Putting ethics and clinical decision making before politics: requiring COVID-19 immunization for Solid Organ Transplantation (SOT) Candidates and their Support Team.

We recommend that vaccination for COVID-19 should be a requirement for waitlist activation for solid organ transplant (SOT). We also recommend that such vaccination be required of the primary member of the in-home support team. We argue that these requirements are consistent with current standard practices that draw on a well-established ethical framework. As a result, these recommendations should be easily received and are only controversial owing to the inflamed and politicized state of public discourse.

Dimensions and Role-Specific Mediators of Surrogate Trust in the ICU.

OBJECTIVE: In the ICU, discussions between clinicians and surrogate decision makers are often accompanied by conflict about a patient's prognosis or care plan. Trust plays a role in limiting conflict, but little is known about the determinants of trust in the ICU. We sought to identify the dimensions of trust and clinician behaviors conducive to trust formation in the ICU. DESIGN: Prospective qualitative study. SETTING: Medical ICU of a major urban university hospital. SUBJECTS: Surrogate decision makers of intubated, mechanically ventilated patients in the medical ICU. MEASUREMENTS AND MAIN RESULTS: Semistructured interviews focused on surrogates' general experiences in the ICU and on their trust in the clinicians caring for the patient. Interviews were audio-recorded, transcribed verbatim, and coded by two reviewers. Constant comparison was used to identify themes pertaining to trust. Thirty surrogate interviews revealed five dimensions of trust in ICU clinicians: technical competence, communication, honesty, benevolence, and interpersonal skills. Most surrogates emphasized the role of nurses in trust formation, frequently citing their technical competence. Trust in physicians was most commonly related to honesty and the quality of their communication with surrogates. CONCLUSIONS: Interventions to improve trust in the ICU should be role-specific, since surrogate expectations are different for physicians and nurses with regard to behaviors relevant to trust. Further research is needed to confirm our findings and explore the impact of trust modification on clinician-family conflict.

A qualitative study of unmet healthcare needs in chronic obstructive pulmonary disease. A potential role for specialist palliative care?

RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) have high symptom burdens and poor health-related quality of life. The American Thoracic Society issued a consensus statement outlining the need for palliative care for patients with chronic respiratory diseases. A better understanding of the unmet healthcare needs among patients with COPD may help determine which aspects of palliative care are most beneficial. OBJECTIVES: To identify the unmet healthcare needs of patients with COPD hospitalized for exacerbation using qualitative methods. METHODS: We conducted 20 semistructured interviews of patients admitted for acute exacerbations of COPD focused on patient understanding of diagnosis and prognosis, effect of COPD on daily life and social relationships, symptoms, healthcare needs, and preparation for the end of life. Transcribed interviews were evaluated using thematic analysis. MEASUREMENTS AND MAIN RESULTS: Six themes were identified. (1) Understanding of disease: Most participants correctly identified their diagnosis and recognized their symptoms worsening over time. Only half understood their disease severity and prognosis. (2) SYMPTOMS: Breathlessness was universal and severe. (3) Physical limitations: COPD prevented participation in activities. (4) Emotional distress: Depressive symptoms and/or anxiety were present in most participants. (5) Social isolation: Most participants identified social limitations and felt confined to their homes. (6) Concerns about the future: Half of participants expressed fear about their future. CONCLUSIONS: There are many unmet healthcare needs among patients hospitalized for COPD exacerbation. Relief of symptoms, physical limitations, emotional distress, social isolation, and concerns about the future may be better managed by integrating specialist palliative care into our current care model.

Perioperative guidelines for elective surgery in the human immunodeficiency virus-positive patient.

BACKGROUND: Human immunodeficiency virus (HIV)-positive patients with changes in body morphology can be challenging for the plastic surgeon. Uncertainty about the advisability of elective procedures for these patients and fears of infection transmission may cause trepidation. Plastic surgeons are likely to encounter these patients in increasing numbers. The authors provide an overview of HIV lipodystrophy and treatment options. Clinical parameters are established that must be met before elective procedures on HIV-positive patients. In addition, ethical and legal considerations are discussed. METHODS: A literature review was conducted to identify articles reporting specific, identifiable factors influencing operative risk in HIV-positive patients. Legal and ethical experts were consulted. RESULTS: Specific risk factors influencing operative morbidity include an absolute CD4 count of less than 200 cells/cc3 or viral load greater than 10,000 copies/ml. Patients with CD4 counts greater than 200 cells/cc3 and a low viral load have a risk of postoperative complications similar to that of the general population and should therefore be evaluated on established preoperative parameters (e.g., American Society of Anesthesiologists class, nutrition, and age). CONCLUSIONS: Patients with HIV-associated body morphology changes can be safely treated by the plastic surgeon, provided that a thorough preoperative workup is performed. There is minimal risk of disease transmission. There is an ethical and legal obligation to treat these patients if the patient is suitable and the procedure in question falls under the expertise of the consulting surgeon.