Permanent brain arrest as the sole criterion of death in systemic circulatory arrest.

Historically, there has been a tendency to think that there are two types of death: circulatory and neurological. Holding onto this tendency is making it harder to navigate emerging resuscitative technologies, such as extracorporeal membrane oxygenation and the recent well-publicised experiment that demonstrated the possibility of restoring cellular function to some brain neurons 4 h after normothermic circulatory arrest (decapitation) in pigs. Attempts have been made to respond to these difficulties by proposing a unified brain-based criterion for human death, which we call 'permanent brain arrest'. The clinical characteristics of permanent brain arrest are the permanent loss of capacity for consciousness and permanent loss of all brainstem functions, including the capacity to breathe. These losses could arise from a primary brain injury or as a result of systemic circulatory arrest. We argue that permanent brain arrest is the true and sole criterion for the death of human beings and show that this is already implicit in the circulatory-respiratory criterion itself. We argue that accepting the concept of permanent cessation of brain function in patients with systemic permanent circulatory arrest will help us better navigate the medical advances and new technologies of the future whilst continuing to provide sound medical criteria for the determination of death.

Ethical Issues in the Use of Extracorporeal Membrane Oxygenation in Controlled Donation After Circulatory Determination of Death.

The use of donor extracorporeal membrane oxygenation (ECMO) to improve graft outcomes by some controlled donation after circulatory determination of death (cDCDD) programs raises ethical issues. We reviewed cDCDD protocols using ECMO and the relevant ethics literature to analyze these issues. It is not obvious that ECMO in cDCDD improves graft outcomes. In our opinion, ECMO implemented before death can interfere with end-of-life care and damage bodily integrity. By restoring systemic circulation, ECMO risks invalidating the preceding declaration of death if brain and cardiac perfusion is not adequately excluded because of malfunction or misplacement of the supradiaphragmatic aortic occlusion balloon. The use of ECMO is not compatible with the acronym DCDD because circulation is restored after the determination of death. Because of these deficiencies, we concluded that other techniques are preferable, such as rapid recovery or in situ cold infusion. If ECMO is performed, it requires a specific informed consent and transparency.

To tell or not to tell? Revealing the diagnosis in multiple sclerosis.

We review briefly (1) the history of patient-physician relationship and its evolution from a physician-centered to patient-centered model; (2) the impact of the McDonald Criteria for Multiple Sclerosis (MS); (3) why it is important to tell patients of their diagnosis; (4) how physicians should disclose the diagnosis to patients; (5) dealing with suspected MS; and (6) prognosis and treatment. For the majority of clinically definite MS patients we advocate disclosure, identify steps for physicians to communicate the diagnosis and propose a framework to follow when revealing a diagnosis of MS.

American Academy of Neurology policy on pharmaceutical and device industry support.

OBJECTIVE: To examine the American Academy of Neurology (AAN)'s prevention and limitation of conflicts of interest (COI) related to relationships with pharmaceutical and medical device manufacturers and other medically related commercial product and service companies (industry). METHODS: We reviewed the AAN's polices governing its interactions with industry, mechanisms for enforcement, and the recent findings of the board-appointed COI task force, in the context of the 2009 David Rothman and colleagues' article in JAMA, the Council of Medical Specialty Societies (CMSS) Code for Interactions with Companies (Code), efforts of the American Medical Association in this area, and increased public and Congressional scrutiny of physician/physician organizations' relationships with industry. RESULTS: The AAN's Policy on Conflicts of Interest provides 4 mechanisms for addressing COI: avoidance, separation, disclosure, and regulation. The AAN's Principles Governing Academy Relationships with External Sources of Support, including recent amendments proposed by the COI task force, regulate industry interaction with AAN programming, products, and leadership. With the Policy, Principles, and other methods of COI prevention, the AAN meets or exceeds all recommendations of the CMSS Code. CONCLUSIONS: With its adherence to the Principles since 2004, the AAN has been a leader among professional medical associations in appropriately managing COI related to interactions with industry. Recent amendments to the Principles maintain the AAN's position as a leader in a time of increased public scrutiny of physicians' and professional medical associations' relationships with industry. The AAN is responsive to the recommendations of the COI task force, and has adopted the CMSS Code.

