Tag: nurses

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

Press Release – “The Worst Outcome” Prof Dominic Wilkinson

This afternoon the long-running, deeply tragic and emotionally fraught legal dispute over treatment of Charlie Gard reached its sad and sadly inevitable conclusion. Following further medical assessment of Charlie by several international experts, Charlie’s parents and doctors finally reached agreement that continuing life support and experimental treatment could not help him.

This is the worst possible outcome for Charlie’s family. They have had to accept the devastating news that their beloved son cannot recover and that their hopes for an experimental treatment cannot be realised.

There are important lessons to learn from this case. Cases of deep disagreement between parents and doctors about treatment for a child are rare. Where they occur, it is often possible with time, patience, and support to find common ground. Where agreement cannot be reached, there is an important role for the courts in helping to reach a decision. However, court review of cases like this is not ideal. It is adversarial, costly, and lengthy. In this case, Charlie has received months of treatment that doctors and nurses caring for him felt was doing him more harm than good.

We need to find better ways to avoid cases of disagreement from coming to court. There is an important role for mediation to help parents and doctors where they have reached an impasse.

We also need a fair, expedient way of resolving disputes. This would mean that patients can access early experimental treatment if there is a reasonable chance that it would not cause significant harm. It would also mean that futile and harmful treatment is not prolonged by a protracted legal process.

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

Confronting Medicine in the Holocaust & Beyond

By Hedy S. Wald

Galilee, Israel, May 7-11, 2017. I was privileged to be at the Second International Scholars Workshop on “Medicine in the Holocaust and Beyond.” Why so meaningful?  Why so needed? 140 purposeful, passionate scholars from 17 countries delved into the past history of medicine at its worst in order to inform the future.  From 1933-1945, presumed healers within mainstream medicine (sworn to uphold the Hippocratic Oath) turned into killers (1).  Yes, medical ethics in Nazi-era medical school curricula existed, yet included “unequal worth of human beings, authoritative role of the physician, and priority of public health over individual-patient care”(2).  In Western Galilee College, (Akko), Bar-Ilan University Faculty of Health Sciences (Safed), and Galilee Medical Center and Ghetto Fighters’ Museum, (both in Nahariya), historians, physicians, nurses, medical and university educators, medical students, ethicists and more gathered to grapple with this history and consider how learning about medicine in the Holocaust can support healthy professional identity formation with a moral compass for navigating the future of medical practice with issues such as prejudice, assisted reproduction and suicide, resource allocation, obtaining valid informed consent, and challenges of genomics and technology expansion (3)…

The conference, in essence, served as a lens for the here and now, reinforcing my contention (and others’) that history of medicine in the Holocaust curricula including confronting the Nazi physicians’ and scientific establishment’s euthanasia of “lives unworthy of life,” forced sterilizations, horrific experimentation on their victims, and medicalized genocide (leading to the destruction of a third of the European Jewish population and many others) is a “moral imperative” in healthcare professions education (1,4).

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

Critical Care Nurses Urge Physicians Not Allow Families to Override Patient Wishes. Many

A new study in the July/August 2017 Dimensions of Critical Care Nursing  reports suggestions from 500 critical care nurses on how to improve end-of-life care obstacles.  


Major themes include:

  • Ensuring characteristics of a good death
  • Improving physician communication with patients and families
  • Adjusting nurse-to-patient ratios to 1:1
  • Recognizing and avoiding futile care
  • Increasing EOL education
  • Physicians who are present and ‘‘on the same page”
  • Need for more support staff
  • Not allowing families to override patients’ wishes

I want to second this final suggestion.  In my discussions with nurses this is a very common question.  The study’s quotes are consistent with my own experience:

  • “The most troubling aspect is when patients’ wishes are not followed.”
  • “Respect patients’ wishes NOT families!”
  • “Follow the patient’s DNR/POLST form regardless of the family’s wishes. The patient filled it out for a reason.”
As I have written several times, surrogates who contradict the patient’s own instructions or wishes can and should be replaced.  

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

What’s the Point of Professional Ethical Codes?

