Refusal of Emergency Medical Treatment: Case Studies and Ethical Foundations.

Informed consent is an important component of emergency medical treatment. Most emergency department patients can provide informed consent for treatment upon arrival. Informed consent should also be obtained for emergency medical interventions that may entail significant risk. A related concept to informed consent is informed refusal of treatment. Patients may refuse emergency medical treatment during their evaluation and treatment. This article addresses important considerations for patients who refuse treatment, including case studies and discussion of definitions, epidemiology, assessment of decisional capacity, information delivery, medicolegal considerations, and alternative care plans.

How Hospital Leaders and Risk Managers Can Nurture Ethics-Driven Lawyering.

How hospital lawyers assess legal risk in clinically and ethically complex cases can shape risk management operations, influence clinicians' morale, and affect the care patients receive. This article suggests that many disagreements, particularly those involving key ethical and legal questions arising from a patient's care, should launch a process that might include family meetings, early palliative care integration, and ethics consultation or committee review of clinical teams' and surrogates' reasons and perspectives. This article also explains why exploration of these perspectives can motivate fuller understanding of the sources of clinical and ethical disagreements and inform the approach to legal advice that hospital executives and risk managers should foster.

Physician-assisted Death: Ethical Implications for Emergency Physicians.

Physician-assisted death (PAD) has long been a strongly debated moral and public policy issue in the United States, and an increasing number of jurisdictions have legalized this practice under certain circumstances. In light of changing terminology, laws, public and professional attitudes, and the availability of published data about the practice, we review key concepts and terms in the ongoing PAD debate, moral arguments for and against PAD, the current legal status of PAD in the United States and in other nations, and data on the reported experience with PAD in those U.S. jurisdictions where it is a legal practice. We then identify situations in which emergency physicians (EPs) may encounter patients who request PAD or have attempted to end their lives with physician assistance and consider EP responses in those situations. Based on our analysis, we offer recommendations for emergency medical practice and professional association policy.

Higher Priced Older Pharmaceuticals: How Should We Respond?

We and our patients have been aware of the high cost of medications in the United States for decades; however, we are now witnessing a relatively new phenomenon: exponential price increases for some older pharmaceuticals that have been available for years. To assist practitioners in how to respond to the issue of higher priced pharmaceuticals, an interprofessional session was developed and held at CHEST 2016 in Los Angeles. The session proceedings and a few updates are presented here to summarize what pulmonologists; a sarcoidosis expert; a retired executive of a medical society, an executive of a pharmaceutical company and of a pharmacy; and an ethicist advise that we do about the problem. Because the comments presented at the session and in this manuscript represent the opinions of each author, this commentary in essence is a compilation of nine editorials. It does not represent a comprehensive discussion of the field of pricing of drugs. In reflecting upon the answers to the questions posed, and regardless of their sector of health care, all participants stated that they focused on the patient. However, actually providing patient-focused care (ie, the care defined from the patient's perspective) is another matter. To significantly improve patient satisfaction and health-care outcomes, patient-focused care needs to embody the 3 Cs of (1) communication, (2) continuity of care, and (3) concordance of expectations (ie, finding the common ground). Therefore, we discuss how the 3 Cs apply to responses to higher priced pharmaceuticals.

Pediatric genitourinary emergencies.

Pediatric medical complaints and differential diagnoses often vary from adults, requiring a specialized knowledge base and behavioral skill set. This article addresses a variety of congenital and acquired pediatric genitourinary disorders. Genitourinary emergencies include paraphismosis, priapism, serious infection, significant traumatic injury and gonadal torsion.

A double-blind randomized clinical trial evaluating the analgesic efficacy of ketorolac versus butorphanol for patients with suspected biliary colic in the emergency department.

OBJECTIVES: Patients presenting to the emergency department (ED) with suspected biliary colic often require intravenous (IV) analgesia. The choice of IV analgesia typically includes opioids and ketorolac. Although ultrasound (US) is the initial diagnostic study in these patients, nondiagnostic scans and a high clinical suspicion may require the patient to undergo hepatobiliary scintigraphy (HIDA). Opioids such as morphine interfere with the HIDA scan and thus may limit its value as an analgesic in the ED for these patients. Analgesics that do not interfere with HIDA scanning include ketorolac and butorphanol, an opioid agonist-antagonist. This study evaluates the efficacy of IV ketorolac compared to butorphanol for the treatment of biliary colic pain in the ED. METHODS: Between June 2005 and February 2007, a convenience sample of patients presenting to the ED with abdominal pain suspected to be biliary colic were randomized to receive either 30 mg of IV ketorolac or 1 mg of IV butorphanol. Pain level was assessed using a 1 to 10 "faces" visual analog pain scale initially, as well as 15 and 30 minutes after medication infusion. Side effect profiles and the need for rescue analgesia were also assessed. Patients and clinicians were blinded to the study drug given. RESULTS: Forty-six patients were enrolled in the study. Both groups had similar demographics and baseline pain scores. The mean (+/-standard deviation [SD]) pain score in the butorphanol group decreased from 7.1 (+/-1.7) to 2.1 (+/-2.2) after 30 minutes. The mean (+/-SD) pain score in the ketorolac group decreased from 7.4 (+/-2.0) to 3.1 (+/-3.3) after 30 minutes. Both groups had similar needs for rescue analgesia. Side effects included dizziness and sedation with butorphanol and nausea with ketorolac. CONCLUSIONS: Although limited by small sample size and convenience sample, this study demonstrates that both ketorolac and butorphanol provide pain relief in biliary colic. Both agents should be considered reasonable options in the ED treatment of biliary colic, especially in patients that may undergo HIDA.