Ethical dilemmas in anesthesia mission trips.

PURPOSE OF REVIEW: Health inequities continue to exist globally especially when it comes to surgical and anesthesia services. Due to the lack of physician anesthesiologists in low- and middle-income countries, there has been an increase in the number of medical mission trips. Although these volunteers are attempting to fulfill a need they must be mindful and remember to adhere to ethical principles as they work collaboratively with host institutions. We will review the ethical dilemmas inherent in anesthesia mission trips. RECENT FINDINGS: Physician volunteers for medical missions may cause significant harm to patients and host communities if they do not work in tandem with host institutions. SUMMARY: Medical missions fulfill acute medical needs and have the opportunity to make a positive contribution to host communities by fulfilling local needs and supporting educational efforts for local providers.

"It's Case by Case, and It's a Struggle": A Qualitative Study of Hospice Practices, Perspectives, and Ethical Dilemmas When Caring for Hospice Enrollees with Full-Code Status or Intensive Treatment Preferences.

Objective: Characterize hospice staff practices and perspectives on discussing end-of-life care preferences with patients/families, including those desiring intensive treatment and/or full code. Background: Patients in the United States can elect hospice while remaining full code or seeking intensive interventions, for example, blood transfusions, or chemotherapy. These preferences conflict with professional norms, hospice philosophy, and Medicare hospice payment policies. Little is known about how hospice staff manage patient/family preferences for full-code status and intensive treatments. Methods: We recruited employees of four nonprofit US hospices with varying clinical and hospice experience for semi-structured, in-depth interviews. Open-ended questions explored participants' practices and perceptions of discussing end-of-life care preferences in hospice, with specific probes about intensive treatment or remaining full code. Interdisciplinary researchers coded and analyzed data using the constant comparative method. Results: Participants included 25% executive leaders, 14% quality improvement administrative staff, 61% clinicians (23 nurses, 21 social workers, 7 physicians, and 2 chaplains). Participants reported challenges in engaging patients/families about end-of-life care preferences. Preferences for intensive treatment or full-code status presented an ethical dilemma for some participants. Participants described strategies to navigate such preferences, including educating about treatment options, and expressed diverse reactions, including accepting or attempting to shift enrollee preferences. Discussion: This study illuminates a rarely studied aspect of hospice care: how hospice staff engage with enrollees choosing full code and/or intensive treatments. Such patient preferences can produce ethical dilemmas for hospice staff. Enhanced communication training and guidelines, updated organizational and federal policies, and ethics consult services may mitigate these dilemmas.

The Safety Assessment Measure for persons with traumatic brain injury: Item pool development and content validity.

BACKGROUND: Persons with moderate to severe TBI are at increased risk for unintentional injury or harm in the home and community; however, there is currently no standard measure of safety risk they face now and in the future. OBJECTIVE: To develop comprehensive and content valid scales and item pools for assessing safety and risk for persons with moderate to severe traumatic brain injuries. METHOD: Qualitative psychometric methods for developing scales and items were used including literature review, item development and revision, focus groups with interdisciplinary rehabilitation staff (n = 26) for rating content validity, and cognitive interviewing of TBI family members (n = 9) for assuring item clarity. RESULTS: The Safety Assessment Measure is comprised of 6 primary scales - Cognitive Capacity, Visuomotor Capacity, Wheelchair Use, Risk Perception, Self-Regulation, and Compliance Failures with Safety Recommendations - in which family caregivers or clinicians rate the risk for unintentional injury or harm in adults who have sustained moderate or severe TBI. The scale item pools encompass a broad spectrum of everyday activities that pose risk in the home and community and were rated as having excellent levels of content validity. CONCLUSIONS: The Safety Assessment Measure scales and items cover a broad range of instrumental activities of daily living that can increase the risk of unintentional injuries or harm. Empirical evidence suggests that the Safety Assessment Measure items have excellent content validity. Future research should use modern psychometric methods to examine each scale unidimensionality, model fit, and precision.

Reliability and validity of the revised photographic wound assessment tool on digital images taken of various types of chronic wounds.