For a few reasons, I’ve been thinking a bit over the last few months about professionalism and professional codes.  In fact, that’s the topic that’s attracted most of my attention here since… oooh, ages ago.  I find the idea of a code of professional ethics troubling in many ways, but also fascinating.  And one of the fascinating questions has to do with what they’re for.

They can’t be meant as a particularly useful tool for solving deep moral dilemmas: they’re much too blunt for that, often presuppose too much, and tend to bend to suit the law.  To think that because the relevant professional code enjoins x it follows that x is permissible or right smacks of a simple appeal to authority, and this flies in the face of what it is to be a moral agent in the first place.  But what a professional code of ethics may do is to provide a certain kind of Bolamesque legal defence: if your having done φ attracts a claim that it’s negligent or unreasonable or something like that, being able to point out that your professional body endorses φ-ing will help you out.  But professional ethics, and what counts as professional discipline, stretches way beyond that.  For example, instances of workplace bullying can be matters of great professional and ethical import, but it’s not at all obvious that the law should be involved.

There’s a range of reasons why someone’s behaviour might be of professional ethical concern.  Perhaps the most obvious is a concern for public protection. 

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

Human Milk Banking in Guatemala City: All for All

Martha Paynter compares human milk banking practices in Guatemala City and Atlantic Canada.

__________________________________________

Last month, non-profit human milk banking staff and researchers from across the continent met in Dallas for the Human Milk Banking of North America 2017 Symposium to share best practices and new developments. The use of human donor milk is growing and non-profit banks must compete with for-profit enterprises and private milk markets. Human donor milk health and safety standards in North America continue to evolve in response to scientific evidence, epidemiological developments such as Zika, and funding changes including the recent Medicaid coverage for banked milk in New York State. While we adapt processes and goals for milk banking in North America, it is worth examining alternative models of milk bank operations.

In Atlantic Canada, for example, three level-3 Neonatal Intensive Care Units (NICU) provide human donor milk to infants under 1500 grams who are unable to receive sufficient milk from their own mothers. The milk is purchased at approximately $5/ounce, including shipping, from the Northern Star Mothers Milk Bank in Calgary. Northern Star is a private, community-based non-profit business. Milk is collected from healthy volunteer lactating women across Canada who meet donor criteria. Donors may take some medications, but not pharmaceuticals or herbs to promote lactation. Donors ship the frozen milk by courier to Northern Star, where it is pasteurized and distributed to NICUs, inpatients and outpatients across the country according to need and availability. Since opening in 2012, Northern Star has distributed over 500,000 ounces of milk.

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

Canada’s Biggest Health Problem: Indigenous Health

Alison Reiheld calls attention to André Picard’s assertion that Indigenous health is currently the most urgent issue in Canada.

__________________________________________

In a recent interview in Chatelaine with André Picard, a well-known Canadian health columnist for the Globe and Mail, Picard discusses the deficits and merits of Canada’s healthcare system. For anyone working on Canadian healthcare or on health policy anywhere, it is worth reading. He discusses dental care, home care, long-term care, the effect of an aging population, and more. One of his takeaway quotes no doubt is “Nearly 40 countries in the world have universal healthcare, and it’s all more universal than ours.” But something interesting, important, and under-attended is raised when the interviewer asks Picard, “What is the most urgent issue in Canada right now?” Picard’s answer:

Indigenous health. It’s been a problem for more than 100 years. There’s a real opportunity to make a dramatic difference, quickly. The indigenous community is young and the fastest growing by far – more than 50 percent of indigenous people in Canada are under the age of 15. This is the time to stop generation after generation of disaster, poverty, isolation, addiction and suicide – we’ve created all that. We have an apartheid system designed to oppress people and it’s given the exact results it was designed to produce. Take away their culture, their language, their ability to earn money, their ability to have land, and then, oh, we’re surprised they’re the most unhealthy people in our country? It’s not a surprise at all.

Island Lake, First Nations Community

The problems are many for Canada’s indigenous people (Aboriginals, including First Nations, Métis, and Inuit).

