Tag: hemodialysis

Bioethics Blogs

End-of-Life Healthcare Sessions at ASBH 2017

The 2017 ASBH
conference
 in October 2017 includes over 400 workshops, panels, and
papers in bioethics and the health humanities.  Here are ones that pertain
to end-of-life issues.


THURSDAY, OCTOBER 19


THU 1:30 pm:  End-of-Life Care and Decision-Making in the ICU – Limited
English Proficiency as a Predictor of Disparities (Amelia Barwise)


Importance: Navigating choices in predominantly English-speaking care settings
can present practical and ethical challenges for patients with limited English
proficiency (LEP). Decision-making in the ICU is especially difficult and may
be associated with disparities in health care utilization and outcomes in critical
care. 


Objective: To determine if code status, advance directives, decisions to limit
life support, and end-of-life decision-making were different for ICU patients
with LEP compared to English-proficient patients. 


Methods: Retrospective cohort study of adult ICU patients from
5/31/2011-6/1/2014. 779 (2.8%) of our cohort of 27,523 had LEP. 


Results: When adjusted for severity of illness, age, sex, education, and
insurance status, patients with LEP were less likely to change their code
status from full code to do not resuscitate (DNR) during ICU admission (OR,
0.62; 95% CI, 0.46-0.82; p


Conclusion: Patients with LEP had significant differences and disparities in
end-of-life decision-making. Interventions to facilitate informed
decision-making for those with LEP is a crucial component of care for this
group.


THU 1:30 pm:  “But She’ll Die if You Don’t!”: Understanding and
Communicating Risks at the End of Life (Janet Malek)


Clinicians sometimes decline to offer interventions even if their refusal will
result in an earlier death for their patients. For example, a nephrologist may
decide against initiating hemodialysis despite a patient’s rising creatinine
levels if death is expected within weeks even with dialysis.

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

Beyond the Destination LVAD

There are many forms of life sustaining treatment available
to patients thanks to advances in medical technology. When a person’s
physiology weakens or fails, devices may be attached or implanted to take over
for organs that can no longer bear the workload of processing, moving, or
taking in the elements needed to keep a body alive. Conceptually, this is
appealing to a society that is as averse to death as are those of us here in
the US. But we still struggle to accommodate the range of needs that crop up
when function is compromised. As an ethicist, the general trend in my work
suggests that the more advanced the technology, the more questions it raises
when it comes time to talk about halting the mechanical support. Among the more
advanced tools for sustaining physiological function is the Left Ventricular
Assist Device, or LVAD, which maintains the circulatory function for persons
with severe heart failure.

There is little doubt that individuals who are eligible for
the device can experience remarkable quality of life gains whether they move on
to receive a heart transplant or receive the implant as a destination
treatment. Recipients of LVADs can typically return to their daily activities,
and enjoy a level of independence not previously possible for persons with
otherwise lethal heart conditions. However, these patients are not just like
everyone else when complications arise. Decisions about how best to manage long
term care for persons who have LVADs can be unexpectedly complex, most notably
when the patient lives outside a major metropolitan city center.

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

Professional Judgment and Justice: Equal Respect for the Professional Judgment of Critical-Care Physicians

by David Magnus, PhD and Norm Rizk, MD

This issue’s target article by Kirby (2016) raises an incredibly important and challenging set of issues: Whether, when, and how should limits be placed on patient access to intensive medical care? What are limits of shared decision making? Is bedside rationing ever appropriate? Kirby’s move away from bedside rationing to a mesolevel approach is novel and interesting. However, as some of the commentaries note, the question of whether there are limits to what will be offered to patients and their families often has to be made at the bedside.

Consider the following cases:

  1. An 84-year-old man with altered mental status, severe aortic stenosis, congestive heart failure, coronary artery disease, and chronic kidney disease presents with increased difficulty breathing. Standard medical management of the patient’s heart failure is no longer working. His desperate family asks for a surgical consult to consider whether there are any surgical interventions (including a ventricular assist device) that would give the patient a chance to live longer. The cardiology team and the cardiothoracic surgeons all agree that there is a small chance (different physicians vary in their estimate, but it ranges from 5 to 20%) that the patient will have his life prolonged by the surgery, but a very high chance he will die either during surgery or from postoperative complications. Considering his background state of health, likely quality of life, and the risks and benefits, the surgeons (with support from the cardiologists) decide that the burdens of treatment outweigh the benefits and decide that the patient is not a surgical candidate.

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

My Thoughts While Doing Chest Compressions: Reflections on Care in the Intensive Care Unit from an Intern Physician-Medical Anthropologist by Kimberly Sue

I was doing chest compressions on a 29-year-old woman who had just come up from the Emergency Room, and I was trying not to look at her face. She was gravely sick, intubated, and we had no idea what was wrong with her. When she went pulseless, we started the American Heart Association’s Advanced Cardiac Life Support (ACLS) algorithm for pulseless arrest. It is the intern’s job to do chest compressions, a somewhat apt metaphor for their lowly but absolutely necessary position in the medical hierarchy of healthcare training institutions. The intern is the workhorse, the one both performing and enduring the brute and long labor of modern healthcare.

