Ethical and legal obligation to avoid long-term tunneled catheter access.

Despite recent national initiatives promoting the arteriovenous fistula as the initial, primary, and sole vascular access to be used by hemodialysis patients and recommending a decrease in the prevalence of tunneled cuffed catheters to less than 10%, the prevalence of tunneled cuffed catheters as hemodialysis access is increasing. This study describes the risks of tunneled cuffed catheters, explores the reasons why they remain prevalent, and presents the stance that nephrologists have an obligation to offer tunneled cuffed catheters only for temporary use and not as an acceptable alternative for long-term vascular access to patients for whom a properly functioning arteriovenous fistula or graft is possible. Recommendations for tunneled cuffed catheter use were based on dialysis clinical practice guidelines and the medical evidence regarding outcomes of use of arteriovenous fistulas and tunneled cuffed catheters. The authors found that compared with dialysis with arteriovenous fistulas, long-term dialysis with tunneled cuffed catheters is associated with (1) two to threefold increased risk of death, (2) a five to 10-fold increased risk of serious infection, (3) increased hospitalization, (4) a decreased likelihood of adequate dialysis, and (5) an increased number of vascular access procedures. To adequately inform patients about access options, nephrologists are ethically obligated to systematically explain to patients the harms of tunneled cuffed catheters. If catheters must be used to initiate dialysis, nephrologists should present catheters only as "temporary" measures and "unsafe for long-term use."

Whodunit? Ghost surgery and ethical billing.

A senior vascular surgery resident started an autogenous radical-cephalic arteriovenous fistula procedure on a comatose patient in the surgical intensive care unit (SICU), expecting you to arrive momentarily. You were nevertheless unexpectedly detained establishing hemostasis in the main operating suite. You arrived in the SICU as the dressing was being applied. Fistula flows were excellent and there were no operative complications. The resident who began and finally completed the case was highly skilled and in the final month of his vascular training; you had supervised his satisfactory performance of many procedures like this one during the last 2 years. The patient's elderly wife had consented to the procedure, which she was told you would be directly supervising while the resident performed the surgery. When the operation was over you met with her to explain your emergency conflict and assure her that you checked the resident's work and found it entirely satisfactory. She accepted your explanation and was relieved that the operation went well. The patient's multiple comorbidities nevertheless necessitated an extended postoperative stay in the SICU, where you personally cared for him. The resident had dictated routinely that you attended the procedure, and your billing clerk had no reason to doubt the operative report's accuracy when she submitted your surgical fees to Medicare and the patient's private insurer, which paid to their contractual limits without challenge. On many occasions you have had your billings shorted by both. The resident since has graduated. What should you do?