A Comprehensive Analysis of Litigation in Organ Transplantation for Allegations of Insufficient Policy Coverage, Discrimination and Malpractice.

Introduction: Transplantation is a field with unique medical and administrative challenges that involve an equally diverse array of stakeholders. Expectantly, the litigation stemming from this field should be similarly nuanced. There is a paucity of comprehensive reviews characterizing this medicolegal landscape. Design: The Caselaw Access Project Database was used to collect official court briefs of 2053 lawsuits related to kidney, liver, heart, lung, and pancreas transplantation. A thematic analysis was undertaken to characterize grounds for litigation, defendant type, and outcomes. Cases were grouped into policy, discrimination, poor or unsuccessful outcome, or other categories. Results: One hundred sixty-four court cases were included for analysis. Cases involving disputes over policy coverage were the most common across all organ types (N = 55, 33.5%). This was followed by poor outcomes (N = 51, 31.1%), allegations of discrimination against prison systems and employers (N = 37, 22.6%) and other (N = 21, 12.8%). Defendants involved in discrimination trials won with the greatest frequency (N = 29, 90.62%). Defendants implicated in policy suits won 65.3% (N = 32), poor outcomes 62.2% (N = 28), and other 70% (N = 14). Of the 51 cases involving poor outcomes, plaintiffs indicated lack of informed consent in 23 (45.1%). Conclusion: Reconsidering the informed consent process may be a viable means of mitigating future legal action. Most discrimination suits favoring defendants suggested previous concerns of structural injustices in transplantation may not be founded. The prevalence of policy-related cases could be an indication of financial burden on patients. Future work and advocacy will need to substantiate these concerns and address change where legal recourse falls short.

Abortion restrictions: the case for conscientious non-compliance on the part of providers.

This paper offers a qualified defence of physician non-compliance with antiabortion legislation in the wake of the Supreme Court's decision in Dobbs v. Jackson Women's Health Organization. The paper examines two ethically troubling trends of post-Dobbs legislation: narrow and vague maternal health exemption clauses and mandatory reporting of miscarriages in jurisdictions where patients may criminal prosecution for medically induced abortions. It then examines and defends a professional obligation on the part of physicians to comply with the law. This obligation, however, is defeasible. The paper then argues that physicians' obligations to comply with the law is defeated when the law is illegitimate and following the law would constitute bad medical practice. Finally, it argues that the ethically troubling trends in post-Dobbs antiabortion legislation may meet these criteria.

The Ethics of Refusing Lifesaving Treatment Following a Failed Suicide Attempt.

AbstractInjuries from failed suicide attempts account for a large number of patients cared for in the emergency and trauma setting. While a fundamental underpinning of clinical ethics is that patients have a right to refuse treatment, individuals presenting with life-threating injuries resulting from suicide attempts are almost universally treated in this acute care setting. Here we discuss the limitations on physician ability to determine capacity in this setting and the challenges these pose in carrying out patient wishes.

The Extremity/Mechanism/Shock Index/GCS (EMS-G) score: A novel pre-hospital scoring system for early and appropriate MTP activation.

BACKGROUND: Numerous in-hospital scoring systems to activate massive transfusion protocols (MTP) have been proposed; however, to date, pre-hospital scoring systems have not been robustly validated. Many trauma centers do not have blood or pre-thawed plasma available in the trauma bay, leading to delays in balanced transfusion. This study aims to assess pre-hospital injury and physiologic parameters to develop a pre-hospital scoring system predictive of need for massive transfusion (MT) prior to patient arrival. METHODS: A retrospective review of all adult full and partial trauma team activations from July 2014-July 2018 from an urban level 2 trauma center was performed utilizing our trauma registry. Stepwise logistic regression analysis was performed to develop a new scoring system, with point totals assigned proportional to the odds ratios of requiring MT for each variable. Internal validation of the EMS-G score was performed using a subset of the data which was not utilized for development of the scoring system, and sensitivity and specificity were compared to previously validated in-hospital scoring systems applied in the pre-hospital setting. RESULTS: 763 patients were included with 94 patients (12.3%) receiving early MT, defined as 4 units pRBC in 4 h or ED death. In-hospital models for predicting MT such as Assessment of Blood Consumption (ABC) or Shock Index (SI) have sensitivities and specificities of 46/85% and 94/79% respectively for early MTP utilization based on pre-hospital data. Pre-hospital variables found to be predictive of MT were used to develop the EMS-G (Extremity, Mechanism, Shock Index, GCS) score. This system assigns obvious extremity injury-1-point, penetrating mechanism -2 points, shock index ≥0.9-2 points, GCS ≤8-3 points. A score of 3 or greater was chosen to maximize sensitivity and specificity for pre-hospital MT activation. EMS-G score based on pre-hospital report is 89% sensitive, 84% specific, with a PPV of 44% and NPV of 98% for early MT. Using this system, 25% of full and partial trauma team activations met criteria for pre-hospital MTP activation. CONCLUSION: The EMS-G Score has increased sensitivity and specificity compared to the ABC Score in the pre-hospital setting and appears more appropriate than shock index alone at predicting massive transfusion. This scoring system allows trauma centers to activate MTP prior to patient arrival to ensure early and appropriate blood product administration without blood product wastage.