Report of a National Conference on Donation after cardiac death.

A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.

Informed consent.

Physicians have an ethical and legal duty to obtain patients' informed consent before ordering testing and treatment. Informed consent encompasses informed refusal, the correlative right of patients to refuse tests and therapies they do not want. A patient's informed consent requires adequate information, capacity to decide, and absence of coercion. Informed consent is incorporated into a process of agreement between a patient and a physician called "shared decision making." The procedural requirements of informed consent vary as a function of the risks of the tests or treatments. Incompetent patients require surrogate decision makers to consent or refuse on their behalf. Older children and adolescents should be asked to provide their assent for treatment in addition to their parents' permission. Treatment may be provided in an emergency situation without consent if the treatment given represents the standard of emergency care. Consent of human subjects for participation in research requires that they fully understand their role and risks, not be coerced, and be allowed to withdraw at any time without penalty. Institutional review boards help guarantee the protection of human subjects. Vulnerable research subjects, such as children and the cognitively or mentally impaired, require additional protection.

Ethical and legal issues in palliative care.

This article reviews the ethical principles underlying palliative care, stressing the importance of respecting patient's rights to withdraw or withhold life-sustaining treatment, including artificial hydration and nutrition. There is no ethical or constitutional right to receive physician-assisted suicide or voluntary active euthanasia. This article discusses current ethical controversies in palliative care, including futility, medication dosage and double-effect, terminal sedation, legalization of physician-assisted suicide and euthanasia, and patient refusal of hydration and nutrition. Relevant legal issues are discussed in tandem with the ethical issues.

US neurologists: attitudes on rationing.

OBJECTIVE: To assess neurologists' attitudes on rationing health care and to determine whether neurologists would set healthcare priorities in ways that are consistent with cost-effectiveness research. BACKGROUND: Cost-effectiveness research can suggest ways to maximize health benefits within fixed budgets but is currently being underused in resource allocation decisions. METHODS: The authors surveyed a random sample of neurologists practicing in the United States (response rate, 44.4%) with three hypothetical scenarios. Two scenarios were designed to address general attitudes on allocating finite resources with emphasis on formulary decisions for costly drugs. The third scenario was designed to assess whether neurologists would optimize the allocation of a fixed budget as recommended by cost-effectiveness analysis. RESULTS: Three-quarters of respondents thought that neurologists make daily decisions that effectively ration healthcare resources, and 60% felt a professional responsibility to consider the financial impact of individualized treatment decisions on other patients. Only 25% of respondents thought that there should be no restrictions placed on any of the five newer antiepileptic agents. In a 1995 survey, 75% of similarly sampled neurologists agreed that no restrictions should be placed on the availability of FDA-approved medications. Nearly half (46%) of respondents favored a less effective test and would be willing to let patients die to ensure the offering of a more equitable alternative. CONCLUSIONS: Most neurologists recognize the need to ration health care, and although they think cost-effectiveness research is one method to achieve efficient distribution of resources, many think that considerable attention should also be given to equity.

End-of-life care: a survey of US neurologists' attitudes, behavior, and knowledge.

OBJECTIVE: The American Academy of Neurology (AAN) surveyed the attitudes, behavior, and knowledge of its members regarding care at the end of life. Three groups of AAN members were surveyed: neuro-oncologists, ALS specialists, and a representative sample of US neurologists. METHODS: The survey presented two clinical scenarios involving end-of-life care. Neurologists were asked a series of questions to assess their knowledge of existing medical, ethical, and legal guidelines; their willingness to participate in physician-assisted suicide (PAS) or carry out voluntary euthanasia (VE); and their general attitudes regarding end-of-life care. RESULTS: Neurologists support a patient's right to refuse life-sustaining treatment, but many believe that they are killing their patients in supporting such refusals. Thirty-seven percent think it is illegal to administer analgesics in doses that risk respiratory depression to the point of death. Forty percent believe they should obtain legal counsel when considering stopping life-sustaining treatment. One half believe that PAS should be made explicitly legal by statute for terminally ill patients. Under current law, 13% would participate in PAS and 4% would carry out VE; if those procedures were legalized, 44% would participate in PAS and 28% in VE. Approximately one third believe that physicians have the same ethical duty to honor a terminally ill patient's request for PAS as they do to honor a such a patient's refusal of life-sustaining therapy. CONCLUSIONS: There is a gap between established medical, legal, and ethical guidelines for the care of dying patients and the beliefs and practices of many neurologists, suggesting a need for graduate and postgraduate education programs in the principles and practices of palliative care medicine. Many neurologists would participate in PAS and carry out VE if legalized.

