RESUMEN
Expertise in a medical specialty requires countless hours of learning and practice and a combination of neural plasticity and contextual case experience resulting in advanced gestalt clinical reasoning. This holistic thinking assimilates complex segmented information and is advantageous for timely clinical decision-making in the emergency department and paediatric or neonatal intensive care units. However, the same agile reasoning that is essential acutely may be at odds with the slow deliberative thought required for ethical reasoning and weighing the probability of patient morbidity. Recent studies suggest that inadequate ethical decision-making results in increased morbidity for patients and that clinical ethics consultation may reduce the inappropriate use of life-sustaining treatment. Behavioural psychology research suggests there are two systems of thinking - fast and slow - that control our thoughts and therefore our actions. The problem for experienced clinicians is that fast thinking, which is instinctual and reflexive, is particularly vulnerable to experiential biases or assumptions. While it has significant utility for clinical reasoning when timely life and death decisions are crucial, I contend it may simultaneously undermine the deliberative slow thought required for ethical reasoning to determine appropriate therapeutic interventions that reduce future patient morbidity. Whilst health-care providers generally make excellent therapeutic choices leading to good outcomes, a type of substitutive thinking that conflates clinical reasoning and ethical deliberation in acute decision-making may impinge on therapeutic relationships, have adverse effects on patient outcomes and inflict lifelong burdens on some children and their families.
Asunto(s)
Toma de Decisiones Clínicas/ética , Toma de Decisiones Clínicas/métodos , Cuidados Críticos/ética , Inutilidad Médica/ética , Pensamiento , Procedimientos Innecesarios/ética , Enfermedad Aguda , Niño , Cuidados Críticos/psicología , Servicio de Urgencia en Hospital/ética , Humanos , Unidades de Cuidado Intensivo Pediátrico/ética , Inutilidad Médica/psicología , Pediatría/ética , Calidad de Vida , Procedimientos Innecesarios/efectos adversos , Procedimientos Innecesarios/psicologíaRESUMEN
Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal.
Asunto(s)
Cuidados Críticos/ética , Inutilidad Médica/ética , Inutilidad Médica/legislación & jurisprudencia , Trastornos Relacionados con Opioides/terapia , Nivel de Atención/ética , Adulto , Anciano , Toma de Decisiones Clínicas/ética , Cuidados Críticos/clasificación , Enfermedad Crítica , Femenino , Humanos , Masculino , Médicos/ética , Médicos/legislación & jurisprudencia , Cumplimiento y Adherencia al Tratamiento/psicología , Resultado del Tratamiento , Privación de Tratamiento/ética , Privación de Tratamiento/legislación & jurisprudenciaRESUMEN
This article critically examines the legal arguments presented on behalf of Charlie Gard's parents, Connie Yates and Chris Gard, based on a threshold test of significant harm for intervention into the decisions made jointly by holders of parental responsibility. It argues that the legal basis of the argument, from the case of Ashya King, was tenuous. It sought to introduce different categories of cases concerning children's medical treatment when, despite the inevitable factual distinctions between individual cases, the duty of the judge in all cases to determine the best interests of the child is firmly established by the case law. It argues that the focus should not have been on a threshold for intervention but on whether his parents had established that the therapy they wanted was a viable alternative therapeutic option. In the April hearing, Charlie's parents relied on the offer of treatment from a US doctor; by July they had an independent panel of international experts supporting their case although by this time the medical evidence was that it was too late for Charlie. One of Charlie's legacies for future disputes may be that his case highlighted the need for evidence as to whether the treatment parents want for their child is a viable alternative therapeutic option before a court can determine which therapeutic option is in the best interests of the child.
Asunto(s)
Defensa del Niño/ética , Inutilidad Médica/ética , Consentimiento Paterno/ética , Padres/psicología , Terapias en Investigación/ética , Niño , Toma de Decisiones , Disentimientos y Disputas , HumanosAsunto(s)
Anestesiología/ética , Toma de Decisiones/ética , Prestación Integrada de Atención de Salud/ética , Difusión de Innovaciones , Alfabetización en Salud/ética , Inutilidad Médica/ética , Atención Dirigida al Paciente/ética , Atención Perioperativa/ética , Anestesiología/organización & administración , Anestesiología/normas , Prestación Integrada de Atención de Salud/organización & administración , Prestación Integrada de Atención de Salud/normas , Conocimientos, Actitudes y Práctica en Salud , Disparidades en Atención de Salud/ética , Humanos , Modelos Organizacionales , Educación del Paciente como Asunto/ética , Participación del Paciente , Atención Dirigida al Paciente/organización & administración , Atención Dirigida al Paciente/normas , Atención Perioperativa/normasAsunto(s)
Cuidados Críticos/ética , Curación por la Fe , Inutilidad Médica , Religión y Medicina , Privación de Tratamiento , Toma de Decisiones , Humanos , Unidades de Cuidados Intensivos , Inutilidad Médica/ética , Inutilidad Médica/legislación & jurisprudencia , Cuidados Paliativos , Privación de Tratamiento/ética , Privación de Tratamiento/legislación & jurisprudenciaRESUMEN
The occurrence of cachexia at the end of life of patients suffering from cancer is a common seen problem. Within the last years new definitions, diagnostic criteria and classification systems of cachexia have been developed to improve the clinical practice. Still therapeutic interventions are limited; the role of parenteral nutrition (PN) remains controversial. PN cannot be generally recommended in patients with incurable malignancies, not even in ill-nourished patients with inadequate oral or enteral nutrition due to a changed metabolism. Treating a cachectic endstage patient suffering from head-neck-cancer we were faced with different problems.
