Robert M. Walker

The illusion of futility in clinical practice

The claim that a treatment is futile is often used to justify a shift in the physicians ethical obligations to patients. In clinical situations in which non-futile treatments are available, the physician has an obligation to discuss therapeutic alternatives with the patient. By contrast, a physician is under no obligation to offer, or even to discuss, futile therapies. This shift is supported by moral reasoning in ancient and modern medical ethics, by public policy, and by case law. Given this shift in ethical obligations, one might expect that physicians would have unambiguous criteria for determining when a therapy is futile. This is not the case. Rather than being a discrete and definable entity, futile therapy is merely the end of the spectrum of therapies with very low efficacy. Ambiguity in determining futility, arising from linguistic errors, from statistical misinterpretations, and from disagreements about the goals of therapy, undermines the force of futility claims. Decisions to withhold therapy that is deemed futile, like all treatment choices, must follow both clinical judgments about the chance of success of a therapy and an explicit consideration of the patients goals for therapy. Futility claims rarely should be used to justify a radical shift in ethical obligations.

Resuscitation decision making in the elderly: the value of outcome data

Objective: To assess the relationship between cardiopulmonary resuscitation (CPR) information and desire for CPR in an elderly population and to determine the influence of outcome data on desire for CPR in older persons.Design: An interventional study utilizing an educational program.Setting: Elderly independent retirement community.Participants: One hundred two persons, all more than 62 years old, who were neither demented nor depressed.Intervention: Participants received an educational intervention consisting of descriptive CPR information and quantitative information about CPR outcomes. CPR information, survival estimates, and preferences were recorded prior to and after the intervention.Measurements and main results: Subjects exhibited a high level of basic knowledge about CPR, which did not change with the intervention. While subjects consistently overestimated their chances of survival post CPR, these estimates decreased toward more realistic levels after the intervention (p<0.001). CPR preferences changed in three of five hypothetical clinical scenarios after the intervention (p<0.05). Those who were more realistic in their estimates of CPR survival desired less CPR in the hypothetical scenarios (p<0.01). A trend in our data suggests that quantitative outcome information may have a greater influence on CPR preferences than has descriptive information (p=0.07).Conclusions: CPR preferences changed after an educational intervention. An improved understanding of quantitative outcome data appears to influence the desire for CPR and therefore should be included in CPR discussions with older patients.

Life Values, Resuscitation Preferences, and the Applicability of Living Wills in an Older Population

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills.

Physicians’ and nurses’ perceptions of ethics problems on general medical services

AbstractObjective:To understand the kinds of clinical situations physicians and nurses regard as “ethics problems.” Design:The authors prospectively studied physicians’ and nurses’ perceptions of ethics problems using paired interviews. Individual interviews were conducted with physicians and nurses as they cared for the same patients during a six-week period. Each was asked whether any ethics problems had arisen in the care of his or her patients and, if so, to give a brief description of each problem.Setting:Three general medical services in a 497-bed community teaching hospital.Participants:13 physicians (mostly family medicine residents) and 42 nurses caring for 142 patients.Main results:The physicians and nurses thought ethics problems were present in 75 of the 142 patient cases. Physicians and nurses identified ethics problems with similar frequencies; however, they often identified ethics problems in different patient cases or identified different ethics problems in the same case. Physicians and nurses described a variety of problem types. Physicians identified more problems related to quality of life, inappropriate hospital admissions, and cost of care; nurses identified more problems related to patient preferences, family wishes, pain management, implementing treatments, and discharge planning. A fourth of the ethics problems identified by physicians and nurses involved interstaff conflicts.Conclusions:The physicians and nurses studied considered a broad range of clinical situations to be “ethics problems,” and they perceived them to occur frequently. Systematic differences were found between physicians’ and nurses’ perceptions of ethics problems, and many ethics problems generated interstaff conflicts. Incorporating this kind of information into clinical ethics education programs, and into hospital policies, may represent a useful approach toward improving physician—nurse interaction.

