Lachlan Forrow

Am I Doing the Right Thing? Provider Perspectives on Improving Palliative Care in the Emergency Department

STUDY OBJECTIVE Although the focus of emergency care is on the diagnosis and treatment of acute illnesses and injuries or the stabilization of patients for ongoing treatment, some patients may benefit from a palliative approach. Little is known about delivering palliative care in the emergency department (ED). We explore the attitudes, experiences, and beliefs of emergency providers about palliative care in the ED, using structured qualitative methods. METHODS We studied 3 focus groups with 26 providers, including 14 physicians (10 residents, 4 attending physicians), 6 nurses, 2 social workers, and 4 technicians, working in 2 academic EDs in Boston. We used a grounded theory approach to code responses, resolving discrepancies by consensus. RESULTS Six distinct themes emerged: (1) participants equated palliative care with end-of-life care; (2) participants disagreed about the feasibility and desirability of providing palliative care in the ED; (3) patients for whom a palliative approach has been established often visit the ED because family members are distressed by end-of-life symptoms; (4) lack of communication between outpatient and ED providers leads to undesirable outcomes (eg, resuscitation of patients with a do-not-resuscitate order); (5) conflict around withholding life-prolonging treatment is common (eg, between patients family and written advance directives); and (6) training in pain management is inadequate. CONCLUSION Providers ranked improved communication and documentation from outpatient providers as their highest priority for improvement. Attitudinal and structural barriers may need to be overcome to improve palliative care in the ED. Despite targeted recruitment, attending physician participation was low.

Interdisciplinary education: evaluation of a palliative care training intervention for pre-professionals.

Purpose. Medical education inadequately prepares students for interdisciplinary collaboration, an essential component of palliative care and numerous other areas of clinical practice. This study developed and evaluated an innovative interdisciplinary educational program in palliative care designed to promote interdisciplinary exchange and understanding. Method. The study used a quasi-experimental longitudinal design. Thirty-three medical students (third and fourth year) and 38 social work students (second year of masters degree) were recruited. The intervention group students (21 medical and 24 social work students) participated in a series of four training sessions over four weeks while the control group students received written materials after the study. The curriculum and teaching methods were based on theories of professional socialization and experiential learning. The intervention included experiential methods to promote interdisciplinary interaction to foster communication, exchange of perspectives, and the building of mutual trust and respect. Both groups completed assessments of perceived role understanding, a primary component of effective interdisciplinary teamwork, in palliative care. Self-administered surveys were completed at baseline, intervention completion, and three months later. The intervention group also completed an anonymous evaluation about the interdisciplinary education. Results. The intervention group demonstrated a significant increase in perceived role understanding compared with the control group. Three-month follow-up data suggested that intervention group subjects maintained gains in perceived role understanding. Conclusion. An interdisciplinary educational intervention improves role understanding early in the process of professional socialization in a pilot program. Further implementation of interdisciplinary education should evaluate the effect on subsequent interdisciplinary practice and the quality of patient care.

Emergency department experiences of acutely symptomatic patients with terminal illness and their family caregivers.

CONTEXT Despite increased focus on improving palliative care in the emergency department (ED), there is little research on how to best address the specific needs of this patient population. OBJECTIVES To better understand the experiences of acutely symptomatic patients seen in the ED. METHODS Using in-person semi-structured interviews, we explored the attitudes, experiences, and beliefs of 14 patients and seven family caregivers on the inpatient palliative care consult service, who had been admitted through the ED at two academic medical centers. We used a grounded theory approach to code responses. Transcripts were coded by a palliative medicine physician, an emergency medicine physician, and a general internist. Discrepancies were resolved by consensus. Coded sections were iteratively reviewed for interpretation, and concepts were collapsed into themes. RESULTS Five distinct themes emerged: 1) unprepared for managing symptoms at home; 2) uncertainty and anxiety; 3) communication is essential; 4) mixed experiences with symptom management; and 5) conflicting perspectives about the purpose of palliative care clinicians in the ED. CONCLUSION Patients and caregivers identified systems, communication, and clinical issues in ED care that should be a focus for future research.

A New educational approach for supporting the professional development of third-year medical students

This paper describes a new course designed to support the professional development of third-year medical students. The course runs through the clinical clerkships, and has several additional features: it includes a multidisciplinary faculty; it is centrally based in the medical school; it addresses students’ values and attitudes in addition to their knowledge and skills; and it makes use of small-group learning methods, and faculty, student, and group continuity during the year. The curriculum, which addresses ethical, social, and communicative issues in medicine, plus the evaluation of students and of the course, are described.

Transcranial magnetic stimulation: a historical evaluation and future prognosis of therapeutically relevant ethical concerns

Transcranial Magnetic Stimulation (TMS) is a non-invasive neurostimulatory and neuromodulatory technique increasingly used in clinical and research practices around the world. Historically, the ethical considerations guiding the therapeutic practice of TMS were largely concerned with aspects of subject safety in clinical trials. While safety remains of paramount importance, the recent US Food and Drug Administration approval of the Neuronetics NeuroStar TMS device for the treatment of specific medication-resistant depression has raised a number of additional ethical concerns, including marketing, off-label use and technician certification. This article provides an overview of the history of TMS and highlights the ethical questions that are likely arise as the therapeutic use of TMS continues to expand.

