Disaster medicine: the caring contradiction.

The nature of mankind is a concern for those in need. Disasters, both natural and manmade, have been with us since the beginning of recorded history but media coverage of them is a relatively new phenomenon. When these factors come together, there is great potential to both identify and serve the sick and injured. However, the mass media by its nature tends to enhance the humanistic aspect of rescue while minimizing the practical problems involved. We describe a recent scenario in Haiti that puts some of these complications into a practical perspective.

Ethics roundtable: 'Open-ended ICU care: can we afford it?'.

THE CASE: The patient is a 27-year-old previously healthy male with a diagnosis of viral encephalitis with a lymphocytic pleocytosis on cerebrospinal fluid examination. For 3 months, he has been in status epilepticus (SE) on high doses of barbiturates, benzodiazepines, and ketamine and a ketogenic feeding-tube formula. He remains in burst suppression on continuous electroencephalography (EEG). He is trached and has a percutaneous endoscopic gastrostomy (PEG) feeding tube. He has been treated several times for pneumonia, and he is on a warming blanket and is on vasopressors to maintain his blood pressure. His vitals are stable and his lab work is within limits. The sedation is decreased under EEG guidance every 72 hours, after which he goes back into SE and heavy sedation is resumed. The latest magnetic resonance imaging (MRI) shows edema but otherwise no obvious permanent cortical damage. The family wants a realistic assessment of the likely outcome. The neurologist tells them the literature suggests the outlook is poor but not 100% fatal. As long as all of his other organs are functioning on life support, there is always a chance the seizures will stop at some time in the future, and so the neurologist recommends an open-ended intensive care unit (ICU) plan and hopes for that outcome.

Ethics review: dark angels--the problem of death in intensive care.

Critical care medicine has expanded the envelope of debilitating disease through the application of an aggressive and invasive care plan, part of which is designed to identify and reverse organ dysfunction before it proceeds to organ failure. For a select patient population, this care plan has been remarkably successful. But because patient selection is very broad, critical care sometimes yields amalgams of life in death: the state of being unable to participate in human life, unable to die, at least in the traditional sense. This work examines the emerging paradox of somatic versus brain death and why it matters to medical science.

Ethics roundtable debate: patients and surrogates want 'everything done'--what does 'everything' mean?

Highly complex and specialized care plans sometimes overwhelm the comprehension of patients and families. Many optimistic surrogates of critically ill patients err on the side of desiring that everything be done but with a nebulous idea of what 'everything' entails. Physicians must work closely to educate surrogates as to the benefits versus the risks of treatment. Our roundtable experts ponder the question of whether providers possess the authority to interpret unilaterally the nature of requests for everything.

Brain death and withdrawal of support.

The definition of death has evolved to include the concept of brain death. The brainstem is an indispensable central integrative unit for all vital functions. The clinical criteria for brain death consist of the demonstration of the absence of function of the brainstem. Confirmatory testing, which mostly evaluates higher clinical function, is usually not required for the diagnosis of brain death.

Medical treatment for the terminally ill: the 'risk of unacceptable badness'.

When patients or their families rarely request inappropriate end of life care in the ICU for capricious reasons. End of life treatment decisions that only prolong discomfort and death are usually emotional and based on unrealistic expectations. I explore some of those reasons in this paper.

Pro/con ethics debate: when is dead really dead?

Contemporary intensive care unit (ICU) medicine has complicated the issue of what constitutes death in a life support environment. Not only is the distinction between sapient life and prolongation of vital signs blurred but the concept of death itself has been made more complex. The demand for organs to facilitate transplantation promotes a strong incentive to define clinical death in a manner that most effectively supplies that demand. We consider the problem of defining death in the ICU as a function of viable organ availability for transplantation.

Ethics roundtable debate: is a physician-patient confidentiality relationship subservient to a greater good?

Is a health care provider's most proximal obligation to individuals or society as a whole? Our International panel of critical care providers grapple over the issue of whether patient-physician confidentiality exists as an open ended ideal it should be subservient to a greater good.

Pro/con clinical debate: life support should have a special status among therapies, and patients or their families should have a right to insist on this treatment even if it will not improve outcome.

Most hospitals are facing the dilemma caused by demand for critical care beds outstripping supply. This imbalance is likely to get worse over the coming years as a result of many factors, including aging of the population, improved technology, and improved therapies, among other factors. As a result we are likely to have to make further tough decisions about rationing of this service. In this issue of Critical Care, two authors debate the appropriateness of providing life support in accordance with a family's wishes to an individual who is unlikely to survive admission to the intensive care unit. Understanding both sides of this debate is an important aspect of an intensivist's job.

Ethics roundtable debate: withdrawal of tube feeding in a patient with persistent vegetative state where the patients wishes are unclear and there is family dissension.

The decision to withdraw or withhold life supporting treatment in moribund patients is difficult under any circumstances. When the patient becomes incompetent to clarify their wishes regarding continued maintenance in long-term facilities, surrogates sometimes cannot agree, further clouding the issue. We examine a case where the State's interests come into play, forcing a controversial resolution.

Initial plaque score as an indicator of patient appointment compliance.

High plaque score is widely recognized as predicting patients' likely restorative needs and future caries risk. This study evaluated high plaque scores as predictors of patient appointment compliance behavior. It was found that high initial plaque scores can predict poor compliance with subsequent recall appointments.

Cardiac abnormalities after aneurysmal subarachnoid hemorrhage: effects of ß-blockers and angiotensin-converting enzyme inhibitors.

BACKGROUND: Cardiac abnormalities attributed to adrenergic surge are common after aneurysmal subarachnoid hemorrhage. Prescribed medications that block adrenergic stimulation may suppress the onset of cardiopulmonary compromise in patients after aneurysmal subarachnoid hemorrhage. OBJECTIVES: To compare the incidence of early cardiac complications between patients who reported prescribed use of ß-blockers and/or angiotensin-converting enzyme inhibitors before aneurysmal subarachnoid hemorrhage and patients who did not. METHODS: A retrospective review of 254 adult patients after acute aneurysmal subarachnoid hemorrhage who were enrolled in an existing R01 study. Demographic data and history were obtained from patients'/proxies' reports and charts. Cardiac enzyme levels, 12-lead electrocardiograms, and chest radiographs were obtained on admission. Holter monitoring and echocardiograms were completed as a part of the R01 study. RESULTS: Patients reporting prescribed use of angiotensin-converting enzyme inhibitors or ß-blockers before aneurysmal subarachnoid hemorrhage had more ventricular and supraventricular ectopy on a Holter report than did patients who did not (P < .05). When age, race, sex, and injury (Fisher grade) were controlled for, patients reporting use of ß-blockers were 8 times more likely than others to have occasional to frequent ventricular ectopy (P = .02). CONCLUSION: No concrete evidence was found that exposure to adrenergic blockade before aneurysmal subarachnoid hemorrhage provides protection from neurocardiac injury.