Asunto(s)
Caquexia/terapia , Carcinoma de Células Escamosas/terapia , Neoplasias Hipofaríngeas/terapia , Cuidados Paliativos/ética , Cuidados Paliativos/métodos , Nutrición Parenteral/ética , Nutrición Parenteral/métodos , Seno Piriforme , Cuidado Terminal/ética , Cuidado Terminal/métodos , Austria , Carcinoma de Células Escamosas/patología , Terapia Combinada/ética , Terapia Combinada/métodos , Progresión de la Enfermedad , Ética Médica , Adhesión a Directriz/ética , Humanos , Neoplasias Hipofaríngeas/patología , Masculino , Inutilidad Médica/ética , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Privación de Tratamiento/éticaRESUMEN
Medical advances over the past 50 years have helped countless patients with advanced cardiac disease or who are critically ill in the intensive care unit (ICU), but have added to the ethical complexity of the care provided by clinicians, particularly at the end of life. Palliative care has the primary aim of improving symptom burden, quality of life, and the congruence of the medical plan with a patient's goals of care. This article explores ethical issues encountered in the cardiac ICU, discusses key analyses of these issues, and addresses how palliative care might assist medical teams in approaching these challenges.
Asunto(s)
Cuidados Críticos/ética , Insuficiencia Cardíaca/terapia , Cuidados Paliativos/ética , Planificación Anticipada de Atención/ética , Comunicación , Unidades de Cuidados Coronarios/ética , Unidades de Cuidados Coronarios/organización & administración , Ética Médica , Corazón Auxiliar/ética , Humanos , Hipnóticos y Sedantes/uso terapéutico , Inutilidad Médica/ética , Marcapaso Artificial/ética , Cuidados Paliativos/organización & administración , Participación del Paciente/métodos , Relaciones Profesional-Familia , Negativa al Tratamiento , Respiración Artificial/ética , Apoyo Social , Espiritualidad , Enfermo TerminalRESUMEN
PURPOSE: There is limited empirical research exploring the nature of clinical ethical consultations within the oncology population. Our objective was to review and describe clinical ethics consultations at two National Cancer Institute-designated comprehensive cancer centers to identify opportunities for systems improvement in clinical care and opportunities for staff education. METHODS: This case series is derived from two institutional prospectively maintained clinical ethics consultation databases. All ethics consultations from 2007 through 2011 that related to adult patients with cancer were included. RESULTS: A total of 208 eligible patient cases were identified. The most common primary issues leading to ethics consultation were code status and advance directives (25%), surrogate decision making (17%), and medical futility (13%). Communication lapses were identified in 45% of patient cases, and interpersonal conflict arose in 51%. Before ethics consultation, 26% of patients had do-not-resuscitate orders, which increased to 60% after ethics consultation. Palliative care consultation occurred in 41% of patient cases. CONCLUSION: Ethics consultations among patients with cancer reflect the complexities inherent to their clinical management. Appropriately honoring patients' wishes within the context of overall goals of care is crucial. Thoughtful consideration of the role of and relationship with palliative care experts, communication barriers, sources of interpersonal conflict, symptom control, and end-of-life care is paramount to optimal management strategies in this patient population.
Asunto(s)
Consultoría Ética , Neoplasias/terapia , Cuidado Terminal/ética , Adolescente , Adulto , Directivas Anticipadas/ética , Anciano , Anciano de 80 o más Años , Instituciones Oncológicas , Toma de Decisiones/ética , Femenino , Humanos , Masculino , Inutilidad Médica/ética , Persona de Mediana Edad , Adulto JovenAsunto(s)
Ética Médica , Programas Nacionales de Salud , Personeidad , Política , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Actitud Frente a la Muerte , Cuidados Críticos/ética , Alemania , Salud Holística/ética , Humanos , Consentimiento Informado/ética , Voluntad en Vida/ética , Inutilidad Médica/ética , Persona de Mediana Edad , Menores , Naturopatía/ética , Trasplante de Órganos/ética , Participación del Paciente , Autonomía Personal , Relaciones Médico-Paciente/ética , Relaciones Profesional-Familia/ética , Religión y Medicina , Obtención de Tejidos y Órganos/ética , Adulto JovenRESUMEN
The integration of medical humanities into future patient care and medical research will become as importance for trust, care and health as the natural sciences were during the last 100 years. In particular, improvements of lay health literacy and responsibility, new forms of physician-nurse partnership and expert-lay interaction, also revisions of clinical research towards models of informed contract will improve trust and health on a global scale, allow for healthier and happier citizens and populations and eventually might reduce health care costs.
