Jeffrey T. Berger

Reporting by Physicians of Impaired Drivers and Potentially Impaired Drivers

Physicians routinely care for patients whose ability to operate a motor vehicle is compromised by a physical or cognitive condition. Physician management of this health information has ethical and legal implications. These concerns have been insufficiently addressed by professional organizations and public agencies. The legal status in the United States and Canada of reporting of impaired drivers is reviewed. The American Medical Association’s position is detailed. Finally, the Bioethics Committee of the Medical Society of the State of New York proposes elements for an ethically defensible public response to this problem.

The delivery of futile care is harmful to other patients

Objective:Intensive care units (ICUs) in different parts of the world provide care to patients with advanced age and terminal illness at different rates and in different patterns. In the United States, ICU beds make up a disproportionate number of acute care beds. Nearly half of all patients who die in U.S. hospitals have received ICU, some of which may be futile. The objective of this study was to examine ways in which the delivery of futile care in the ICU can cause harm to patients other than those receiving the futile care. Design:Review of available studies of patient and family attitudes about cardiopulmonary resuscitation and other supportive modalities, including antibiotic therapy, and the relationship of the delivery of such care to the outcomes of others treated in the ICU. Patients:Those treated in ICUs and those receiving futile care. Measurements and Main Results:Compared with younger patients, the elderly in the United States use more ICU care, at higher cost, have more serious comorbidities, and have a higher mortality rate. Certain populations demand ICU care more than others and often with less benefit than less-demanding populations. In a situation of unlimited resources, the provision of ICU care, even when futile, has been viewed as an individual patient decision with no harm to others within the hospital. However, even with unlimited resources, the use of antibiotics for those who are receiving futile care can be considered unethical by egalitarian theory because it can lead to antibiotic resistance that may make the treatment of other patients impossible. In the setting of limited resources, like in pandemic influenza, or with the potential limiting of resources, in a pay-for-performance environment, the provision of futile care can also harm the hospital population as a whole. Conclusions:The delivery of futile care is not only an individual patient decision, but must be viewed in a broader context. Societal awareness of this problem is necessary, and better scoring systems to identify when ICU care has limited benefit are needed to address these difficult and challenging realities.

Ethics of Practicing medical procedures on newly dead and nearly dead patients

OBJECTIVE: To examine the ethical issues raised by physicians performing, for skill development, medically nonindicated invasive medical procedures on newly dead and dying patients.DESIGN: Literature review; issue analysis employing current normative ethical obligations, and evaluation against moral rules and utilitarian assessments manifest in other common perimortem practices.RESULTS: Practicing medical procedures for training purposes is not uncommon among physicians in training. However, empiric information is limited or absent evaluating the effects of this practice on physician competence and ethics, assessing public attitudes toward practicing medical procedures and requirements for consent, and discerning the effects of a consent requirement on physicians’ clinical competence. Despite these informational gaps, there is an obligation to secure consent for training activities on newly and nearly dead patients based on contemporary norms for informed consent and family respect. Paradigms of consent-dependent societal benefits elsewhere in health care support our determination that the benefits from physicians practicing procedures does not justify setting aside the informed consent requirement.CONCLUSION: Current ethical norms do not support the practice of using newly and nearly dead patients for training in invasive medical procedures absent prior consent by the patient or contemporaneous surrogate consent. Performing an appropriately consented training procedure is ethically acceptable when done under competent supervision and with appropriate professional decorum. The ethics of training on the newly and nearly dead remains an insufficiently examined area of medical training.

Rethinking Guidelines for the Use of Palliative Sedation

Current guidelines on palliative sedation to unconsciousness restrict its use in ways that are extraordinary in medicine. A closer look at the kinds of cases in which PSU is used suggests changes. Current guidelines treat palliative sedation to unconsciousness as an effective medical treatment for terminally ill patients who need relief from severe symptoms, yet also restrict its use in ways that are extraordinary for medical treatments. A closer look at the kinds of cases in which palliative sedation is used suggests a way of adjusting the guidelines to resolve this seeming contradiction.

