Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework.

Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.

Interatrial Stent to Treat Stiff Left Atrium Syndrome.

BACKGROUND: Catheter ablation for atrial fibrillation (CAAF) can result in stiff left atrial syndrome (SLAS) in up to 8% of patients. SLAS can be challenging to diagnose and difficult to distinguish from heart failure with preserved ejection fraction (HFpEF), presenting with similar signs and symptoms. CASE PRESENTATION: We report the first case of using an interatrial stent to maintain therapeutic benefit of atrial septostomy in a patient with symptomatic SLAS. While interatrial shunt devices have preliminarily been shown to be safe and efficacious for the treatment of HFpEF, their utilization in those with SLAS has not previously been described [1]. CONCLUSIONS: In patients with prior CAAF, SLAS should be considered to explain dyspnea when alternative processes have been excluded. Treatment of SLAS can be challenging with medical therapy alone, and septostomy may provide significant symptomatic benefit in these patients. Interatrial stenting can improve the patency of such interventions.

Clerkship Ethics: Unique Ethical Challenges for Physicians-in-Training.

Three ethical conflicts in particular are paradigmatic of what we define as "clerkship ethics." First, a distinction that differentiates the clerkship student from the practicing physician involves the student's principal role as a learner. The clerkship student must skillfully balance her commitment to her own education against her commitment to patient care in a fashion that may compromise patient care. While the practicing physician can often resolve the tension between these two goods when they come into conflict, the clerkship student is left with a more ambiguous set of choices. Second, evaluative scrutiny during clinical clerkships often forces medical students to balance doing what is morally fitting against the perceived expectations of the medical teams in which they work. Third and finally, a deeply entrenched culture of medical hierarchy presents a particular challenge to innovation and improvement in ethics education during the clerkship years. Students regard faculty as exemplars, but are not provided with the tools to assess when technical medical competence is not matched by moral competence; moreover, these faculty are unlikely to have experienced the ethics education in which students are asked to demonstrate mastery.

Family presence in the trauma setting: A case study.

The topic of family presence during resuscitation (FPDR) has been in the medical literature for several decades. However, these discussions have largely failed to delineate a difference between resuscitation of patients in cardiac arrest and the resuscitation and stabilisation of trauma victims before a necessary procedure. Through a case-based scenario, this primer aims to explore the ethical considerations of FPDR in emergent trauma care - particularly in the case of a motor vehicle collision. In doing so, consideration is given to the relevant aspects of patient dignity and privacy; as well as to the benefits of exposing family to clinician efforts, including how FPDR can aid in the grieving process.

Duty, Empathy, and Hierarchy: Healing "Difficult Patients".

Anthony is a fourth-year medical student, currently on service during an away surgery rotation. He is rounding with a first-year intern, Dr. Lovett, and the attending, Dr. Todd. They stop outside the room of Mr. Turpin, a 54-year-old male who has recently had a toe amputation due to uncontrolled diabetes mellitus. His chart lists him as a drug-seeker managed for chronic pain. As such, his analgesics are being closely monitored. Before entering the room, Dr. Lovett mentions that the patient had been irritated the night prior, complaining of uncontrolled pain, and upset at staff for refusing increased pain medication. Dr. Todd knows this, remarking that Mr. Turpin has a history of being a "difficult patient."

CD117/c-kit in Cancer Stem Cell-Mediated Progression and Therapeutic Resistance.

Metastasis is the primary cause of cancer patient morbidity and mortality, but due to persisting gaps in our knowledge, it remains untreatable. Metastases often occur as patient tumors progress or recur after initial therapy. Tumor recurrence at the primary site may be driven by a cancer stem-like cell or tumor progenitor cell, while recurrence at a secondary site is driven by metastatic cancer stem cells or metastasis-initiating cells. Ongoing efforts are aimed at identifying and characterizing these stem-like cells driving recurrence and metastasis. One potential marker for the cancer stem-like cell subpopulation is CD117/c-kit, a tyrosine kinase receptor associated with cancer progression and normal stem cell maintenance. Further, activation of CD117 by its ligand stem cell factor (SCF; kit ligand) in the progenitor cell niche stimulates several signaling pathways driving proliferation, survival, and migration. This review examines evidence that the SCF/CD117 signaling axis may contribute to the control of cancer progression through the regulation of stemness and resistance to tyrosine kinase inhibitors.