Asunto(s)
Ética Médica , Ética en Investigación , Conducta Cooperativa , Control de Costos/ética , Control de Costos/legislación & jurisprudencia , Consultoría Ética/ética , Consultoría Ética/legislación & jurisprudencia , Alemania , Asignación de Recursos para la Atención de Salud/ética , Asignación de Recursos para la Atención de Salud/legislación & jurisprudencia , Humanos , Comunicación Interdisciplinaria , Cuidados para Prolongación de la Vida/ética , Cuidados para Prolongación de la Vida/legislación & jurisprudencia , Inutilidad Médica/ética , Inutilidad Médica/legislación & jurisprudencia , Programas Nacionales de Salud/ética , Programas Nacionales de Salud/legislación & jurisprudencia , Defensa del Paciente/ética , Defensa del Paciente/legislación & jurisprudencia , Relaciones Médico-Paciente/éticaRESUMEN
Medical futility is a concept commonly used to describe medical therapy that has no known or anticipated immediate or long-term benefit for a patient. The concept of futility has existed since the time of Hippocrates and has become the predominant dilemma for many end-of-life situations. Today, clinicians grapple with ethical conflicts and concepts in their daily practice. Many healthcare providers use the concept of medical futility when they are talking with patients and families who are in a quandary about their loved one's care. This article provides an overview of medical futility.
Asunto(s)
Cuidados Críticos , Inutilidad Médica , Privación de Tratamiento , Arizona , Actitud Frente a la Muerte/etnología , Actitud Frente a la Salud/etnología , Comunicación , Cuidados Críticos/ética , Cuidados Críticos/legislación & jurisprudencia , Cuidados Críticos/psicología , Diversidad Cultural , Disentimientos y Disputas/legislación & jurisprudencia , Familia/psicología , Conocimientos, Actitudes y Práctica en Salud , Humanos , Inutilidad Médica/ética , Inutilidad Médica/legislación & jurisprudencia , Inutilidad Médica/psicología , Ética Basada en Principios , Relaciones Profesional-Familia , Apoderado/legislación & jurisprudencia , Apoderado/psicología , Órdenes de Resucitación/ética , Órdenes de Resucitación/legislación & jurisprudencia , Órdenes de Resucitación/psicología , Gestión de Riesgos/organización & administración , Espiritualidad , Privación de Tratamiento/ética , Privación de Tratamiento/legislación & jurisprudenciaRESUMEN
Broad evidence exists that health care professionals are facing ethical difficulties in patient care demanding a spectrum of useful ethics support services. Clinical ethics consultation is one of these forms of ethics support being effective in the acute setting. An authentic case is presented as an illustration. We introduce an integrative model covering the activities being characteristic for ethics consultation and going beyond "school"-specific approaches. Finally, we formulate some do's and don'ts of ethics consultation that are considered to be key issues for successful practice.
Asunto(s)
Consultoría Ética/ética , Inutilidad Médica/ética , Cuidados Paliativos/ética , Consultoría Ética/organización & administración , Eutanasia Pasiva/ética , Humanos , Hidrocefalia/terapia , Tutores Legales , Leucemia Mielógena Crónica BCR-ABL Positiva/terapia , Grupo de Atención al Paciente/ética , Piodermia/terapia , SuizaRESUMEN
Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.
Asunto(s)
Cuidados para Prolongación de la Vida/ética , Cuidados para Prolongación de la Vida/psicología , Competencia Mental/psicología , Psiquiatría/ética , Derivación y Consulta/ética , Órdenes de Resucitación/ética , Órdenes de Resucitación/psicología , Anciano de 80 o más Años , Femenino , Humanos , Inutilidad Médica/ética , Inutilidad Médica/psicología , Relaciones Profesional-Familia/ética , Apoderado/psicologíaRESUMEN
This report addresses the difficult situation in which a patient or surrogate decision maker wishes cardiopulmonary resuscitation to be attempted even though the physician believes that resuscitation efforts would be futile. It also reviews current controversies surrounding the subject of do-not-resuscitate (DNR) orders and medical futility, discusses the complex medical, legal, and ethical considerations involved, and then offers recommendations as a guide to clinicians and ethics committees in resolving these difficult issues. Conflicts over DNR orders and medical futility should not be resolved through a policy that attempts to define futility in the abstract, but rather through a predefined and fair process that addresses specific cases and includes multiple safeguards. As it examines these issues, the report focuses on the Veterans Health Administration (VHA). Current national VHA policy constrains physicians from entering a DNR order over the objection of a patient or surrogate even if the physician believes cardiopulmonary resuscitation to be futile. The VHA National Ethics Committee recommends that VHA policy be changed to reflect the opinions expressed in this report. The National Ethics Committee, which is composed of VHA clinicians and leaders, as well as veterans advocates, creates reports that analyze ethical issues affecting the health and care of veterans treated in the VHA, the largest integrated health care system in the United States. This report does not change or modify VHA policy.