The teaching goes that if you’re not breaking ribs, you’re not doing chest compressions correctly. You have to be doing at least 100 compressions a minute. With your hands, you are literally trying to physically pump the blood out of the heart to the brain and other critical organs. Violence is absolutely necessary here.

I think about this woman’s life and my life. We are roughly the same age, brought together by the most unfortunate circumstances. I wonder what her voice sounds like. I will never hear it. As sweat drips off my face, I realize, sadly, that I am getting physical exercise for the first time in a week. It is during this moment that I have a glimmer of recognition that there are so many upstream structural forces that shape the texture of my day-to-day experience in the hospital, as well as the experiences of the patients we serve.

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

Actions vs. Words: What counts most in understanding patient preferences?

Clinicians striving to help patients achieve healthcare
goals often encounter the perplexing dichotomy of the patient’s stated goals
and preferences and actions to the contrary. Some of these challenges can be
overcome with education and close follow up to help reinforce adherence to
medical recommendations, but other times, these barriers are more enigmatic.

Take for example, a patient who requires hemodialysis to
sustain life. She sometimes shows up for her outpatient dialysis, but more
often does not show up and is admitted to the hospital for emergent dialysis
several months in a row. In consultation with her providers she is adamant that
she does not want to die, and knows that she needs the dialysis to remain
alive. She is discharged, and the pattern continues. Liberal scheduling with
the outpatient service, transportation, reminders are all offered.
Psychological tests and support are provided, and yet, her action pattern of
not adhering to the treatment plan continues. Again, she is advised it is acceptable
to halt and she will be offered palliative care. She refuses, and says she
wants to live and will sit for dialysis. What is her genuine preference? Should
we honor these statements, or accept her actions as the more authentic
expression of her wishes? Though this hypothetical example is quite familiar to
renal care providers, the dynamic spans many scenarios leaving many
practitioners with a dilemma about the practical limits of honoring verbalized
wishes that are not supported by congruent actions.

In such scenarios, it seems that the principle of
beneficence overrides the obligation to interpret which autonomous expressions,
words or actions are most genuine.

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

Don’t Categorically Refuse CPR to Ebola Patients

Recently it has been argued that cardiopulmonary resuscitation (CPR) should, as a matter of policy, not be offered to persons with Ebola disease. Such a categorical restriction of CPR based solely on a patient’s diagnosis rather than his prognosis would be unique in modern medical practice. Beyond this, the general public’s concerns about Ebola, marked by fear and manifested by the social exclusion of recovered patients and their families, makes it especially important to avoid even unintentional suggestions that Ebola is not like any other life-threatening illness.

While the overall survival rates for persons requiring in-hospital CPR are low, specific patients may benefit from CPR, and categorically restricting use of this procedure could further contribute to the social devaluation of Ebola patients. However, staff who courageously accept the responsibility of caring for them are entitled to every effort we can make to secure their safety from the contagion. 

Several commentators have proposed that, while a range of intensive interventions may be appropriate in caring for patients with Ebola, “the line should be drawn at CPR.”  Some institutions are said to be considering similar limitations. (See Reuters and the Wall Street Journal .) The arguments of those opposed to offering CPR have rested on several presumptions: the concern that resuscitation would be counterproductive (nonmaleficence), the claim that persons with Ebola who experience cardiorespiratory arrest cannot be saved (futility), that the requirements for adequate personal protective gowning would delay resuscitative efforts unacceptably, and the fear that CPR would expose hospital staff to unacceptably high risks for infection.

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

Should We Perform Kidney Transplants on Foreign Nationals?

The title of the article in the Journal of Medical Ethics
asks this question.
[1]  The authors from the University of Montreal consider
this subject while the topic of “illegal aliens” or foreign nationals (FN’s) has
been a hot topic in the United States.
 
They however attempt to answer the problem from an international
perspective.
  The FN that we hear about
is usually in the country illegally, but may be in the country as a legal non-citizen,
visitor, non-permeant resident, refuge claimant, resettled refugee and in rare
cases a person detained by the government.

A patient who arrives at the emergency room requiring
hemodialysis would likely rapidly be started on renal replacement therapy.
  This is an emergency and since this is considered,
an emergency there would likely not be a question about the provision of such therapy.
What then about transplantation of a kidney?
 
Is renal transplantation an emergency treatment?  We usually consider transplantation to be a
more economical form of treatment of the acute renal failure in the end, but the
lack of long term funding for medical care of the FN puts a different spin on
the subject. It is not just the procurement of the organ and the surgery but
also provision of and management of the immunotherapy necessary to prevent
rejection of the kidney and the technology to manage the therapy.
   A foreign national that returns to their
home country where there is not an infrastructure that can provide the drug
therapy or monitoring will reject the kidney.

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.