Tag: family practice

Bioethics Blogs

M[Emory] Enhancement and its Implications

By Shweta Sahu
Imagine a situation in which you suffer from severe anterograde amnesia, a form of short term memory loss, and can’t recall information presented to you even 7 seconds before– let alone being able to remember the one thing you went to Target to buy, but forgot. Such is the case of Clive Wearing, a man known for his lack of short term memory. His wife notes, “you ask him a question and he’ll give you an answer but while he’s giving me the answer, he’s already forgotten the question. That’s how short it is.” He himself notes “the brain has been totally inactive—day and night the same—no thoughts at all.” Though this is one of the most severe cases of amnesia observed, it underscores how crucial memory is not only to every day functioning, but also for one’s sense of self. Autobiographical memories and the ability to recall these emotional and important events are an integral component of one’s identity. These events, in turn, get tied into personal narratives that our personalities are built on. In the case of Mr. Wearing, he is stuck in this personality because of the damage to his hippocampus and closely related brain regions, an area of the brain necessary for transferring information from short term to long term memory. As a result, he reports that he feels like he is dead and is constantly waking up into a new reality.
Video courtesy of YouTube

Realizing how significant memory is one thing, but the ability to recover or enhance memory is another.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care

Ann Denny’s image on recording healthcare directives
It was a real pleasure to be part of this project on adding video testimonials / messages to advance directives.  This was released today in the Journal of Patient Safety.  This is the 8th in the series of TRIAD articles – The Realistic Interpretation of Advance Directives.

Objective: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.

Methods: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine.  Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.

Results: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%–78%noted “DNR”). Two of 9 scenarios attained consensus for code status (97%–98% responses) and treatment decisions (96%–99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7%to 57%(P ≤ 0.005)

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Assisted Dying, Mental Illness, & Patient Age

Ellen Wiebe, a physician who has provided medical assistance in dying, discusses her views about providing this service when the request is from a young person suffering from mental illness.

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Earlier this year I assisted the only person in Canada known to have received medical assistance in dying primarily for suffering caused by mental illness. The patient, identified as EF by the Alberta Court that granted her permission to access medical assistance in dying, died peacefully in Vancouver on June 1, 2016. She was surrounded by friends and family. The four judges who heard her case, her family doctor, and I had no hesitation in respecting her right to end her suffering.

A few weeks later, on June 16, “An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying)” received Royal Assent. According to the Act, people are eligible for medical assistance in dying as long as they meet all of the following criteria:

(a) they are eligible … for health services funded by a government in Canada;

(b) they are at least 18 years of age and capable of making decisions with respect to their health;

(c) they have a grievous and irremediable medical condition;

(d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and

(e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Is Being Nice Part of Being Ethical as a Healthcare Provider?


Being on the other side of the healthcare equation is always
illuminating.
  That is, last week I was a
patient at our institution having major, elective, abdominal surgery.  Most of the care I received was kind and
humane, but when it was not the negative effects were not small.
  Before I “go negative” I would like to say
that every nurse I encountered treated me with respect and empathy, and most
did not know I was an attending physician.


 


But now to the negative. 
An attending anesthesiologist came into my pre-operative cubicle to
interview me prior to the surgery.  She
started speaking very softly, and she asked me a question that I could not understand.  I told her I was hearing impaired, and that I
needed her to speak up a bit, and she responded with a snort of derision.  I was shocked, and I looked over at my wife
who seemed to have read the situation the same way.  She then proceeded to speak too loudly for
the rest of the interview, and then stood there silently for several minutes
filling out paperwork before just turning and walking out.  “Can you request another anesthesiologist,”
my wife asked.
  “Do you think you can
trust her to take care of you while you’re asleep?’  I had no answer to these questions, and while
it follows logically that her rude behavior does not directly impugn her
clinical skills, she sowed a seed of doubt in my mind that even Versed (the
pre-operative sedative given to patients) did not completely overcome.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Dollars to Doctors: Sun Rises on Sunshine Act’s Open Payments Database

by Craig Klugman, Ph.D.

Today, Tuesday, September 29, the Centers for Medicare and Medicaid Services will release most of the Open Payments database. The public will now have access to the monetary value of gifts, marketing, and payments for clinical testing made by the pharmaceutical industry to physicians. The database is being rolled out 12 days later than planned and with one-third of the 2013 data unavailable until June 2015: There have been some glitches including mix-up of names and wrong provider and license numbers entered.

The Open Payment database is a part of the Sunshine Act, a provision of the 2010 Affordable Care Act. Under this law, entries must include the name and address of the physician, amount and date of payments, the form of the payment, and the nature of the payment (is it for consulting, gifts, entertainment). All gifts and payments over $10 that do not directly benefit patients must be reported.

The goal is to increase transparency and reduce conflict of interest. Knowledge of payments should theoretically increase patient awareness of factors that may effect recommendations made by their physicians. Studies and reports demonstrate that pharmaceutical gifts and marketing visits impact physicians’ prescribing practices.

The American Medical Association supports the database but feels it has had some rollout problems and is not ready for release. Specifically, the AMA feels that a delay is necessary “to allow physicians adequate time to review and seek correction of inaccurate claims made by pharmaceutical companies, device manufacturers, and group purchasing organizations.” Physicians have to register with the database to be able to review any entries about them.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

A Stethoscope for the Soul

The book title was familiar: “The Soul of Medicine.”

Sherwin Nuland, the influential surgeon, bioethicist and author, who died this spring, gave that name to his 2009 collection of stories, subtitled “Tales from the Bedside.”

The title is thoughtfully provocative. Does medicine have a soul? Do people? And what happens in the doctor-patient relationship when one answers yes and the other no? As I said, the title is thoughtfully provocative.

And here it comes again. “The Soul of Medicine”  (Johns Hopkins University Press) is also the title of a 2011 collection of stories co-edited by John R. Peteet and Michael N. D’Ambra and used as the text for “Spirituality and Healing in Medicine,” the course they teach at Harvard Medical School.

Two books with the same title is a little confusing, but it’s a healthy confusion. Especially if Peteet, D’Ambra and spirituality-minded colleagues are correct about “widespread concern that medicine may be losing its soul.”

“Prominent scientific critics such as Richard Dawkins have painted religion as an inherently biased phenomenon defined by irrationality, and anything associated with it as the antithesis of scientific progress,” writes Marta Herschkopf, a Harvard-trained physician, Yale- and Oxford-trained theologian and contributor to “The Soul of Medicine.” 

“No doubt influenced by such rhetoric, many physicians and administrators feel that spirituality has no place in a medical curriculum or in medical practice. Despite a significant body of research arguing to the contrary, they do not see religion and spirituality as directly contributing to human health and therefore consider it irrelevant.” 

I was reading Peteet and D’Ambra’s book as a three-day course in bioethics began at Harvard Medical School, which I attended as a member of the Harvard Community Ethics Committee.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.