"Futile Care"-An Emergency Medicine Approach: Ethical and Legal Considerations.

Futility often serves as a proposed reason for withholding or withdrawing medical treatment, even in the face of patient and family requests. Although there is substantial literature describing the meaning and use of futility, little of it is specific to emergency medicine. Furthermore, the literature does not provide a widely accepted definition of futility, and thus is difficult if not impossible to apply. Some argue that even a clear concept of futility would be inappropriate to use. This article will review the origins of and meanings suggested for futility, specific challenges such cases create in the emergency department (ED), and the relevant legal background. It will then propose an approach to cases of perceived futility that is applicable in the ED and does not rely on unilateral decisions to withhold treatment, but rather on avoiding and resolving the conflicts that lead to physicians' believing that patients are asking them to provide "futile" care.

Emergency physician professionalism versus wellness: A conceptual model.

Striking the balance between professional duties, obligations, and responsibility with protecting one's wellness as a physician and as an individual have been brought into sharper focus during COVID-19. The objective of this paper is to describe ethical principles in the balance between emergency physician wellness and professional responsibility to patients and the public. We propose a schematic that helps us as emergency physicians visualize continuously striving to be both well and professional.

Racism, Not Race: A Physician Perspective on Anti-Black Racism in America.

In this commentary, which responds to the article "Anti-Black Racism as a Chronic Condition," by Nneka Sederstrom and Tamika Lasege, I draw on my experience as a physician who cares for a largely Black patient population. Physicians are trained to "first do no harm" and strive to treat patients to the best of their abilities. However well intentioned, many of us fall short of this goal and witness the consequences of health inequities that disproportionally impact the lives of Black patients. Recent years have brought increased acknowledgment and understanding of social determinants of health, but these modest changes fail to identify the true culprit of health disparities. Racism, not race, is responsible for the negative outcomes that we see in our communities of color. Both subtle and overt forms of systemic racism plague the educational systems and scientific metrics of medicine in the United States. Physicians' training, culture, and biases are founded in White norms. To decenter Whiteness as a normality, medicine must enact a multipronged approach that begins with increasing the diversity of physicians and providers to better reflect the patients that they care for. Bioethicists must publicly state that racism is real and that we are dedicated to changing it, but to get beyond statements, we must also have a measure of improvement and success in battling racism.

Diversity pipelines: The rationale to recruit and support minority physicians.

Emergency physicians care for patients from all backgrounds with respect and expertise. We aspire to treat everyone equitably and make decisions at the bedside that are not based on age, race, socioeconomic status, gender, sexual orientation, religion, language, or any other category. In many settings, there is a stark contrast between the diversity of our patient populations and that of the physicians caring for them. Despite our intention to minimize the effects of implicit and explicit bias, when the physician workforce does not reflect the patient population, there may be significant assumptions, mistrust, and misunderstandings between people from different backgrounds. As medical professionals, increasing the diversity of our workforce and support for programs and policies that increase underrepresented minority (URM) physicians in emergency medicine is important. Increasing URM physicians will not only improve the quality of care for our patients, but also the quality of education and training in our profession. It is crucial that we prioritize pipeline programs that recruit and support URM physicians. This article describes the rationale to increase diversity within the profession of emergency medicine and the essential mechanisms to achieve this goal. In the same way that we hold individuals accountable to a clinical standard of care, we should hold our institutions to an organizational standard of diversity.

Addressing end-of-life care in the chronically ill: Conversations in the emergency department.

Patients present to the emergency department in various stages of chronic illness. Advance directives (ADs) aid emergency physicians in making treatment decisions, but only a minority of Americans have completed an AD, and the percentage of those who have discussed their end-of-life wishes may be even lower. This article addresses the use of common ADs and roadblocks to their use from the perspectives of families, patients, and physicians. Cases to examine new approaches to optimizing end-of-life conversations in patients who are chronically ill, such as the Improving Palliative Care in Emergency Medicine Project, a decision-making framework that opens discussion for patients to gain understanding and determine preferences, and the Brief Negotiated Interview, a 7-minute, scripted, motivational interview that determines willingness for behavior change and initiates care planning, are used.

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.