Nuclear terrorismCommentary: The myth of nuclear deterrence in south AsiaCommentary: The psychology of terrorists

# Nuclear terrorism {#article-title-2} Three members of International Physicians for the Prevention of Nuclear War and Physicians for Social Responsibility discuss the threat of nuclear terrorism and conclude that the only effective way to tackle it is to abolish nuclear weapons The attack on the World Trade Center in New York clearly showed that there are terrorists who are willing to inflict civilian casualties on the scale that would be expected with the use of a weapon of mass destruction. In this article we consider the form that nuclear terrorism could take and estimate the casualties that would occur if a nuclear bomb the size of that dropped on Hiroshima was detonated in a large urban area. The enormous casualties to be expected from such an attack argue strongly for a strategy of primary prevention. #### Summary points In the aftermath of 11 September 2001 nuclear terrorism has emerged as a real threat Nuclear terrorism could take several forms, from an attack on nuclear power plants and reactors to the detonation of a nuclear bomb in an urban area The international community urgently needs to expand its efforts to secure existing stockpiles of nuclear weapons and materials, particularly in Russia, Pakistan, and India The elimination of nuclear weapons should be high on the global public health agenda Nuclear terrorism might take several forms. An attack on a nuclear power plant or other nuclear installation could result in a massive release of radioactive material. Despite initial statements by the US Nuclear Regulatory Commission that commercial power plants could withstand an aircraft crashing into them, it seems likely these plants are highly vulnerable. As early as 1982 a study by the Argonne National Laboratory of the US Department of Energy found that, if a jet aircraft crashed into a nuclear reactor and only 1% of its fuel ignited after … Correspondence to: Z A Bhutta

Accidental Nuclear War — A Post-Cold War Assessment

BACKGROUND In the 1980s, many medical organizations identified the prevention of nuclear war as one of the medical professions most important goals. An assessment of the current danger is warranted given the radically changed context of the post-Cold War era. METHODS We reviewed the recent literature on the status of nuclear arsenals and the risk of nuclear war. We then estimated the likely medical effects of a scenario identified by leading experts as posing a serious danger: an accidental launch of nuclear weapons. We assessed possible measures to reduce the risk of such an event. RESULTS U.S. and Russian nuclear-weapons systems remain on a high-level alert status. This fact, combined with the aging of Russian technical systems, has recently increased the risk of an accidental nuclear attack. As a conservative estimate, an accidental intermediate-sized launch of weapons from a single Russian submarine would result in the deaths of 6,838,000 persons from firestorms in eight U.S. cities. Millions of other people would probably be exposed to potentially lethal radiation from fallout. An agreement to remove all nuclear missiles from high-level alert status and eliminate the capability of a rapid launch would put an end to this threat. CONCLUSIONS The risk of an accidental nuclear attack has increased in recent years, threatening a public health disaster of unprecedented scale. Physicians and medical organizations should work actively to help build support for the policy changes that would prevent such a disaster.

Clinical review: influenza pandemic - physicians and their obligations.

An influenza pandemic threatens to be the most lethal public health crisis to confront the world. Physicians will have critical roles in diagnosis, containment and treatment of influenza, and their commitment to treat despite increased personal risks is essential for a successful public health response. The obligations of the medical profession stem from the unique skills of its practitioners, who are able to provide more effective aid than the general public in a medical emergency. The free choice of profession and the societal contract from which doctors derive substantial benefits affirm this commitment. In hospitals, the duty will fall upon specialties that are most qualified to deal with an influenza pandemic, such as critical care, pulmonology, anesthesiology and emergency medicine. It is unrealistic to expect that this obligation to treat should be burdened with unlimited risks. Instead, risks should be minimized and justified against the effectiveness of interventions. Institutional and public cooperation in logistics, remuneration and psychological/legal support may help remove the barriers to the ability to treat. By stepping forward in duty during such a pandemic, physicians will be able to reaffirm the ethical center of the profession and lead the rest of the healthcare team in overcoming the medical crisis.

Assessing competence in clinical ethics: are we measuring the right behaviors.

ConclusionSinger et al. are to be commended for making a first attempt at developing behavioral measures of physicians’ abilities to implement an ethically justifiable course of action. Many of the objections noted above are not intrinsic to all possible OSCEs, and future adaptations of the OSCE approach may well overcome them. Moreover, by forcing faculty to articulate clearly and explicitly the goal according to which success or failure should be measured, the process of developing appropriate evaluation methods can lead to improvements in all aspects of curriculum design.However, caution is needed as attempts to refine evaluation methods in medical ethics progress. An evaluation method that does not measure the behaviors one wants to promote is, regardless of how reliable or internally consistent, unhelpful. As we move forward with evaluation, we must articulate more clearly the knowledge, attitudes, skills, and behaviors that constitute competence in clinical ethics. Only then can we proceed effectively with developing methods to measure them.

“Apologies” from Pathologists Why, When, and How to Say “Sorry” After Committing a Medical Error

How pathologists communicate an error is complicated by the absence of a direct physician–patient relationship. Using 2 examples, we elaborate on how other physician colleagues routinely play an intermediary role in our day-to-day transactions and in the communication of a pathologist error to the patient. The concept of a “dual-hybrid” mind-set in the intermediary physician and its role in representing the pathologists’ viewpoint adequately is considered. In a dual-hybrid mind-set, the intermediary physician can align with the patients’ philosophy and like the patient, consider the smallest deviation from norm to be an error. Alternatively, they might embrace the traditional physician philosophy and communicate only those errors that resulted in a clinically inappropriate outcome. Neither may effectively reflect the pathologists’ interests. We propose that pathologists develop strategies to communicate errors that include considerations of meeting with the patients directly. Such interactions promote healing for the patient and are relieving to the well-intentioned pathologist.