When patients are harmed, but are not wronged: ethics, law, and history.

Iatrogenic injury-injury caused unintentionally by medical treatment-breaks the oldest and most famous rule of medical ethics: primum non nocere, or above all, do no harm. Medical malpractice law, however, focuses on whether an injury was caused by negligence, not on whether an injury was iatrogenic. Iatrogenic injury inflicted without negligence is a common pattern in medical malpractice lawsuits; it is likely the pattern of Jacobs v Cross (Minnesota, 1872), in which Dr W. W. Mayo testified as an expert witness. As a matter of law, the doctor defendants should win all those lawsuits, for iatrogenic injury inflicted without negligence is not a legal wrong in the United States and has not been considered a legal wrong for hundreds of years. However, the medical ethics applicable to doctors' duties to report incompetence in colleagues, including those who inflict excessive iatrogenic injury, have developed dramatically over time. In 1872, the ethical codes in the United States exhorted doctors not to criticize another doctor, even if incompetent. Today, doctors in the United States are ethically required to report an incompetent colleague.

Ten common questions (and their answers) on medical futility.

The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.

Diversion of drugs within health care facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection, and prevention.

Mayo Clinic has been involved in an ongoing effort to prevent the diversion of controlled substances from the workplace and to rapidly identify and respond when such diversion is detected. These efforts have found that diversion of controlled substances is not uncommon and can result in substantial risk not only to the individual who is diverting the drugs but also to patients, co-workers, and employers. We believe that all health care facilities should have systems in place to deter controlled substance diversion and to promptly identify diversion and intervene when it is occurring. Such systems are multifaceted and require close cooperation between multiple stakeholders including, but not limited to, departments of pharmacy, safety and security, anesthesiology, nursing, legal counsel, and human resources. Ideally, there should be a broad-based appreciation of the dangers that diversion creates not only for patients but also for all employees of health care facilities, because diversion can occur at any point along a long supply chain. All health care workers must be vigilant for signs of possible diversion and must be aware of how to engage a preexisting group with expertise in investigating possible diversions. In addition, clear policies and procedures should be in place for dealing with such investigations and for managing the many possible outcomes of a confirmed diversion. This article provides an overview of the multiple types of risk that result from drug diversion from health care facilities. Further, we describe a system developed at Mayo Clinic for evaluating episodes of potential drug diversion and for taking action once diversion is confirmed.

The subversion of urine drug testing.

Since government and private industry have instituted urine drug testing to ensure a drug-free work force, an industry dedicated to subverting the results of those tests has developed. This article describes that industry, the types of products it markets, and efforts to curb the sale of those products.

The addicted physician. A rational response to an irrational disease.

Physicians are as likely to experience drug and alcohol addiction as anyone in the general population. They are more likely than others, however, to abuse prescription medications. Dealing with an impaired colleague is a difficult, emotionally charged job for physician leaders and hospital administrators, who've often had little training on how to handle such a situation. In addition to describing a case of an addicted physician, this article reviews data about the incidence of addiction among physicians and the challenges associated with confronting such a problem. It also describes the legal reporting requirements and resources such as the Minnesota Health Professionals Services Program and Physicians Serving Physicians that can help physicians get into treatment programs designed specifically for health care professionals. Physicians who go through such treatment programs and subsequent monitoring have been found to have remarkable recovery rates.

Chemical dependency and the physician.

Although the nature and scope of addictive disease are commonly reported in the lay press, the problem of physician addiction has largely escaped the public's attention. This is not due to physician immunity from the problem, because physicians have been shown to have addiction at a rate similar to or higher than that of the general population. Additionally, physicians' addictive disease (when compared with the general public) is typically advanced before identification and intervention. This delay in diagnosis relates to physicians' tendency to protect their workplace performance and image well beyond the time when their life outside of work has deteriorated and become chaotic. We provide an overview of the scope and risks of physician addiction, the challenges of recognition and intervention, the treatment of the addicted physician, the ethical and legal implications of an addicted physician returning to the workplace, and their monitored aftercare. It is critical that written policies for dealing with workplace addiction are in place at every employment venue and that they are followed to minimize risk of an adverse medical or legal outcome and to provide appropriate care to the addicted physician.

Prolonged coma from refractory status epilepticus.

OBJECTIVE: Status epilepticus is a life-threatening medical condition. In its most severe form, refractory status epilepticus (RSE) seizures may not respond to first and second-line anti-epileptic drugs. RSE is associated with a high mortality and significant medical complications in survivors with prolonged hospitalizations. METHODS: We describe the clinical course of RSE in the setting of new onset lupus in a 31-year-old male who required prolonged barbiturate coma. RESULTS: Seizure stopped on day 64 of treatment. Prior to the resolution of seizures, discussion around withdrawal of care took place between the physicians and patient's family. Medical care was continued because of the patient's age, normal serial MRI studies, and the patient's reversible medical condition. CONCLUSION: Few evidence-based data exist to guide management of RSE. Our case emphasizes the need for continuous aggressive therapy when neuroimaging remains normal.

Resource utilization and outcome in gravely ill intensive care unit patients with predicted in-hospital mortality rates of 95% or higher by APACHE III scores: the relationship with physician and family expectations.

OBJECTIVE: To assess resource utilization and outcome in gravely ill patients admitted to an intensive care unit (ICU) and the potential association with health care workers' and family members' expectations. PATIENTS AND METHODS: We retrospectively evaluated ICU patients with a predicted in-hospital mortality rate of 95% or higher (PM95) using the Acute Physiology and Chronic Health Evaluation III (APACHE III) on 2 consecutive days. All patients were admitted to a single institution between September 30, 1994, and August 9, 2001. RESULTS: The APACHE III database contained data from 38,165 ICU patients during the study interval. Of these, 248 (0.65% of ICU admissions) achieved PM95 status and were included in the study. Between PM95 and hospital discharge, resource utilization (eg, blood transfusion, hemodialysis, surgery, and computed tomography or magnetic resonance imaging) was extensive. A total of 23% of patients survived to hospital discharge, yet all but 1 were moderately or severely disabled. One year after achieving PM95, 10% (95% confidence interval, 7%-15%) of patients were alive. For 229 patients, the medical records contained physician documentation that indicated a likely fatal outcome. Thirty-six of these medical records documented unrealistic family expectations of a good outcome. The latter finding correlated with increased resource utilization without significant improvement in 1-year survival. In contrast, absence of physician documentation of a likely fatal outcome In 19 patients correlated with an improved likelihood of hospital (74%) and 1-year (47%) survival. CONCLUSION: Despite better-than-predicted survival outcomes, patient functionality and 1-year survival were poor. Unrealistic family expectations were associated with increased resource utilization without significant survival benefit, whereas absence of physician documentation of likely impending death (which correlated with improved survival) may denote the prognostication skills of experienced clinicians.

New-onset neurologic deficits after general anesthesia for MRI.

Two patients with spine disease were unable to tolerate supine placement for magnetic resonance imaging (MRI) because of severe back pain. General anesthesia was administered to enable the patients to undergo MRI. Both patients awakened from anesthesia with new-onset paraplegia and underwent emergency decompressive laminectomy. Acute paraplegia after anesthesia occurs infrequently and is most commonly associated with mechanical injury, vascular compromise, or anesthetic technique. The physical limitations of the MRI environment make it difficult to position some patients in a manner that accommodates their pathophysiology and may place certain patients at risk of neurologic compromise. For this subset of patients, the necessity of MRI with general anesthesia should be reassessed and alternative imaging methods considered.