The Islamic tradition and health inequities: A preliminary conceptual model based on a systematic literature review of Muslim health-care disparities.

OBJECTIVE: The objective of this study was to identify mechanisms by which Islamic beliefs, values, and Muslim identity might contribute to health inequities among Muslim populations. METHODS: A systematic literature review of empirical studies in Medline from 1980 to 2009 was conducted. The search strategy used three terms covering health-care disparities, ethnicity, and location to uncover relevant papers. RESULTS: A total of 171 articles were relevant based on titles and abstracts. Upon subsequent full-text review, most studies did not include religious identity or religiosity as explanatory variables for observed health disparities. Of 29 studies mentioning Islam within the text, 19 implicated Muslim identity or practices as potential explanations for health differences between Muslim and non-Muslim groups. These 19 studies generated six mechanisms that related the Islamic tradition, Muslim practices, and health inequities: (1) Interpretations of health and/or lack of health based on Islamic theology; (2) Ethical and/or cultural challenges within the clinical realm stemming from Islamic values or practices; (3) Perceived discrimination due to, or a lack of cultural accommodation of, religious values or practices in the clinical realm; (4) Health practices rooted within the Islamic tradition; (5) Patterns of health-care seeking based on Islamic values; and (6) Adverse health exposures due to having a Muslim identity. CONCLUSION: While there is scant empirical research on Muslim health-care disparities, a preliminary conceptual model relating Islam to health inequities can be built from the extant literature. This model can serve to organize research on Muslim health and distinguish different ways in which a Muslim identity might contribute to the patterning of health disparities.

Maintaining the Punitive Element of Tort through Social Sanctions in Malpractice Reform.

In this piece, I focus on the limitations of moving medical malpractice from a tort to contracts basis, particularly in the loss of the punishment aspect of punitive damages. In doing so, I present the way in which medical malpractice is currently implemented in the United States under tort law. I then briefly review current malpractice reform efforts, focusing more so on the idea of "no-fault" administrative systems. Here, I also explore the fundamental legal differences between contracts and tort. I then discuss the ethics of blame-shielding and whether or not we are losing something by failing to blame bad actors. In doing so, I focus on the ethical implications of punishment. Operating under the assumption that the current tort-based medical malpractice system is driving up health care costs, I conclude by proposing a hybrid system that combines contract theory with noneconomic punitive sanctions: a "no-fault fault system."

The Views of Clergy Regarding Ethical Controversies in Care at the End of Life.

CONTEXT: Although religion often informs ethical judgments, little is known about the views of American clergy regarding controversial end-of-life ethical issues including allowing to die and physician aid in dying or physician-assisted suicide (PAD/PAS). OBJECTIVE: To describe the views of U.S. clergy concerning allowing to die and PAD/PAS. METHODS: A survey was mailed to 1665 nationally representative clergy between 8/2014 to 3/2015 (60% response rate). Outcome variables included beliefs about whether the terminally ill should ever be "allowed to die" and moral/legal opinions concerning PAD/PAS. RESULTS: Most U.S. clergy are Christian (98%). Clergy agreed that there are circumstances in which the terminally ill should be "allowed to die" (80%). A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable. Mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of PAD/PAS, in contrast to all other clergy groups (6%-17%). Greater end-of-life medical knowledge was associated with moral disapproval of PAD/PAS (adjusted odds ratio [AOR], 1.51; 95% CI, 1.04-2.19, P = 0.03). Those reporting distrust in health care were less likely to oppose legalization of PAD/PAS (AOR 0.93; 95% CI, 0.87-0.99, P < 0.02). Religious beliefs associated with disapproval of PAD/PAS included "life's value is not tied to the patient's quality of life" (AOR 2.12; 95% CI, 0.1.49-3.03, P < 0.001) and "only God numbers our days" (AOR 2.60; 95% CI, 1.77-3.82, P < 0.001). CONCLUSION: Most U.S. clergy approve of "allowing to die" but reject the morality or legalization of PAD/PAS. Respectful discussion in public discourse should consider rather than ignore underlying religious reasons informing end-of-life controversies.