Hospital Policies During COVID-19: An Analysis of Visitor Restrictions.

OBJECTIVE: In response to the COVID-19 pandemic, hospitals have developed visitor restriction policies in order to mitigate spread of infection. We reviewed hospital visitor restriction policies for consistency and to develop recommendations to highlight fair and transparent restrictions, exceptions, and appeals in policy development and implementation. DESIGN: Collection and analysis of public-facing visitor restriction policies during the first 3 months of the pandemic. SETTING: General acute care hospitals representing 23 states across all 4 major regions of the United States. PARTICIPANTS: A cohort of the 70 largest hospitals by total bed capacity. MEASUREMENTS: Characteristics of visitor restriction policies including general visitor restriction statement, changes/updates to policies over time, exceptions to policies, and restrictions specific to COVID-19-positive patients. RESULTS: Sixty-five of the 70 hospitals reviewed had public-facing visitor restriction policies. Forty-nine of these 65 policies had general "no-visitor" statements, whereas 16 allowed at least 1 visitor to accompany all patients. Sixty-three of 65 hospitals included exceptions to their visitor restriction policies. Setting-specific exceptions included pediatrics, obstetrics/gynecology, emergency department, behavioral health, inpatient rehabilitation, surgery, and outpatient clinics. Exceptions that applied across settings included patients at end of life and patients with disabilities. CONCLUSION: Visitor restriction policies varied significantly among hospitals in this review. These variances create challenges in that their fair application may be problematic and ethical issues related to allocation may arise. Five recommendations are offered for hospitals revising or creating such policies, including that offering transparent, accessible, public-facing policies can minimize ethical dilemmas. In addition, hospitals would benefit from communicating with each other in the development of visitor policies to ensure uniformity and support patients and family members as they navigate hospital visitation.

"I still feel so lost": experiences of women receiving SANE care during the year after sexual assault.

OBJECTIVE: Emergency caregivers provide initial care to women sexual assault (SA) survivors. An improved understanding of the issues facing this population can aide emergency care practitioners in providing high quality care. The goal of this study was to share the experiences of women SA survivors with the emergency care practitioners that care for them. METHODS: English-speaking adult women (n = 706) who received SA Nurse Examiner (SANE) evaluation within 72 hours of SA at 1 of 13 geographically distributed sites were enrolled in a prospective, longitudinal multi-site observational study. We qualitatively analyzed responses to the open-ended question: "What do you think is most important for researchers to understand about your experience since the assault?" asked 1 week, 6 weeks, 6 months, and 1 year after enrollment. RESULTS: Themes from responses (n = 1434) from 590 women (84% of study sample) fell into 12 broad categories: daily life, justice, medical, and social services, mental health, physical health, prior trauma, recovery, romantic relationships, safety, self, shame, and social interactions. Responses demonstrated that the assault permeates many aspects of assault survivors' daily lives. CONCLUSIONS: Qualitative analyses of open-ended responses from a large cohort of women SA survivors receiving SANE care highlight the challenges for survivors and can increase understanding among the emergency care practitioners who care for them. The authors propose a brief acronym to help emergency care practitioners recall important messages for SA survivors.

Clinical discussion of Medical Aid-in-Dying: minimizing harms and ensuring informed choice.

OBJECTIVE: The implementation of medical aid-in-dying (MAID) poses new challenges for clinical communication and counseling. Among these, health care providers must consider whether to initiate a discussion of MAID with eligible patients who do not directly ask about it. Norms and policies concerning this issue vary tremendously across jurisdictions where MAID is legally authorized, reflecting divergent assumptions about patients' rights to information about end-of-life options and the purpose and potential harms of clinical disclosure. METHOD: This discussion forum essay draws on informed consent doctrine to analyze two policies concerning clinical communication about MAID: the legal prohibition against provider-initiated discussions of MAID in Victoria, Australia, and the Canadian Association of MAID Assessors and Providers (CAMAP) position that providers have an ethical and professional responsibility to inform eligible patients about MAID. CONCLUSIONS: Informed consent requires that clinicians strike a balance between minimizing potential harms to patients caused by initiating discussions of MAID and the imperative to inform and counsel patients about all of their legally available medical options. PRACTICE IMPLICATIONS: Clinicians should be aware of both the importance of communication as a tool to inform patients and the potential for clinical language to cause harm to or to unduly influence patients.