What and How Psychiatry Residents at Ten Training Programs Wish to Learn About Ethics

The study’s objective was to survey what and how psychiatry residents want to learn about ethics during residency. A 4-page questionnaire developed for this study was sent to 305 residents at 10 adult psychiatry programs in the United States. One-hundred and eighty-one (59%) of those surveyed responded. Seventy-six percent reported facing an ethical dilemma in residency for which they felt unprepared. Forty-six percent reported having received no ethics training during residency. More than 50% of the respondents requested that “more” curricular attention be paid to 19 specific ethics topics and more than 40% for 25 topics. Preferences with respect to learning methods are presented. This survey may provide guidance in structuring the content and process of ethics education for psychiatry residents. These findings should stimulate the efforts of faculty to commit time and attention to this important curricular area.

The lack of advance directives among hospice patients.

This study reported a lower than expected prevalence of advance directives among hospice patients. The presence of an advance directive was related to certain sociodemographic factors, diagnosis, and previous physician-patient advance directive discussions. Barriers that precluded the completion of an advance directive primarily involved a lack of physician-patient advance directive discussions or a lack of patient understanding. This study confirmed the importance of physician-patient discussion toward completion of an advance directive. Improving physician-patient communication about this issue should increase the prevalence of advance directive completion among hospice patients.

The Influence of Intravenous Albunex Injections on Pulmonary Arterial Pressure, Gas Exchange, and Left Ventricular Peak Intensity

Contrast ultrasonography may be used to assess regional tissue perfusion. The purpose of this study was to evaluate the safety and efficacy of a new, commercially prepared ultrasound contrast agent (Albunex) in dogs. The injections were administered from peripheral intravenous (IV), right atrial (RA), and pulmonary artery (PA) sites. Acute pulmonary hemodynamic and gas exchange effects of low-dose (0.5, 1.0, 2.0 ml) Phase I injections, and high-dose (2.0, 5.0, 10, 20 ml) Phase II injections of Albunex were evaluated in nine dogs. Immediately before and after each injection, pulmonary artery pressure (PAP) and oxygen tension (PO2) were determined. In addition, left ventricular cavity opacification was assessed visually and by videodensitometric off-line analysis. Visual assessment was performed by four blinded observers who graded on a scale of 0 to 3 (0 = no contrast enhancement of the left ventricular (LV) cavity; 1 = weak or suboptimal contrast enhancement; 2 = optimal or excellent contrast enhancement; and 3 = attenuation of the ultrasound signal following a contrast injection). Peak pixel intensity was also determined with videodensitometric analysis. Results showed that significant changes in PAP or PO2 were not noted after Albunex injections, regardless of injection site or dose range. The average change in PAP after Albunex injection was 1.0 mm Hg +/- 1.2 mm Hg (NS), and the average change in PO2 after Albunex injections was 6.2 mm Hg +/- 6.7 mm Hg (NS). The left ventricular cavity peak pixel intensity was dependent on both injection site (PA = RA > IV) and dose range (2.0 = 1.0 > 0.5).(ABSTRACT TRUNCATED AT 250 WORDS)

Development of a Teaching Program in Clinical Medical Ethics at the University of Chicago.

&NA; The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)

Should informed consent be required for laboratory testing for drugs of abuse in medical settings

Laboratory testing for drugs of abuse is often conducted in medical settings, with little consideration of the technical limitations and the potential for legal and social harm to the patient. We consider several technical problems associated with such testing, including the lack of chain-of-custody procedures, the possibility of false-positive results with screening immunoassays, and the infrequency of confirmatory testing. Important ethical issues arise because of the sensitive nature of drug test results, the ramifications of false-positive results, the limitations of confidentiality protection, and the practice of testing without the patients knowledge. Taken together, these technical and ethical concerns suggest that drug testing policies in medical settings should specify which conditions require explicit informed consent, as well as create procedures for protecting this sensitive information.

Socioeconomic Status and Resuscitation Preferences in the Elderly

Elderly subjects (N = 166) of varying socioeconomic backgrounds from two sites were given identical resuscitation information and were studied to determine the relationship between socioeconomic status and resuscitation preferences. Resuscitation preferences varied among the four hypothetical scenarios. Univariate analyses revealed that those who were older, male, non-Caucasian, less educated, and had less income desired more cardiopulmonary resuscitation (CPR) in the scenarios. Multivanate analysis limited significant variables to age, gender, race, and level of education. Thus there appears to be a strong relationship between socioeconomic status and desire for CPR. Future research should evaluate whether the sociodemographic variables represent proxy variables for underlying life values that may influence resuscitation preferences. Implications for CPR decision making and health policy are discussed.