Vital signs after cardiac arrest following withdrawal of life-sustaining therapy: a multicenter prospective observational study.

OBJECTIVE: Controversies regarding the process and timing of the determination of death for controlled organ donation after circulatory death persist. This study assessed the feasibility of conducting a prospective, observational study of continuous monitoring of vital signs for 30 minutes after the clinical determination of death in five Canadian ICUs. Waveform data were analyzed. DESIGN: Prospective observational cohort study. SETTING: One pediatric and four adult Canadian ICUs. PATIENTS: One month of age or older, admitted to the ICU, and for whom a consensual decision to withdraw life-sustaining therapies had been made, with an anticipation of imminent death. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Invasive arterial blood pressure, electrocardiogram, and oxygen saturation plethysmography activity were recorded and reviewed for 30 minutes after declaration of death. Feasibility was assessed (recruitment, consent rate, protocol compliance, and staff satisfaction). Of 188 subjects screened over 16 months, 41 subjects were enrolled (87% consent rate). Data collection was complete for 30 subjects (73% protocol compliance). In four subjects, arterial blood pressure resumed following cessation of activity. The longest period of cessation of arterial blood pressure before resumption was 89 seconds. The duration of resumed activity ranged from 1 to 172 seconds. No cases of sustained resumption of arterial blood pressure activity were recorded, and no instances of clinical autoresuscitation were reported. In nearly all patients (27 of 30), electrocardiogram activity continued after the disappearance of arterial blood pressure. CONCLUSIONS: This is the first observational study to prospectively collect waveform data for 30 minutes after the declaration of death. A future larger study may support initial data suggesting that circulatory function does not resume after more than 89 seconds of absence. Furthermore, persistence of cardiac electrical activity with the documented absence of circulation may not be relevant to declaration of death.

Canadian health care professionals' knowledge, attitudes and perceptions of nutritional genomics.

Nutritional genomics has reached the public through applications of the Human Genome Project offered direct to consumers (DTC). The ability to pursue nutrigenetic testing without the involvement of a health care professional has received considerable attention from academic and policy commentators. To better understand the knowledge and attitudes of Canadian health care professionals regarding nutritional genomics and nutrigenetic testing, qualitative research in the form of focus group discussions was undertaken. Four key themes emerged: (1) concerns over DTC testing; (2) lack of health care professional competency; (3) genetic scepticism and inevitability; (4) expectation of regulation. Together, they indicate that health care professionals have little knowledge about nutritional genomics and hold contradictory attitudes towards genomics in general, and to nutritional genomics in particular. Respondents argue in favour of a delivery model where health care professionals act as intermediaries. They are also aware of their lack of competency to provide such services. To ensure greater public protection, respondents cite the importance of more stringent regulatory oversight of DTC genetic testing. Whether such an approach is necessary to address the various ethical and social issues raised by nutrigenetic testing remains an open debate.

Physicians' ethical responsibilities in addressing racial and ethnic healthcare disparities.

Patients belonging to racial and ethnic minority populations continue to receive lesser-quality healthcare relative to other patients, even when controlling for relevant demographic variables. Such disparities represent a significant challenge for physicians who are ethically committed to serving all patients equally, irrespective of personal characteristics. Accordingly, this report explores the ethical obligations of individual physicians and the medical profession as they pertain to racial and ethnic disparities in healthcare. To address these disparities, the AMA Council on Ethical and Judicial Affairs recommends that physicians customize the provision of medial care to meet the needs and preferences of individual patients. Moreover, physicians must learn to recognize racial and ethnic healthcare disparities and critically examine their own practices to ensure that inappropriate considerations do not affect clinical judgment. Physicians can also work to eliminate racial and ethnic healthcare disparities by encouraging diversity within the profession, continuing to investigate healthcare disparities, and supporting the development of appropriate quality measures.

Atypical Face Perception in Autism: A Point of View?

Face perception is the most commonly used visual metric of social perception in autism. However, when found to be atypical, the origin of face perception differences in autism is contentious. One hypothesis proposes that a locally oriented visual analysis, characteristic of individuals with autism, ultimately affects performance on face tasks where a global analysis is optimal. The objective of this study was to evaluate this hypothesis by assessing face identity discrimination with synthetic faces presented with and without changes in viewpoint, with the former condition minimizing access to local face attributes used for identity discrimination. Twenty-eight individuals with autism and 30 neurotypical participants performed a face identity discrimination task. Stimuli were synthetic faces extracted from traditional face photographs in both front and 20° side viewpoints, digitized from 37 points to provide a continuous measure of facial geometry. Face identity discrimination thresholds were obtained using a two-alternative, temporal forced choice match-to-sample paradigm. Analyses revealed an interaction between group and condition, with group differences found only for the viewpoint change condition, where performance in the autism group was decreased compared to that of neurotypical participants. The selective decrease in performance for the viewpoint change condition suggests that face identity discrimination in autism is more difficult when access to local cues is minimized, and/or when dependence on integrative analysis is increased. These results lend support to a perceptual contribution of atypical face perception in autism.

Managing familial risk in genetic testing.