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

Unwanted Treatment Case Going to Trial – Alicea v. Augusta Doctors Hospital

Bucilla Stephenson

I recently published a summary of new lawsuits against healthcare providers who administered end-of-life treatment contrary to patient wishes.  


This 2017 article updated my 2013 comprehensive legal review of unwanted end-of-life treatment.  Some of these cases were profiled last month in the New York Times. One is now heading to a jury trial on June 12. 


The case, Alicea v. Augusta Doctors Hospital, already reached the Supreme Court of Georgia, last year, on a question of immunity.  The court issued a strong decision on the duty to honor advance directives.  “A clear objective of the Act is to ensure that . . . it is the will of the patient or her designated agent, and not the will of the health care provider, that controls.”


Bucilla Stephenson did it right.  She completed an advance directive with clear and specific instructions.  And she appointed a faithful and diligent agent.  But all this was not enough.


Contrary to her wishes, the attending physician had Bucilla intubated and put on a ventilator.  The nurses urged the physician to call the agent.  But the physician refused.


The plaintiff is seeking the $200,000 in medical expenses charged after the March 7, 2012, intubation, punitive damages, and attorneys’ fees.

Bucilla Stephenson

I recently published a summary of new lawsuits against healthcare providers who administered end-of-life treatment contrary to patient wishes.  


This 2017 article updated my 2013 comprehensive legal review of unwanted end-of-life treatment.  Some of these cases were profiled last month in the New York Times. One is now heading to a jury trial on June 12. 

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

Hastings Center – “The Last Stage of Life”

The Hastings Center has started a new project – 
 “The Last Stage of Life.”


People are living longer, but with more years of chronic illness and frailty. Many lack the financial, community, or health care resources they need to secure their own well-being, and often die in isolation or with family caregivers who themselves have become ill from the stress of their caregiving burdens. 


With support from the Robert Wilson Charitable Trust and with additional funds from Hastings’s endowment, the Hastings Center has begun a two-year planning process to determine how best the field of bioethics can meet the new and complex needs of our aging society and of aging people and their caregivers.  


As a first step, the Center recently brought together a wide variety of experts from numerous disciplines and societal sectors – including health policy experts, demographers, architects, philosophers, gerontologists, physicians, nurses, urban planners, and grant makers concerned with aging and end-of-life care. The meeting focused on defining a social ethics approach to this challenge and began identifying the values that should guide structures and policies to promote good and prevent harms and injustices to aging people and their caregivers. Among the questions explored were:

  • What is the epidemiology of population aging in the United States?
  • How well do our current structures and policies respond to age-related illness and frailty?
  • What is human flourishing in the face of frailty?
  • How can we understand and articulate what makes for a good life for people living with age-related illness and frailty, especially those with limited resources?

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

Hastings Center – “The Last Stage of Life”

The Hastings Center has started a new project – 
 “The Last Stage of Life.”


People are living longer, but with more years of chronic illness and frailty. Many lack the financial, community, or health care resources they need to secure their own well-being, and often die in isolation or with family caregivers who themselves have become ill from the stress of their caregiving burdens. 


With support from the Robert Wilson Charitable Trust and with additional funds from Hastings’s endowment, the Hastings Center has begun a two-year planning process to determine how best the field of bioethics can meet the new and complex needs of our aging society and of aging people and their caregivers.  


As a first step, the Center recently brought together a wide variety of experts from numerous disciplines and societal sectors – including health policy experts, demographers, architects, philosophers, gerontologists, physicians, nurses, urban planners, and grant makers concerned with aging and end-of-life care. The meeting focused on defining a social ethics approach to this challenge and began identifying the values that should guide structures and policies to promote good and prevent harms and injustices to aging people and their caregivers. Among the questions explored were:

  • What is the epidemiology of population aging in the United States?
  • How well do our current structures and policies respond to age-related illness and frailty?
  • What is human flourishing in the face of frailty?
  • How can we understand and articulate what makes for a good life for people living with age-related illness and frailty, especially those with limited resources?

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.