Development and implementation of a pre-tracheostomy multidisciplinary conference: An initiative to improve patient selection.

OBJECTIVE: To describe our institutional experience in implementing a pre-tracheostomy multidisciplinary conference and assess its effects on patient selection and communication between team members and with families. METHODS: Descriptive study and retrospective review of patient outcomes in a period prior to (4/2016-1/2018) and following (2/2018-11/2019) implementation of the conference and conference participant survey. RESULTS: In the 21 months prior to the conference, 53 patients out of 67 consults (79%) went on to have a tracheostomy. After implementation, 96 patients, 42 females and 54 males, between 2 weeks and 22 years of age were discussed. 58 (60%) of patients referred for tracheostomy ultimately underwent surgery. Of those managed without tracheostomy, 16% were extubated, 11% were managed with noninvasive respiratory support, and 13% of families chose to redirect care. There was no difference in time between consultation and surgery (p = 0.9), or post-surgical length of stay after the conference was implemented (p = 0.9). Survey responses were gathered from 34 conference participants. Respondents agreed that the conference was useful in facilitating communication among the care team (91%), promoting understanding of the patient's treatment options (85%), promoting understanding about long-term outcomes and progression of underlying disease process (79%), clarifying risks, benefits, and alternatives of treatment options (82%), and informing discussions with the family (70%). DISCUSSION: Potential benefits of a multidisciplinary pre-tracheostomy conference include improved provider communication and shared decision making between the medical team and family. We found a reduction in the proportion of patients who ultimately underwent tracheostomy as a result of a formal multidisciplinary discussion, but did not find either any delays in care, or reduction in post-operative length of stay. IMPLICATIONS FOR PRACTICE: A multidisciplinary team approach to patient selection can foster communication between team members, identify barriers to discharge and quality care at home, and provide caregivers with information necessary to make an informed decision about their child's care.

Medical, ethical, and legal aspects of end-of-life dilemmas in the intensive care unit.

Physicians in the intensive care unit face a myriad of ethical dilemmas involving end-of-life care, yet they receive only minimal training about their jurisprudential obligations, and misconceptions about legal responsibilities abound. In particular, significant uncertainty exists among critical care physicians as to ethical and legal obligations for terminally ill patients. This paper presents 3 hypothetical cases to elucidate the medical, ethical, and legal considerations in common end-of-life situations encountered in the intensive care unit.

Pursuit to Post: Ethical issues of social media use by international medical volunteers.

Medical volunteers from high-income countries seek short-term global health experiences in low- and middle-income countries to learn and practice medicine, complete service-learning projects, conduct research, and burnish their curricula vitae. The uniqueness and poignancy of these global health experiences frequently compel medical volunteers to not only capture visual reminders of their experience but to share them online through social media. Prioritizing image creation and sharing, which center on the volunteer's priorities over patient-centered priorities, risks failing to acknowledge the ethical issues inherent in power imbalances between the medical volunteers, patients, hosts, organizational partners and others, and bypasses the values of the host community. Using social media as an example of an emerging ethical challenge in the context of short-term experiences in global health, the authors examine potential consequences for patients, host communities, and international partnerships and discuss important pre-posting considerations.

Hormones and their Structural and Functional Effects on the Brain: How Can We Change our Practice Moving Forward?

Is hormone treatment an invasive procedure? In this paper, we discuss aspects related to the choice of treating disorders of sex development (DSD) using hormones. Specifically, we focus on some of the challenging issues related to this treatment and the need to establish a standard of care for the use of hormone therapy in this patient population. The objectives of this paper are to: 1) Enhance understanding of the uncertainties in the decision-making process regarding hormonal interventions to treat patients with DSD. 2) Recognize that the effects of hormonal interventions might require a consent process similar to that applied for surgical procedures. 3) Emphasize the need to establish treatment algorithms that could form the basis of a standard of care for this patient population.

Telemedicine and telesurgery in cancer care: inaugural conference at MD Anderson Cancer Center.

BACKGROUND: Despite the growing incidence of cancer worldwide, there are an insufficient number of primary care physicians, community oncologists, and surgeons to meet the demand for cancer care, especially in rural and other medically underserved areas. Teleoncology, including diagnostics, treatment, and supportive care, has the potential to enhance access to cancer care and to improve clinician education and training. OBJECTIVES: Major cancer centers such as The University of Texas MD Anderson Cancer Center must determine how teleoncology will be used as part of strategic planning for the future. The Telemedicine and Telesurgery in Cancer Care (TTCC) conference was convened to determine technologically based strategies for addressing global access to essential cancer care services. RESULTS: The TTCC conference brought policy makers together with physicians, legal and regulatory experts to define strategies to optimize available resources, including teleoncology, to advance global cancer care. CONCLUSIONS: The TTCC conference discourse provided insight into the present state of access to care, expertise, training, technology and other interventions, including teleoncology, currently available through MD Anderson, as well as a vision of what might be achievable in the future, and proposals for moving forward with a comprehensive strategy.