Is failure to awaken and wean malpractice?

BACKGROUND: Respiratory failure is among the most common primary causes of or complications of critical illness, and although mechanical ventilation can be lifesaving, it also engenders substantial risk of morbidity and mortality to patients. Three decades of research suggests that the duration of invasive mechanical ventilation can be reduced substantially, reducing morbidity and mortality. Mean duration of ventilation reported in recent international studies suggests a quality chasm in management of this common critical illness. METHODS: This is a selective review of the literature and synthesis with precepts of medical professionalism and ethics. CONCLUSIONS: To the extent that daily wake-up-and-breathe reduces morbidity, mortality, and length of stay, failure to deploy this strategy is, by definition, malpractice (ie, poor practice). Practical measures are offered to close this quality chasm.

An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

On Medicaid and the Affordable Care Act in Connecticut: the problem with subspecialty services.

BACKGROUND: Medicaid is the federal program, administered by states, for health care for the poor. The Affordable Care Act (ACA) has added a large number of new recipients to this program. HYPOTHESIS: Medicaid programs in some, if not many, states do not provide patients uniform access to subspecialty care guaranteed by the federal statutes. Insofar as the ACA does not address this pre-existing "sub-specialty gap" and more patients are now covered by Medicaid under the ACA, the gap is likely to increase and may contribute to disparities of health care access and outcomes. METHODS: A brief description of previous studies demonstrating or suggesting a subspecialty gap in Medicaid services is accompanied by perspectives of the authors, using published literature - most notably the Denver, Colorado health care system - to propose various solutions that may be deployed to address gaps in subspecialty coverage. RESULTS: All published studies describing the Medicaid subspecialty gap are qualitative, survey designs. There are no authoritative objective data regarding the exact prevalence of gaps for each subspecialty in each state. However, surveys of caregivers suggest that gaps were prevalent in the United States prior to initiation of the ACA. Even fewer papers have addressed solutions (in light of the paucity of data describing the magnitude of the problem), and proposed solutions remain speculative and not grounded in objective data. CONCLUSIONS: There is reason to believe that a substantial proportion of U.S. citizens - those who are guaranteed a full complement of health services through Medicaid - have difficult or no access to some subspecialty services, many of which other citizens take for granted. This problem deserves greater attention to verify its existence, quantify its magnitude, and develop solutions.

The brave new world revealed: wrestling with reality, rationing, and rationality.

When Dr. Joseph Lynch, editor of Seminars in Respiratory and Critical Care Medicine, invited us to organize and edit this topic we-and our contributors-were initially baffled about how we could marry outcomes, ethics, and economics. His perspective as an elder-statesman, who has observed the evolution of critical care medicine over 4 decades, provided perspective as to how these three areas are intimately related and that their synthesis is essential if the US medical system is to best serve our populace as resources become increasingly limited.

Critical care rationing: international comparisons.

Every country has finite resources that are expended to provide citizens with social "goods," including education, protection, infrastructure, and health care. Rationing-of any resource-refers to distribution of an allotted amount and may involve withholding some goods that would benefit some citizens. Health-care rationing is controversial because good health complements so many human endeavors. We explored (perceptions regarding) critical care rationing in seven industrialized countries. Academic physicians from England, Spain, Italy, France, Argentina, Canada, and the United States wrote essays that addressed specific questions including: (1) What historical, cultural, and medical institutional features inform my country's approach to rationing of health care? (2) What is known about formal rationing, especially in critical care, in my country? (3) How does rationing occur in my ICU? Responses suggest that critical care is rationed, by varying mechanisms, in all seven countries. We speculate that while no single "best" method of rationing is likely to be acceptable or optimal for all countries, professional societies could serve international health by developing evidence-based guidelines for just and effective rationing of critical care.

Medicaid patients' access to subspecialty care in Connecticut: teaching clinics questionnaire.

OBJECTIVE: To determine whether Medicaid patients have ready access to subspecialty care. METHODS: A survey was administered to training program directors and federal clinic chiefs to ascertain, for each medical and surgical subspecialty, whether their patients had access to care "never, rarely, sometimes, usually, or always." RESULTS: Seventeen respondents indicated that, on average, subspecialty care in Connecticut was available "never, rarely or sometimes," 36% of the time. Results of a smaller national sample, mirrored Connecticut responses. CONCLUSION: Despite government mandates, Medicaid patients have insufficient access to subspecialty care.

Sustaining Medicare's promise.

Medicare is projected to face shortfalls by 2024. Structural changes of the program have been discussed, but current healthcare reform proposals have not included modifications that are certain to reduce expenditures. One idea that is gaining political traction is to advance the age of beneficiaries to match that of Social Security (ie, 67). This article reviews the rationale and savings associated with this proposal.

Patients' predilections regarding informed consent for hospital treatments.

BACKGROUND: Respect for patient autonomy is a core principle of American medicine. Informed consent is required for surgical procedures and blood transfusions but not for most medical treatments of hospitalized patients. HYPOTHESIS: If given the option, patients want to give permission for common medical therapies during hospitalization. SUBJECTS: Participants in the study were patients admitted to the medical service of a 350-bed community teaching hospital. METHODS: A questionnaire comprising 4 scenarios of varying risk/benefit ratios was administered to all patients who agreed to participate. RESULTS: A total of 634 patients were admitted to the medicine service between June and August 2006. Two hundred and ten patients (103 men, 107 women), with a mean age (+/- SE) of 63.3 +/- 1.1 years, agreed to answer the questionnaire. Of these patients, 85% wished to participate in even trivial medical decision making (ie, potassium supplementation), 92% wished to participate in treatments with moderate risk (ie, diuretic for congestive heart failure). When a risk was initially posed as less than a 5% risk of brain hemorrhage and benefits of therapy were substantially higher (eg, thrombolysis for pulmonary embolus), 93% wanted to make the decision. If the risk of brain hemorrhage was 20% or greater, 95% wanted to make the decision. Younger patients (<65 years) were more likely to prefer requiring doctors to obtain their "permission no matter what" than were older patients (>or=65 years), and older patients were more likely to waive consent across levels of risk. CONCLUSIONS: Most acutely ill hospitalized medicine patients wished to participate in even the most mundane aspects of their medical decision making. Although it is not logistically feasible to obtain informed consent for every treatment of every hospitalized patient, clinicians should be aware of patients' predilections and might consider offering opportunities for patients to participate in clinical decision making, especially for therapies that carry substantial risk.