Steven H. Miles

Treatment of Pain in Cognitively Impaired Compared with Cognitively Intact Older Patients with Hip-Fracture

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture.

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.

Deaths Caused by Bedrails

OBJECTIVES: To determine how bedrails cause death in order to suggest clinical and ergonomic changes to prevent such deaths and to promote research to improve the use and design of bed systems.

The Do-Not-Resuscitate Order in a Teaching Hospital: Considerations and a Suggested Policy

We present a policy for implementing the do-not resuscitate orders by medical residents in a teaching hospital, and discuss decision making, legal and ethical considerations, the primary physicians responsibility, and record documentation. THe establishment of a policy and procedure for implementing do-not-resuscitate orders resulted in greater consideration of patient and family rights and improved communication and sensitivity in dealing with those concerned with the patients medical care and welfare.

Limited-treatment policies in long-term care facilities

Two‐thirds of the long‐term care facilities in Minnesota accept do‐not‐resuscitate (DNR) orders and 73% accept care plans to limit medical treatment. The major objectives for limited‐treatment plans cited by the 16.3% of facilities with administrative protocols for such plans was to provide for the residents physical and emotional comfort and dignity. Nearly half of the protocols said limited treatment plans were intended to limit emergency care or hospitalization or to allow death to occur. Protocols advocated the alleviation of physical discomfort, anxiety, and social isolation. Tube feedings were not recommended when oral feeding became impossible. Airway suctioning, oxygen, or antibiotic treatment was suggested only as needed to alleviate suffering. Only a fourth of the protocols described a primary role for the resident in these decisions. This study demonstrates that nursing homes are developing administrative protocols for the formulation of limited‐treatment plans and suggests that model policy statements describing key decision‐making principles, issues, and procedural safeguards could play a constructive role in this process.

Contributions of empirical research to medical ethics

Empirical research pertaining to cardiopulmonary resuscitation (CPR), clinician behaviors related to do-not-resuscitate (DNR) orders and substituted judgment suggests potential contributions to medical ethics. Research quantifying the likelihood of surviving CPR points to the need for further philosophical analysis of the limitations of the patient autonomy in decision making, the nature and definition of medical futility, and the relationship between futility and professional standards. Research on DNR orders has identified barriers to the goal of patient involvement in these life and death discussions. The initial data on surrogate decision making also points to the need for a reexamination of the moral basis for substituted judgment, the moral authority of proxy decision making and the second-order status of the best interests standard. These examples of empirical research suggest that an interplay between empirical research, ethical analysis and policy development may represent a new form of interdisciplinary scholarship to improve clinical medicine.

AIDS and the geriatrician.

Ten percent of acquired immune deficiency syndrome (AIDS) cases are in persons over 50 years of age with 25% of these cases in persons over 60, and 4% in persons over 70 years of age. If the present age distribution holds, there will be 27,000 AIDS cases in persons over 50, and 1100 cases in persons over 70 years of age, by 1991. Older persons are more likely to acquire AIDS through blood transfusions than to homosexual exposure or drug abuse. Changes in the management of blood products will benefit older persons. The nearly 1 million elderly homosexual men, who have been sheltered from the virus by their pattern of sexual activity, will face greater risks as the prevalence of the virus and the age of the carriers increases. The underappreciated neurological consequences of human T‐cell lymphotrophic virus type III (HTLV‐III) infection, subacute encephalitis, vacuolar myelopathy, and psychiatric disorders will be of particular interest to geriatricians who are often consulted to evaluate neurological dysfunction. Geriatricians will need to become familiar with the spectrum of HTLV‐III infection and prepared to counsel patients and extended‐care facilities.