Increasing numbers of people are seeking genetic testing and uncovering information that directly concerns their biological relatives as well as themselves. This familial quality of genetic information raises ethical quandaries for physicians, particularly related to their duty of confidentiality. In this article, the American Medical Association's Council on Ethical and Judicial Affairs examines the informed consent process in the specific context of genetic testing, giving particular consideration to the handling of information that has consequences for biological relatives. Furthermore, it addresses the question of whether physicians' obligation to warn biological relatives ever should override the obligation to protect patient confidentiality.

Knowledge and attitudes of Canadian consumers and health care professionals regarding nutritional genomics.

With advances in the field of nutrigenomics, commercial laboratories have begun marketing genotyping services, nutritional advice, and dietary supplements "tailored" to match individual genetic predispositions. Although primarily offered by American companies, these services are available to Canadian consumers via the Internet. Qualitative research in the form of focus groups with members of the Canadian public was undertaken to assess the current level of understanding of and receptivity toward this new genomic application. Additionally, focus groups with health care professionals (physicians, pharmacists, dieticians, nutritionists, and naturopaths) investigated their interest in integrating nutrigenomics into health care delivery, and their capacity to do so. Gauging knowledge and attitudes early in the introduction of a new technology serves to identify potential "blind spots" regarding the ethical, legal, and social implications. Preliminary results indicate consumers believe potential benefits of nutrigenomics outweigh risks, while health care professionals express more skepticism. Both groups agree that more public education about nutrigenomics is needed and that regulatory oversight should ensure consumer protection.

Physician health and wellness.

BACKGROUND: Impaired physician health can have a direct impact on patient health care and safety. In the past, problems of alcoholism and substance abuse among physicians have received more attention than other conditions-usually in the form of discipline. While patient safety is paramount, the medical profession may be more successful in achieving the required standards by fostering a culture committed to health and wellness as well as supporting impaired physicians. OBJECTIVE: To develop ethical guidelines regarding physician health and wellness. METHODS: The American Medical Association's (AMA's) Council on Ethical and Judicial Affairs developed recommendations based on the AMA's Code of Medical Ethics, an analysis of relevant Medline-indexed articles, and comments from experts. The report's recommendations were adopted as policy of the Association in December 2003. RESULTS: Individually, physicians can promote their personal health and wellness through healthy living habits, including having a personal physician. The medical profession can foster health and wellness if its members are taught to identify colleagues in need of assistance and initiate appropriate methods of intervention, including referrals to physician health programs. CONCLUSIONS: Physicians whose health or wellness is compromised should seek appropriate help and engage in honest self-assessment of their ability to practice. The medical profession should provide an environment that helps to maintain and restore health and wellness. Physicians need to ensure that impaired colleagues promptly modify or cease practice until they can resume professional patient care. In addition, physicians may be required to report impaired colleagues who continue to practice despite reasonable offers of assistance.

Managing conflicts of interest in the conduct of clinical trials.

The interaction between medical research and for-profit corporations is not new, but it has expanded considerably in recent years. Some of the recent trends may accelerate the research process, particularly when large clinical trials are required. However, a renewed commitment to the application of high ethical standards is essential to ensure that societal trust in research is not eroded, subjects enrolled in trials do not become merely a means to an end, and medical research is efficiently translated into clinical advances that will benefit future patients. This article focuses on the analysis of conflicts of interest in the conduct of clinical trials in both academic and community-based settings. Specifically, it discusses how the roles of research scientists and clinical practitioners differ and the importance of ensuring that participants' consent to enroll in clinical trials is not the result of confusion about the goals of an experimental treatment that may resemble clinical care. The article also discusses the potential conflicts of interest that can arise when clinicians stand to gain from enrolling their own patients as subjects in clinical trials and examines various instances in which disclosure of information regarding funding and compensation may serve to minimize such conflicts. This article emphasizes that to preserve the integrity of research and to protect the welfare of human subjects who enroll in trials, physicians should have adequate training in the conduct of research and be familiar with the ethics of research. When a physician has treated or continues to treat a patient who is eligible to enroll as a subject in a clinical trial conducted by the same physician, someone other than the treating physician should obtain the participant's informed consent. Finally, the article addresses disclosure of financial incentives and related funding issues.

Surgical "placebo" controls.

OBJECTIVE: To set ethical guidelines on the use of surgical placebo controls in the design of surgical trials. BACKGROUND DATA: Ethical concerns recently arose from surgical trials where subjects in the control arm underwent surgical procedures that had the appearance of a therapeutic intervention, but during which the essential therapeutic maneuver was omitted. Although there are ethical guidelines on the use of a placebo in drug trials, little attention has been paid to the use of a surgical placebo control in surgical trials. METHODS: The Council on Ethical and Judicial Affairs developed ethical guidelines based on a wide literature search and consultation with experts. RESULTS: Surgical placebo controls should be limited to studies of new surgical procedures aimed at treating diseases that are not amenable to other surgical therapies, and are reasonably anticipated to be susceptible to substantial placebo effects. If the standard nonsurgical treatment is efficacious and acceptable to the patient, then it must be offered as part of the study design. CONCLUSIONS: Surgical placebo controls should be used only when no other trial design will yield the requisite data and should always be accompanied by a rigorous informed consent process and a careful consideration of the related risks and benefits. The recommended ethical guidelines were adopted as AMA ethics policy and are now incorporated in the AMA's Code of Medical Ethics.