Ethics Roundtable: Advance Directives, Autonomy, and Gastrostomy Placement.

CL is a 94-year-old male who is brought to the Emergency Department from an assisted living facility due to a new onset of weakness and altered mental status. He was in his usual state of moderately compensated health, requiring assistance for most activities of daily living due to medical frailty and a previous right brain CVA with residual mild left sided weakness. On the day of admission, the staff found him lethargic and disoriented. The family requested a surgical consult for percutaneous, endoscopic, gastrostomy (PEG) tube placement. A review of the patient's records showed that the patient had refused a PEG tube during his last two hospitalizations. During the last admission, the hospitalist documented that the patient repeatedly refused nutritional support stating "if it's my time, I've lived a full life. I'm ready to die and join my wife." There was no advance care plan ("living will"), but CL did sign a "Selection of Surrogate Decision-maker" form previously, assigning his nephew as primary surrogate. Under pressure from multiple family members, including the designated surrogate, the attending requested a surgical consultation. The surgical team determined that the patient did not have capacity and scheduled CL for PEG tube placement. The care team had concerns regarding the conflict between the patient's previously (and consistently) stated desires and the family's wishes; an ethics consult was requested.

Economic feasibility of no-tillage and manure for soil carbon sequestration in corn production in northeastern Kansas.

This study examined the economic potential of no-tillage versus conventional tillage to sequester soil carbon by using two rates of commercial N fertilizer or beef cattle manure for continuous corn (Zea mays L.) production. Yields, input rates, field operations, and prices from an experiment were used to simulate a distribution of net returns for eight production systems. Carbon release values from direct, embodied, and feedstock energies were estimated for each system, and were used with soil carbon sequestration rates from soil tests to determine the amount of net carbon sequestered by each system. The values of carbon credits that provide an incentive for managers to adopt production systems that sequester carbon at greater rates were derived. No-till systems had greater annual soil carbon gains, net carbon gains, and net returns than conventional tillage systems. Systems that used beef cattle manure had greater soil carbon gains and net carbon gains, but lower net returns, than systems that used commercial N fertilizer. Carbon credits would be needed to encourage the use of manure-fertilized cropping systems.