John E. Jesus

Ethical Challenges and Considerations of Short-Term International Medical Initiatives: An Excursion to Ghana as a Case Study

Medical students, physicians, nongovernmental organizations, and military personnel have participated in short-term international medical initiatives to the developing world for decades. Interest in international medical endeavors, particularly in the field of emergency medicine, has only increased with time and ease of transport. Despite our good intentions, ethical challenges frequently pervade the provision of care in these settings. Through the example of a 2-week medical initiative to Ghana, this article explores the ethical subtleties that underlie those challenges and proposes potential avenues by which to address them.

Preferences for Resuscitation and Intubation Among Patients With Do-Not-Resuscitate/Do-Not-Intubate Orders

OBJECTIVE To determine the accuracy of do-not-resuscitate/do-not-intubate (DNR/DNI) orders in representing patient preferences regarding cardiopulmonary resuscitation (CPR) and intubation. PATIENTS AND METHODS We conducted a prospective survey study of patients with documented DNR/DNI code status at an urban academic tertiary care center that serves approximately 250,000 patients per year. From October 1, 2010, to October 1, 2011, research staff enrolled a convenience sample of patients from the inpatient medical service, providing them with a series of emergency scenarios for which they related their treatment preference. We used the Kendall τ rank correlation coefficient to examine correlation between degree of illness reversibility and willingness to be resuscitated. Using bivariate statistical analysis and multivariate logistic regression analysis, we examined predictors of discrepancies between code status and patient preferences. Our main outcome measure was the percentage of patients with DNR/DNI orders wanting CPR and/or intubation in each scenario. We hypothesized that patients with DNR/DNI orders would frequently want CPR and/or intubation. RESULTS We enrolled 100 patients (mean ± SD age, 78 ± 13.7 years). A total of 58% (95% CI, 48%-67%) wanted intubation for angioedema, 28% (95% CI, 20%-3.07%) wanted intubation for severe pneumonia, and 20% (95% CI, 13%-29%) wanted a trial resuscitation for cardiac arrest. The desire for intubation decreased as potential reversibility of the acute disease process decreased (Kendall τ correlation coefficient, 0.45; P<.0002). CONCLUSION Most patients with DNR/DNI orders want CPR and/or intubation in hypothetical clinical scenarios, directly conflicting with their documented DNR/DNI status. Further research is needed to better understand the discrepancy and limitations of DNR/DNI orders.

Physician Orders for Life-Sustaining Treatment and Emergency Medicine: Ethical Considerations, Legal Issues, and Emerging Trends

Since its original development in Oregon in 1993, Physician Orders for Life-Sustaining Treatment (POLST) is quickly growing in popularity and prevalence as a method of communicating the end-of-life care preferences for the seriously ill and frail nationwide. Early evidence has suggested significant advantages over advance directives and do-not-resuscitate/do-not-intubate documents both in accuracy and penetration within relevant populations. POLST also may contribute to the quality of end-of-life care administered. Although it was designed to be as clear as possible, unexpected challenges in the interpretation and use of POLST in the emergency department do exist. In this article, we will discuss the history, ethical considerations, legal issues, and emerging trends in the use of POLST documents as they apply to emergency medicine.

Treatment of potential organ donors in the emergency department: a review.

The expanding role of emergency medicine in the care of potential organ donors presents unique ethical challenges. This article introduces emergency providers to the ethical challenges of organ donation, including issues of patient autonomy and consent, public perception and trust, goals of care, and the determination of death.

Ethical considerations of research in disaster-stricken populations.

Recently, emphasis has been placed on improving and expanding research in disaster response and the treatment of disaster-stricken populations. However, research in these settings presents unique ethical challenges with which the scientific and biomedical ethics communities continue to struggle. At the core of the controversy is the question of how best to balance the critical need for research with the equally important obligation to respect and protect the interests of research participants within the unique stress of a disaster. This concern stems from the potential of increased vulnerability of individuals stricken by disaster over and above their usual vulnerability to risk and exploitation as research subjects. Ethical principles that must be considered in these situations are the same as those that are important when conducting any human research: respect for persons, non-maleficence, beneficence, and justice. This paper explores the ethical challenges that accompany inadequate resources and personnel, the potential vulnerability of research participants, the dual role of physician-researcher, and the importance of the publics perception and trust are explored. It then proposes a number of potential avenues through which to conduct ethically justifiable research that could answer many of the pressing questions in disaster medicine and response.

Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

Ethical Issues in the Response to Ebola Virus Disease in US Emergency Departments: A Position Paper of the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.

The Anemic and Thrombocytopenic Febrile Neonate

BACKGROUND Babesiosis is a tick-borne, protozoal disease seen primarily in the northeastern and northern Midwest portions of the United States. It is primarily transmitted through the bite of the Ixodes scapularis tick and may cause hemolysis. CASE REPORT In the following case report, we present a 4-week-old male neonate with a temperature of 38.8°C (102.0°F) who presented to our pediatric emergency department with anemia, thrombocytopenia, and splenomegaly. Blood smear analysis demonstrated U-shaped parasitic rings within red blood cells consistent with babesiosis, confirmed by a positive Babesia microti antibody screen. Because the patient was never exposed to a vector for babesiosis, and never lived in an endemic area, the most likely exposure was in-utero transmission of the disease through transplacental migration of the parasite prior to birth. The patient was treated with atovaquone and azithromycin and discharged from the hospital after 6 days. The patients mother also tested positive and was treated with the same medications. The evaluation of a febrile neonate includes a broad differential diagnosis. Although babesiosis is still uncommon in many areas of the United States, a specific constellation of laboratory findings and symptoms should prompt its consideration, even in patients who have not been exposed to an endemic area or a typical vector. Vertical transmission of babesiosis has been previously reported, but the occurrence is quite rare. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Practitioners should include babesiosis in their differential diagnosis where appropriate and be aware that it can be transmitted not only via tick bite, but also from mother to neonate during pregnancy.

Necrotizing Fasciitis in the Setting of Marine Injury

Dr. John Jesus:Today’s case is that of a 26-year-old righthand-dominant healthy patient who sustained a small puncture wound to the hand while disposing of a dead catfish at work. He presented to the Emergency Department (ED) approximately 12 h after his initial injury with significant malaise, chills, and rapidly increasing swelling in the affected hand. The patient reported puncturing the dorsal aspect of his right middle finger with one of the pectoral spines of a catfish at approximately 8:30 in the morning. He attempted to clean the wound by expressing blood from it and washing the wound with warm soapy water. He then went about his day, largely ignoring a seemingly innocuous wound. Shortly before presentation, the patient began to notice increasing pain, erythema, and swelling of the affected finger, quickly tracking up the finger to include the majority of the dorsum of his right hand (Figure 1). Dr. Richard Wolfe: Can you describe the initial appearance of the patient? Dr. Jesus: Upon arrival in the ED the patient was relatively comfortable, initially refusing pain medication. His right middle finger appeared edematous, with mild erythema that was subtle; the puncture wound itself was 3 mm in length, clean, closed, without drainage or visible foreign body. His initial vital signs were: temperature 38.6 C, heart rate 118 beats/min, blood pressure 179/ 93 mm Hg, respiratory rate 18 breaths/min, and an oxygen saturation of 99% on room air. Dr. Carrie Tibbles: Does the patient have any significant past medical history?

Observation Care: Ethical and Legal Considerations for the Emergency Physician

BACKGROUND The Medicare observation rules remain controversial despite Centers for Medicare and Medicaid Services revisions and the new 2-midnight rule. The increased financial risks for patients and heightened awareness of the rule have placed emergency physicians (EPs) at the center of the controversy. DISCUSSION This article reviews the primary ethical and legal (particularly with respect to the Emergency Medical Treatment and Active Labor Act) implications of the existing observation rule for EPs and offers practical solutions for EPs faced with counseling patients on the meaning and ramifications of the observation rule. CONCLUSIONS We conclude that while we believe it does not violate the intent of the Emergency Medical Treatment and Active Labor Act to respond to patient questions about their admission status, the observation rules challenge the ethical principles of transparency related to the physician-patient relationship and justice as fairness. Guidance for physicians is offered to improve transparency and patient fairness.