The Hemasite-incorporated graft. Operative technique and early results.

A new device (the Hemasite-incorporated graft), has been available to provide access for hemodialysis. Herein, we have described the technique to insert the device and reviewed our early experience. Sixteen Hemasite-incorporated grafts were inserted in 11 patients over a 16 month period. Cumulative functional patency at the end of 1 year was 70 percent. The major complication rate was 0.15 per dialysis month. Patient comfort was considerably increased compared with what was achieved with other grafts. The need for temporary blood access methods is also decreased. More patients may be able to receive hemodialysis at home.

Medical ethics. Lesson Two: Making ethically defensible health care decisions.

In this second lesson of a six-part course, Dr. Grochowski introduces the principles of medical ethics and their application to decision-making in both the autonomous and non-autonomous patient.

Ethical issues in health care institutions. Lesson three: Hospital ethics committees.

The hospital ethics committee serves as the topic for this third lesson of a five-part WMU/AHRA magazine course on ethics. Proliferating during the last ten years and fostered by the Karen Ann Quinlan case, hospital ethics committees today function in three areas: education, development of guidelines and policies, and individual case consultation. Using specific examples in the discussion of each function, the authors give a detailed picture of the valuable contribution these committees make to the institutions they serve.

Ethical issues in managed care: can the traditional physician-patient relationship be preserved in the era of managed care or should it be replaced by a group ethic?

Over the last decade managed care has become the dominant form of health care delivery, because it has reduced the cost of health care; however, it has also created serious conflicts of interest for physicians and has threatened the integrity of the traditional physician-patient relationship. In this Article, Dr. Grochowski argues that the efficiencies created by managed care are one time savings and will not in the long run reduce the rate of rise of health care expenditures without a concomitant plan to ration health care. He explores the traditional physician-patient relationship and concludes: a) that while rationing of health care is inevitable, physicians must not ration care at the bedside; b) that physicians must be advocates for their patients; c) that physicians must avoid conflicts of interest whenever possible; d) that physicians must put the needs of the patient before their own self-interests; and e) that physicians must act in ways to promote trust in their relationship with patients.

Collaborative ethics: a standing renal dialysis ethics committee.

We describe a unique, award-winning, multidisciplinary, standing committee focused on ethical issues associated with chronic dialysis. The committee was formed as a collaboration between the National Kidney Foundation of Kansas and Western MO affiliate and the Midwest Bioethics Center, Kansas City, MO in June 1995 to serve the local nephrology community. The committee is comprised of experienced nephrologists, dialysis nurses, and social workers, as well as clergy, medical ethicists, and patient representatives. Committee membership has remained relatively stable over the 4 years of its existence, creating a collaborative spirit among members, which is noteworthy because members are otherwise competing with each other for patients. The committee provides education in a variety of forms, from case consultations to organized seminars. We believe this committee is valuable to the care of patients on dialysis in our local community and that similar committees can be created in other affiliates. We can envision a national network of such committees that together could work on issues in ways that serve both the local and national level.