Reconsidering scarce drug rationing: implications for clinical research.

Hospital systems commonly face the challenge of determining just ways to allocate scarce drugs during national shortages. There is no standardised approach of how this should be instituted, but principles of distributive justice are commonly used so that patients who are most likely to benefit from the drug receive it. As a result, clinical indications, in which the evidence for the drug is assumed to be established, are often prioritised over research use. In this manuscript, we present a case of a phase II investigational trial of intravenous thiamine for delirium prevention in patients undergoing haematopoietic stem cell transplantation to emphasise several shortcomings in the overarching prioritisation of clinical over research uses of scarce drugs. Specifically, we present the following considerations: (1) clinical use may not have stronger evidence than research use; (2) a strong scientific rationale for research use may outweigh the claim for clinical indications in which there is weak evidence; (3) treatment within the context of a clinical trial may be the standard of care; and (4) research use may not only benefit patients receiving the treatment but also offers the prospect of improving future clinical care. In summary, we argue against allocation schemes that prohibit all research uses of scarce drugs and instead recommend that allocation schemes include a balanced approach that weighs risks and benefits of access to scarce drugs irrespective of the research versus clinical use designation.

Clinicians' Perspectives on the Duty to Inform Patients About Medical Aid-in-Dying.

Background: As of 2019, ten jurisdictions in the United States have authorized physicians to prescribe a lethal dose of medication to a terminally ill patient for the purpose of hastening death. Relatively little bioethics scholarship has addressed the question of whether physicians have an obligation to inform qualifying patients about aid-in-dying (AID) in permissive jurisdictions and little is known about providers' actual communication practices with respect to this issue. Methods: One hundred and forty-four in-depth, semi-structured interviews were conducted and analyzed using an inductive analytic approach as part of the Vermont Study on Aid-in-Dying. Results: Seventeen respondents, 14 physicians and 3 nurse practitioners, met the inclusion criteria for this sub-study. Eleven respondents indicated that they at least sometimes inform patients about AID. Respondents described multiple factors that influence whether or not they might initiate discussions of AID, including the importance of informing patients of their options for end-of-life care, worries about undue influence, and worries about the potential effects on the patient-provider relationship. For those providers who do initiate discussion of AID at least some of the time, attention to the particulars of each individual patient's situation and the context of the discussion appear to play a role in shaping communication about AID. Conclusions: While initiating a clinical discussion of AID is undoubtedly challenging, our study provides compelling descriptive evidence that some medical providers who support AID do not unilaterally follow the conventional bioethics wisdom holding that they ought to wait for patients to introduce the topic of AID. Future research should investigate how to approach these discussions so as to minimize ethical worries about undue influence or potential negative consequences.

Responding to Requests for Aid-in-Dying: Rethinking the Role of Conscience.

This case study illustrates the complex role that a physician's conscience can play in end-of-life care. We examine a case from Vermont in which a terminally ill patient requests aid-in-dying from her primary care physician under the state's "Patient Choice and Control at End of Life" Act (Act 39). The physician feels conflicted: she is opposed to prescribing death-hastening medication but does not want to abandon her patient. Much of the medical ethics literature on conscience focuses on whether health care professionals should be permitted to abstain from providing morally contested medical services. Our analysis highlights the interplay of conflicting values that inform the physician's engagement with aid-in-dying, demonstrating that the issue is often more nuanced than the question of whether or not a physician can (or should) opt out.

Health Care Providers' Experiences with Implementing Medical Aid-in-Dying in Vermont: a Qualitative Study.