OBJECTIVE: The objective of this study was to examine the validity and reliability of the revised Photographic Wound Assessment Tool (revPWAT) on digital images taken of various types of chronic, healing wounds. SETTING: This multicenter trial was performed in a variety of settings where chronic wounds are assessed. PARTICIPANTS: A total of 206 different photographs taken of 68 individuals with 95 chronic wounds of various etiologies were reviewed in this study. Wound etiologies included people with venous/arterial leg wounds (n = 13), diabetic foot wounds (n = 18), pressure ulcers (n = 32), and wounds of other etiologies (n = 5). MAIN OUTCOME MEASURES: An initial wound assessment using the revPWAT was performed at the bedside, and 3 digital photographs were taken-2 within 72 hours when no change had occurred, and a third was taken 3.5 to 6 weeks later. MAIN RESULTS: The revPWAT scores derived from photographs assessed by the same rater on different occasions and by different raters showed moderate to excellent intrarater intraclass correlation coefficients (ICCs) (ICC = 0.52-0.93), as well as test-retest (ICC = 0.86-0.90) and interrater (ICC = 0.71) reliability. There was excellent agreement between bedside assessments and assessments using photographs (ICC = 0.89). CONCLUSION: The revPWAT is a valid and reliable tool to assess chronic wounds of various etiologies where digital images are viewed.

Patient perceptions of computed tomographic imaging and their understanding of radiation risk and exposure.

STUDY OBJECTIVE: We describe patient perceptions of computed tomography (CT) and their understanding of radiation exposure and risk. METHODS: This was a cross-sectional study of acute abdominal pain patients aged 18 years or older. Confidence in medical evaluations with increasing levels of laboratory testing and imaging was rated on a 100-point visual analog scale. Knowledge of radiation exposure was ascertained when participants compared the radiation dose of one abdomen-pelvis CT with 2-view chest radiography. To assess cancer risk knowledge, participants rated their agreement with these factual statements: "Approximately 2 to 3 abdominal CTs give the same radiation exposure as experienced by Hiroshima survivors" and "2 to 3 abdominal CTs over a person's lifetime can increase cancer risk." Previous CT was also assessed. RESULTS: There were 1,168 participants, 67% women and mean age 40.7 years (SD 15.9 years). Median confidence in a medical evaluation without ancillary testing was 20 (95% confidence interval [CI] 16 to 25) compared with 90 (95% CI 88 to 91) when laboratory testing and CT were included. More than 70% of participants underestimated the radiation dose of CT relative to chest radiography, and cancer risk comprehension was poor. Median agreement with the Hiroshima statement was 13 (95% CI 10 to 16) and 45 (95% CI 40 to 45) with the increased lifetime cancer risk statement. Seven hundred ninety-five patients reported receiving a previous CT. Of 365 patients who reported no previous CT, 142 (39%) had one documented in our electronic medical record. CONCLUSION: Patients are more confident when CT imaging is part of their medical evaluation but have a poor understanding of the concomitant radiation exposure and risk and underestimate their previous imaging experience.

Spinal cord injury and co-occurring traumatic brain injury: assessment and incidence.

OBJECTIVES: To examine prospectively the incidence and severity of co-occurring traumatic brain injury (TBI) in persons with traumatic spinal cord injury (SCI) and to describe a TBI assessment process for SCI rehabilitation professionals. DESIGN: A prospective, cohort design to collect and analyze clinical variables relevant for diagnosing co-occurring TBI. SETTING: An urban, single-center National Institute of Disability and Rehabilitation Research Model Spinal Cord Injury System in the Southeastern United States. PARTICIPANTS: People (N=198) who met inclusion criteria and provided consent within an 18-month recruitment window. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM cognitive scale. RESULTS: Based on participants' presence and duration of posttraumatic amnesia, initial Glasgow Coma Scale total score, and presence of cerebral lesion documented by neuroimaging, 60% of our traumatic SCI sample also sustained a TBI (n=118). Most co-occurring TBIs were mild (34%). Co-occurring mild complicated (10%), moderate (6%), and severe TBI (10%) were less common but still occurred in a significant percentage (26%) of persons with traumatic SCI. Persons with traumatic SCI who were injured in motor vehicle collisions and falls were more likely to sustain a co-occurring TBI. Cervical level traumatic SCI was associated with greater rates of TBI but not more severe injuries. Tree analyses established a practical algorithm for classifying TBI severity associated with traumatic SCI. Analysis of variance established criterion validity for the algorithm's TBI severity classifications. CONCLUSIONS: Findings from our prospective study provide strong support that TBI is a common co-occurring injury with traumatic SCI. Incomplete acute care medical record documentation of TBI in the traumatic SCI population remains a considerable issue, and there is a significant need to educate emergency department and acute care personnel on the TBI clinical data needs of acute rehabilitation providers. A systematic algorithm for reviewing acute care medical records can yield valid estimates of TBI severity in the traumatic SCI population.