Courts, Gender and "The Right to Die"

Public policy with regard to decisions to forgo lifesustaining medical care has dramatically changed over 15 years. Courts, legislatures, and professional bodies recognize a patient’s right to refuse treatment despite civic or medical values that favor prolonging life. The United States Supreme Court has taken up this issue on an appeal of Missouri’s Supreme Court decision ordering tube feeding for comatose Nancy Cruzan over her family’s objections. The right to refuse life-sustaining treatment exemplifies a changing accommodation between controversial personal choices and the values our society holds collectively. As with other civil rights issues to come before the Court, the courts embody the very cultural canon they critique and redefine. While the relevance of the American tenet of individualism to the “right to die” (properiy, the “righi to refuse life-sustaining treatment”) is well recognized, the role of our culture’s view of gender in these decisions is not appreciated. A “right-to-die’’ case arises when a family member or, less often, a health care provider, asks a court to consider the legality of forgoing life-sustaining treatment. The final state appellate court rulings ordered continuation of life-prolonging care in two of 14 cases about profoundly ill, previously competent women who had not authored living wills. No such order was made in eight similar cases involving men.2 This difference is the result of an even more asymmetric gender-patterned reasoning within the cases. This paper examines the different words and concepts that courts use in writing about men and women to imprint cultural views of gender onto final opinions. Judicial reasoning about profoundly ill, incompetent men accepts evidence of mens’ treatment preferences to define the standing of personal autonomy in decisions about lifesustaining treatment. Judicial reasoning about women defines the role of caregivers in making treatment decisions after either rejecting or failing to consider evidence of womens’ preferences with regard to life-sustaining treatment. This gender-patterned reasoning belies a premise of a universal , purportedly gender-neutral , right to refuse treatment. As the Massachusetts Supreme Court put it, “principles of equality and respect for individuals require the conclusion that a choice exists ... [w]e recognize a general right in all persons to refuse medical treatment ... [which] must extend to the case of an incompetent, as well as a competent patient, because the value of human dignity extends to both” (Saikewicz, MA, 1977). Though this premise endows men and women with an equal range of treatment options, exactly which treatment decision respects this “right” is problematic for particular comatose, demented, or retarded persons who cannot speak on their own behalf. It is both in the judicial conclusion that a patient’s preference can be “constructed” from evidence of his or her values and in the empowerment of a third party when it cannot, that gender patterned reasoning arises. We examine the gender pattern in all appellate-level, civil, state “right-to-die” cases involving incompetent , adult patient^.^ Our analysis is more akin to social criticism or semantic analysis than to conventional law re vie^.^ We examine judicial reasoning for three types of right to die cases, those involving: (1) previously competent persons who have not left written directives (e.g. living wills) for their care, (2) previously competent persons who have left written directives, and (3) persons who have never been competent. We close with a brief discussion of why gender-patterned reasoning might occur, its implications for other areas of judicial involvement in controversial personal choices, and of the possibility of reform to address this phenomenon.

Traditional surgeons in sub-Saharan Africa: images from south Sudan

Itinerant traditional surgeons work throughout sub-Saharan Africa and perform many procedures including: tooth extraction, abortion, injections, incising and draining abscesses, uvulectomy, circumcision, inguinal hernia surgery, non-invasive cataract luxation, and surgery on closed and open fractures. Cutting and injection equipment are not cleaned and are used on a rapid succession of up to 10 patients in a single clinic session. These procedures cause haemorrhage, septicaemia, tetanus, gangrene, contractures, abscesses, airway obstruction, keloids, iatrogenic fistulae, lacerations of vital organs, loss of limbs, and death. Recent work suggesting that many cases of HIV infection may be caused by medical exposure lend a new urgency to researching the work of traditional surgeons. Collaborative programmes for re-training and re-shaping the work of these practitioners is more likely to be effective in reducing the morbidity than attempts to suppress their work.

The Prevalence and Design of Ethics Committees in Nursing Homes

A dramatic increase in the number of ethics committees in long‐term care facilities (LTCFs) has occurred since 1970 in the 487 nursing homes in Minnesota. Ten percent of the LTCFs had ethics committees which were mostly formed by administrators and nurses. The committees are most often found in large urban facilities with a high percentage of skilled‐level beds and a religious name. The committees are multidisciplinary with a median of nine members including two to three nurses, a physician, a social worker, a minister, an administrator, and three other members. Nearly all committees were involved in policy development and staff education. Additional functions included resident care consultation and retrospective case review. More than half of the committees are accountable to administration. Nearly all committees kept minutes. Though all committees incurred costs, only one had a formal budget. Informal evaluation is done in only six committees. No committee had referred cases to the courts.