BACKGROUND: The evolving legal landscape for medical aid-in-dying (AID) in the USA raises clinical and public health challenges and concerns regarding how health care providers will accommodate AID while expanding access to high-quality end-of-life care. OBJECTIVE: To describe Vermont health care providers' experiences practicing under the "Patient Choice and Control at End of Life" Act. DESIGN: Qualitative semi-structured interviews analyzed using grounded theory. PARTICIPANTS: The larger study included 144 health care providers, terminally ill patients, caregivers, policy stakeholders, and other Vermont residents working in 10 out of Vermont's 14 counties. This article reports on a subset of 37 providers who had clinical experience with the law. MAIN MEASURES: Themes from interviews. KEY RESULTS: Physicians were roughly split between hospital and community-based practices. Most were women (68%) and the largest subgroup specialized in internal or family medicine (53%). Most of the nurses and social workers were women (89%) and most worked for hospice and home health agencies (61%). We identified five domains in which participants engaged with AID: (1) clinical communication and counseling; (2) the Act 39 protocol; (3) prescribing medication; (4) planning for death; and (5) professional education. How providers experienced these five domains of clinical practice depended on their practice setting and the supportive resources available. CONCLUSION: Health care providers' participation in AID involves clinical tasks outside of responding to patients' requests and writing prescriptions. Research to identify best practices should focus on all domains of clinical practice in order to best prepare providers.

Caregivers' Experiences With Medical Aid-In-Dying in Vermont: A Qualitative Study.

CONTEXT: Eight jurisdictions in the U.S. currently permit medical aid-in-dying (AID), yet little is known about the direct experience of caregivers in supporting a loved one through the process. OBJECTIVES: To explore the experiences of lay caregivers involved with AID in the U.S., focusing on the day of death. METHODS: Semistructured in-depth interviews were conducted with caregivers of terminally ill patients who pursued AID under Vermont's 2013 "Patient Choice and Control at End of Life" Act. Deidentified interview transcripts were analyzed using an inductive iterative approach. RESULTS: The final sample included 19 caregivers who had cared for a total of 11 patients. Most caregivers were females (89%), and more than half were close friends. Their mean age was 60.3. Social support provided by caregivers on the day of an AID death fell into two broad categories: emotional and instrumental. These overarching forms of support were further distributed between four distinct temporal phases: preparation, ingestion, waiting, and after death. CONCLUSION: Although AID is often presented as a simple matter of individual choice and autonomy, most patients who pursue it do so with tremendous support from caregivers, who are in turn deeply implicated, socially and morally, in the process. Including caregivers in education and planning, where warranted, can mitigate feelings of unpreparedness and ensure a smoother experience for everyone involved.

Duplication and concerted evolution of MiSp-encoding genes underlie the material properties of minor ampullate silks of cobweb weaving spiders.

BACKGROUND: Orb-web weaving spiders and their relatives use multiple types of task-specific silks. The majority of spider silk studies have focused on the ultra-tough dragline silk synthesized in major ampullate glands, but other silk types have impressive material properties. For instance, minor ampullate silks of orb-web weaving spiders are as tough as draglines, due to their higher extensibility despite lower strength. Differences in material properties between silk types result from differences in their component proteins, particularly members of the spidroin (spider fibroin) gene family. However, the extent to which variation in material properties within a single silk type can be explained by variation in spidroin sequences is unknown. Here, we compare the minor ampullate spidroins (MiSp) of orb-weavers and cobweb weavers. Orb-web weavers use minor ampullate silk to form the auxiliary spiral of the orb-web while cobweb weavers use it to wrap prey, suggesting that selection pressures on minor ampullate spidroins (MiSp) may differ between the two groups. RESULTS: We report complete or nearly complete MiSp sequences from five cobweb weaving spider species and measure material properties of minor ampullate silks in a subset of these species. We also compare MiSp sequences and silk properties of our cobweb weavers to published data for orb-web weavers. We demonstrate that all our cobweb weavers possess multiple MiSp loci and that one locus is more highly expressed in at least two species. We also find that the proportion of ß-spiral-forming amino acid motifs in MiSp positively correlates with minor ampullate silk extensibility across orb-web and cobweb weavers. CONCLUSIONS: MiSp sequences vary dramatically within and among spider species, and have likely been subject to multiple rounds of gene duplication and concerted evolution, which have contributed to the diverse material properties of minor ampullate silks. Our sequences also provide templates for recombinant silk proteins with tailored properties.