Ethics consultations masking economic dilemmas in patient care.

The ethical and economic aspects of treatment decisions are often intimately entwined. We demonstrate how clinical economic questions were raised in clinical ethics consultations involving three patients: a 49-year-old retarded man who required short-term tube feeding; a 74-year-old man with metastatic prostatic cancer whose relatives disagreed about whether or not he should have surgical treatment; and a 55-year-old man whose health maintenance organization declined to pay for liver transplantation. Ethics consultants can help to clarify financial constraints and to resolve financial conflicts of interest. All physicians must develop the ability to unmask economic issues in medical care.

A survey of sued and nonsued physicians and suing patients.

To systematically assess the impact of malpractice litigation on the doctor-patient relationship and to collect data that might suggest effective tort reform, we surveyed 642 sued physicians, nonsued physicians, and suing patients in Wisconsin. Parallel forms of survey instruments obtained information regarding changes in physicians' practices, changes in attitudes toward patients or physicians, and changes in physical and emotional well-being as a result of malpractice litigation or the threat of the same. In addition, opinions regarding causes and deterrents of malpractice litigation were obtained. Results suggested that claims or threats of malpractice suits had a negative impact on physicians' practices and emotional well-being; that this negative impact was more pronounced when the sued physician had been more personally involved with his patient prior to the malpractice claim; and that suing patients' and sued physicians' understanding of their relationship before the malpractice claim significantly differed. All respondents viewed improved physician-patient communication as the most effective method of preventing malpractice claims. Informal, alternative dispute resolution mechanisms in hospitals and clinics and improved peer review may decrease litigation and its deleterious effects.

Talking to comatose patients.

Physicians may not talk to comatose patients for several reasons. Comatose patients do not seem to hear or respond. Speaking may not affect their clinical outcome; time spent with them takes time away from other, more "viable" patients. Comatose patients may, however, hear; many have normal brain-stem auditory evoked responses and normal physiologic responses to auditory stimuli. Not talking to comatose patients may promote the notion that they are dead or nearly dead; not talking may become a self-fulfilling prophecy, influencing physicians to inappropriately withhold or withdraw therapy. Because comatose patients are especially vulnerable, and because some comatose patients may recover, physicians should consider talking to these patients. Our analysis suggests that families, medical students, and house staff would benefit from the humane example modeled by those clinicians who care for and talk to all patients.

The total artificial heart. An ethics perspective on current clinical research and deployment.

The development of the total artificial heart (TAH) as a support before cardiac transplantation and as a possible permanent prosthesis has generated intense debate. The social commitment to TAH research entails immense health care costs because of the cost of the implant itself and also because of the large number of patients whose interests impel the research. The deployment of the pre-transplant TAH during the current shortage of donor hearts means that the TAH creates its own incentive as a way to compete in an expanded pool of donor heart candidates. Policies to address the orderly deployment and costs of the pretransplant TAH are needed. Research design and current pre-transplant clinical applications require careful consideration of planning for the termination of TAH support for severely injured but not brain dead patients.

Emergency detention of the elderly: demographics, diagnoses, and outcome.

Involuntary medical detention is an increasing problem in many large teaching hospitals. Forty-two elderly patients involuntarily admitted for protective service to the general medical wards were compared with an age-matched group of 25 elderly persons voluntarily seeking care in the same institution. The comparison showed that most of the involuntarily admitted patients were more than 70 years of age, and more of them lived alone. On admission they had more dementia and dehydration but less urinary-tract infection than did the controls. Their hospital stays were longer. There was no difference between the groups with respect to discharge dispositions.

The decision to forgo CPR in the elderly patient.

KIE: Schiedermayer discusses the findings of Taffet, et al., published in this issue of JAMA, concerning the outcomes of cardiopulmonary resuscitation (CPR) in a population of aged patients in the Houston Veterans Administration Medical Center. He contrasts the conclusion reached by the authors of the Houston study, that it was their clinical impression "that a majority of [their] geriatric patients were not living to discharge after CPR," with the U.S. Office of Technology Assessment's review of CPR in the elderly. The OTA report cited eight studies to support its conclusion that age is not a reliable predictor of the long-term outcome of resuscitation. Scheidermayer urges that the data from the Taffet study should be used in conjunction with the OTA data as the basis for discussions among physicians, patients, and families about CPR, not as the rationale for a more paternalistic approach to do-not-resuscitate orders decided unilaterally by the physician.^ieng

Ethics consultation: skills, roles, and training.

A clinical ethics consultant gathers information firsthand at the patient's bedside. The consultant's special clinical skills include the ability to identify and analyze ethical problems; use reasonable clinical judgment; communicate effectively; negotiate and facilitate negotiations; and teach others how to construct their own ethical frameworks for medical decision making. Appropriate roles for the consultant include those of professional colleague, negotiator, patient and physician advocate, case manager, and educator. The training necessary for an ethics consultant includes substantial patient care experience, instruction in health care law and moral reasoning, and preparation in medical humanism. We favor a clinical model for ethics consultation. When urgent care is needed, other consultants promptly see the patient; the clinical ethics consultant can be expected to do the same.

The clinical ethicist at the bedside.

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside. We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on second hand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.

The artificial heart as a bridge to transplant: ethical and legal issues at the bedside.

The healthy survival of two thirds of patients who receive the total artificial heart as a bridge to transplant is argument for continued use of this technology. Patient selection, informed consent, and treatment termination are the ethical and legal issues that are important at the bedside. Optimum patient selection requires clinical judgment, appropriate institutional review, and the elimination of socioeconomic barriers to transplant. Informed consent enables the patient to participate in the decision and to consider the question of treatment termination in a personalized fashion. Favorable public perception and successful implementation of this bridge to transplant are linked to the quality of this physician-patient communication.