative framework—regardless of cost in terms of effort or displeasure—that defines the individual’s values. Explaining these approaches to defining values to bereaved and upset families could help them to disentangle the complex ‘‘pros and cons’’ underlying the assumed opinion of their loved one regarding postmortem organ donation, and finally to keep consistency with the kind of life he or she wanted to live. Because most cultures and religions attach importance to treat persons—even dead—in a Kantian way, i.e. as ends in themselves rather than merely as means to an end, this framework centred on the patient’s values should be consensually accepted in our pluralistic societies [3].

Évaluation des demandes d'accès au dossier médical au CHU de Nancy

Resume Objectif Nous avons etudie les caracteristiques des demandeurs (patients, ayants droit et representants legaux) de dossiers medicaux dans un centre hospitalier universitaire (CHU) selon les nouvelles dispositions mises en place par la loi du 4 mars 2002. Methodes A partir des lettres de demandes d’acces au dossier medical, un formulaire de base de donnees recueille des informations comme l’etat civil des demandeurs, leurs motivations et les modalites d’acces souhaitees. La periode d’analyse s’etend d’octobre 2002 a septembre 2004 (soit 23 mois). Resultats Le nombre de demandes est de 942, dont 64,5 % de patients et 18,5 % d’ayants droit. Les patients demandant acces a leur dossier avaient en moyenne 53 ans, et etaient plutot des hommes. Les ayants droit avaient en moyenne 49 ans et etaient plutot des femmes. Trente pour cent des patients souhaitaient obtenir un complement d’information et 51 % ont demande une copie integrale du dossier. Conclusion Le droit d’acces direct au dossier medical implique, par ses consequences medico-legales, un changement de comportement des professionnels de la sante concernant la tenue de leurs dossiers.

French Society of Cardiology guidelines on exercise tests (part 1): Methods and interpretation

The exercise test is still a key examination in cardiology, used for the diagnosis of myocardial ischemia, as well as for the clinical evaluation of other heart diseases. The cardiopulmonary exercise test can further define functional capacity and prognosis for any given cardiac pathology. These new guidelines focus on methods, interpretation and indications for an exercise test or cardiopulmonary exercise test, as summarized below. The safety rules associated with the exercise test must be strictly observed. Interpretation of exercise tests and cardiopulmonary exercise tests must be multivariable. Functional capacity is a strong predictor of all-cause mortality and cardiovascular events. Chest pain, ST-segment changes and an abnormal ST/heart rate index constitute the first findings in favor of myocardial ischemia, mostly related to significant coronary artery disease. Chronotropic incompetence, abnormal heart rate recovery, QRS changes (such as enlargement or axial deviations) and the use of scores (based on the presence of various risk factors) must also be considered in exercise test interpretation for a coronary artery disease diagnosis. Arrhythmias or conduction disorders arising during the exercise test must be considered in the assessment of prognosis, in addition to a decrease or low increase in blood pressure during the exercise phase. When performing a cardiopulmonary exercise test, peak oxygen uptake and the volume of expired gas/carbon dioxide output slope are the two main variables used to evaluate prognosis.

French Society of Cardiology guidelines on exercise tests (part 2): Indications for exercise tests in cardiac diseases

The exercise test is performed routinely in cardiology; its main indication is the diagnosis of myocardial ischemia, evaluated along with the subjects pretest probability and cardiovascular risk level. Other criteria, such as analysis of repolarization, must be taken into consideration during the interpretation of an exercise test, to improve its predictive value. An exercise test is also indicated for many other cardiac diseases (e.g. rhythm and conduction disorders, severe asymptomatic aortic stenosis, hypertrophic cardiomyopathy, peripheral artery disease, hypertension). Moreover, an exercise test may be indicated for specific populations (women, the elderly, patients with diabetes mellitus, patients in a preoperative context, asymptomatic patients and patients with congenital heart defects). Some cardiac diseases (such as chronic heart failure or arterial pulmonary hypertension) require a cardiopulmonary exercise test. Finally, an exercise test or a cardiopulmonary exercise test is indicated to prescribe a cardiac rehabilitation programme, adapted to the patient.

Clarification on the legal status of human remains in university collections of human anatomy in France

Civil Code, in particular, the principles of respect for the human body and human dignity. the bioethics laws also specify appropriate uses of the human body through the Code of Public health. the main principles regarding protection of the human body can be found in Article 16 of the Civil Code. In 2004, more specific articles related to dead bodies were added. Article 16-1-1 stipulates that human remains must be treated with respect, dignity, and decency. the Code of Public health, by incorporating these requirements into the 2004 revised bioethics laws, provides guidance in the creation of anatomical collections for samples of research, as a three-stage process: collection, use, and preservation [3] (articles L1211-2, L1232-1, L1235-2, L1243-3). Collections with the sole purpose of teaching or memory do not yet have a legal status, as lawmakers have not yet adopted legislation. We can consider them as awaiting a legal status that would give them legitimacy and protection. the fact that these collections are composed of human remains is bothersome and has complicated the campaign for specific and necessary laws. Media scandals, such as that of St Vincent de Paul [4], have made these collections somewhat undesirable, and the ensuing negative publicity has endangered this historical and educational source [2]. Some pieces of these collections are irreplaceable teaching tool, neither more nor less than new technologies. each contributes to education in different ways, but both are necessary. In 2006, the ethic Chart of the French College of Professors of Anatomy regarding the gift of body was established [5]. According to this Chart, the students who have access to the body or parts must receive prior ethic educations. Nowadays, many university collections of anatomical specimens are neglected, poorly maintained, or forgotten; some have been destroyed. these collections represent the history of our discipline, along with an inestimable legacy of teaching, research and memory, which is disappearing with them [2]. According to French law, only two entities are recognized: a person and a thing. A person, from a legal point of view, was born alive and viable, and this is a cumulative condition. the human body is the support of the person; however, legally, it is the existence that makes the person. In contrast, parts of the human body and human remains are, in a legal sense, only things. But these things are generally considered as sacred because they used to be a person or belong to a person [1]. In 1994, bioethics laws were passed that provided a status to the human body. they established rules as part of the