Effects of Graded Levels of Physical Similarity and Density on Visual Selective Attention in Patients With Alzheimer's Disease

A multitarget visual cancellation test was administered to patients with Alzheimers disease (AD) and age-matched healthy controls (HC). Attentional loads--physical similarity (number of features shared by target and distractors; 3 levels) and density (number of items per page; 3 levels)--were varied systematically. As physical similarity increased, both groups slowed their search, but whereas the HC group maintained accuracy, the AD group increased commission errors and tended to miss more targets. Increased density yielded slower search and more target omissions in the AD group. Commission errors are additional indicators of higher order attentional deficits, especially in early disease. The findings suggest that patients with AD may rely increasingly on physical features of stimuli during a search, leading to inefficient bottom-up processing strategies.

What about process? Limitations in advance directives, care planning, and noncapacitated decision making.

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.

Pharmaceutical Industry Influences on Physician Prescribing: Gifts, Quasi-gifts, and Patient-Directed Gifts

Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003) cogently argue that inexpensive and even trivial gifts from pharmaceutical companies can signiacantly inouence physician prescribing behavior. They also argue that because the pharmaceutical industry inouences physicians in many other ways, the relative inouence of these small gifts on medication prescribing is unclear. If more objective medication prescribing by physicians is the essential purpose of regulating gifts, then we should consider some other giftrelated inouences. I will brieoy discuss three concerns:

Paternalistic Assumptions and a Purported Duty to Deceive

If I tell you that among the measures to be taken to determine the nature and severity of your illness are some that are known to be, and intended to be, ineffectual, it is quite possible (and some would say even inevitable) that your trust in me as a physician—the trust that I had hoped, by my honest disclosure, to maintain—might in fact be undermined, rather than strengthened. If placebos are to be forbidden in clinical medicine, the use of a placebo in this diagnostic context is called into question, despite its obvious utility. The placebo is only effective insofar as it is deceptive. The hope that there can be non-deceptive uses that serve its purpose is confusing at best, and likely futile.

Intensity of Vasopressor Therapy for Septic Shock and the Risk of In-Hospital Death

CONTEXT Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. OBJECTIVES To determine if intensity of vasopressor therapy accurately predicts in-hospital death. METHODS This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. RESULTS A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. CONCLUSION When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patients family.

Medical Therapy of Malignant Bowel Obstruction With Octreotide, Dexamethasone, and Metoclopramide:

Background: Malignant bowel obstruction is a highly symptomatic, often recurrent, and sometimes refractory condition in patients with intra-abdominal tumor burden. Gastro-intestinal symptoms and function may improve with anti-inflammatory, anti-secretory, and prokinetic/anti-nausea combination medical therapy. Objective: To describe the effect of octreotide, metoclopramide, and dexamethasone in combination on symptom burden and bowel function in patients with malignant bowel obstruction and dysfunction. Design: A retrospective case series of patients with malignant bowel obstruction (MBO) and malignant bowel dysfunction (MBD) treated by a palliative care consultation service with octreotide, metoclopramide, and dexamethasone. Outcomes measures were nausea, pain, and time to resumption of oral intake. Results: 12 cases with MBO, 11 had moderate/severe nausea on presentation. 100% of these had improvement in nausea by treatment day #1. 100% of patients with moderate/severe pain improved to tolerable level by treatment day #1. The median time to resumption of oral intake was 2 days (range 1-6 days) in the 8 cases with evaluable data. Of 7 cases with MBD, 6 had For patients with malignant bowel dysfunction, of those with moderate/severe nausea. 5 of 6 had subjective improvement by day#1. Moderate/severe pain improved to tolerable levels in 5/6 by day #1. Of the 4 cases with evaluable data on resumption of PO intake, time to resume PO ranged from 1-4 days. Conclusion: Combination medical therapy may provide rapid improvement in symptoms associated with malignant bowel obstruction and dysfunction.