A defense of the whole-brain concept of death.

The concept of whole-brain death is under attack again. Scholars are arguing that the concept of brain death per se--regardless of the focus on "higher," "stem" or "whole"--is fundamentally flawed. These scholars have identified what they believe are serious discrepancies between the definition and criterion of brain death, and have pointed out that medical professionals and lay persons remain confused about its meaning. Yet whole-brain death remains the standard for determining death in much of the Western world and its defenders believe this concept best maps onto our everyday conception of death.

Quality of neurological care. Balancing cost control and ethics.

As the quality of neurological care becomes a mutual objective of physicians, patients, and health planners, increased demands on cost savings will create conflicts that could threaten the ethical basis of medical practice. Physicians will see increasing ethical conflicts between their fiduciary duties to make treatment decisions in the best interest of their patients and their justice-based duties to conserve societal resources. These conflicts can be best mitigated if physicians maintain their orientation as patient advocates but practice cost-conscious clinical behaviors that consider the cost-effectiveness of tests and treatments and do not squander society's finite resources by ordering medical tests and treatments of zero or marginal utility. Health system planners should resolve their conflicting objectives of quality and cost control by rigorously defining and measuring quality through physician leadership and by implementing cost-control measures that enhance the quality of medical care. Managed care organizations voluntarily should forsake financially successful but blatantly unethical cost-saving schemes, such as gag clauses and end-of-year kickback payments to physicians, because these schemes diminish patients' trust in physicians and degrade the integrity of the patient-physician relationship. State and federal laws should prudently regulate these unethical cost-saving schemes to the same extent as they have for the harmful conflicts in fee-for-service medicine.

Attitudes of US neurologists concerning the ethical dimensions of managed care.

We surveyed attitudes of US neurologists about the ethical dimensions of managed care by administering a written instrument containing paradigmatic cases portraying conflicts of physicians, patients, and managed care organizations (MCOs). After each case, we assessed neurologists' attitudes by asking them their degree of agreement with a series of statements. We found that neurologists (1) generally were willing to follow clinical practice guidelines if they were created by medical societies; (2) experienced frequent conflicts of interest or conflicts of obligation in the care of their MCO patients; (3) feared legal ramifications of their clinical decisions on MCO patients; (4) were unwilling to employ deception or gaming to achieve what they perceived to be good patient care; (5) believed that their professional prerogatives and autonomy were under attack by MCOs; and (6) felt that the good of their patients should not be sacrificed for the good of society.

The problem of physician-assisted suicide.

With the increasing acceptance of the right of patients to refuse life-sustaining treatment, some have argued that terminally ill patients have a corollary right to physician-assisted suicide (PAS) on request. However, there are important moral and legal distinctions between patients' refusals of therapy and requests for certain actions. Physicians must stop life-sustaining therapy when that therapy has been validly refused by patients. But physicians have no similar duty to provide actions, such as assistance in suicide, simply because they have been requested by patients. In deciding how to respond to patients' requests, physicians should use their judgment about the medical appropriateness of the request. The morality of PAS is debatable but it remains illegal in most jurisdictions. Advocates of legalizing PAS should fully understand three issues: (1) that such legalization would have a negative effect on the practice of palliative care and on the physician-patient relationship; (2) that legalization of voluntary euthanasia will follow the legalization of PAS; and (3) that involuntary euthanasia inevitably follows the legalization of voluntary euthanasia, as has occurred in the Netherlands over the past 12 years. Rather than suffer the harms resulting from legalizing PAS, our society should maintain its illegality and make an expanded effort to improve physicians' training and abilities to provide palliative care.