Munchausen Syndrome by Proxy

Munchausen syndrome by proxy is difficult to diagnose unless healthcare providers are astute to its clinical features and management. A case is presented to educate nurses and advanced practice nurses, of the nursing, medical, legal, and social complexities associated with Munchausen syndrome by proxy. This article also provides a brief review of the definition of Munchausen syndrome by proxy, its epidemiology, common features of the perpetrator, implications for healthcare personnel, and the legal and international ramifications of Munchausen syndrome by proxy.

Can regulation improve safety in critical care?

This article examines national and state safety practice initiatives, including the Centers for Medicare and Medicaid Services quality focus, federal and state outcomes reporting, and consumer access to outcomes data. The efforts of national and regional legislators and health care institutions to create regulations for staffing and technology to reduce medical errors is reviewed. The potential of a unified cooperative effort from all stakeholders to implement the above initiatives to improve intensive care unit safety practices is discussed.

Ms B and legal competence: interprofessional collaboration and nurse autonomy

--Ms. B's wish for withdrawal of treatment was refused. --The nurses' role and autonomy in the decision-making is unclear. --Historically, tensions have existed in the doctor-nurse relationship. --Interprofessional collaboration is encouraged in order to facilitate team working. --Evidence is lacking that this is working and suggests continuing problems. --Legal and ethical education needs emphasizing in order to ensure respect for patient autonomy.

Ethical dilemma: voluntarily stopping eating and drinking

Nutritional support is an ethical/legal dilemma that healthcare providers must face when dealing with the elderly population of patients in critical care units. As nurses we have the responsibility to consider the issues concerning this topic. The debate concerning the issue of nutritional support, implications to terminate treatment, and fears concerning liability have shifted the decision-making process from the intensive care bedside to the courtroom. Hence, nurses must face this dilemma daily. This article utilizes a case study approach, explores legal issues, discusses ethical guidelines, and identifies techniques for conflict resolution.

Injury in Women Who Are Raped

Sexual assault is considered the silent, violent epidemic. However, many critical care nurses are unaware of the injury patterns that may indicate that their patient has been sexually assaulted. In addition, critical care nurses are often uncertain how to proceed when caring for someone with a suspected sexual assault. This article provides both background information about sexual assault and guidance to critical care nurses on how to manage this difficult situation.

Analysis of end-of-life content in critical care nursing textbooks

Nurses have identified a need for improving their knowledge and skills in providing end-of-life care. Critical care nursing textbooks can serve as an important source of information on end-of-life care for critical care nurses. Hence, an analysis of end-of-life content in 14 critical care nursing textbooks was conducted. Critical care nursing textbooks used for review were published in 1995 or later and identified from the libraries at the University of Wisconsin-Madison and Brigham Young University. The end-of-life content areas identified by the American Association of Colleges of Nursing (AACN), under which the AACN end-of-life competencies for undergraduate nursing students can be taught, were used as a framework for assessing the presence or absence of end-of-life content in the textbooks. When end-of-life content was present, two reviewers judged whether the information was helpful. Four additional end-of-life content areas were identified in some textbooks during the study, and reviewers also judged whether these were helpful. None of the textbooks had end-of-life content in all the content areas used for the analysis. Three textbooks did not contain any end-of-life content.

Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country

PURPOSE

To analyze the characteristics of moribund patients in a surgical intensive care unit (ICU) and highlight the dilemmas inherent in treating such patients.

METHODS

Data on all patients admitted to the surgical ICU during the period of three years from July 1999 to June 2002 were collected prospectively. Data were collected on very ill patients who died, in whom it appeared obvious that treatment could not have improved their condition and whose death could have been anticipated. The case notes were subjected to further analysis to determine the difficulties encountered in managing patients whose therapy was considered to be futile.

RESULTS

Of 662 admissions, 100 (15.1%) died and 30 (4.5%) patients were treated aggressively, even after a prognosis which reflected futile treatment. The overall mean length of stay for survivors was 7.5 +/- 9.0 [standard deviation (SD)] days and that for the non-survivors was 12.8 +/- 18.1 (SD; P < 0.001). The cost incurred for the treatment of non-survivors was significantly higher than that for the surviving patients. The factors relating to the decisions to continue futile therapy were age of the patient, legal considerations, family wishes and differing opinions between treating physicians.

CONCLUSION

Consideration of futility during end-of-life care did not receive adequate attention in this unit which incurred additional human and material resources.

The physician's role in discussing organ donation with families

Federal Conditions of Participation from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) introduced in 1998 require that all families be presented the option of organ and tissue donation when death is imminent. The perception that physicians were being excluded from participating in this process led to a resolution at the American Medical Association House of Delegates meeting in December 1999, calling on the American Medical Association Council on Scientific Affairs to review the Conditions of Participation "to ensure that there is no prohibition of physician involvement in the organ donation process..." The number of organs procured for transplantation in the United States is insufficient to meet needs. Families' hospital experiences significantly affect their decisions to donate organs. Discussing severe brain injury, brain death, and organ donation after brain death with families is a specialized form of end-of-life decision-making and care in the intensive care unit; however, the knowledge, skills, and attitudes necessary for physicians and nurses to promote good end-of-life decision-making are widely variable. The federal Conditions of Participation require that those making requests of families for organ donation receive specific training. They do not prohibit physician involvement in initiating organ donation requests, provided these individuals are properly trained. Physicians have an important role in caring for patients and families in these circumstances, and the care they provide is enhanced through training, attention to the special issues involved, and collaboration with organ procurement organization personnel.

[Legal responsibilities of anesthesia-resuscitation specialists for professional malpractice]

An experience of consulting at large medical insurance companies is indicative of that anesthesiology and resuscitation belong to most risky professions, which involve a possibility of inflicting an illegal damage on an insured citizen. The reasons of such a situation are as follows: a surface knowledge of the legal-and-normative aspects (which regulate the provision of medical care to citizens) by anesthesiologists and experts in resuscitation; a lack of profound erudition in the main fields of medicine and a comprehensive use of sophisticated medical instruments, which is a source of an extra danger to patients. The protection of both the doctor and the patients is an important issue under such conditions. Therefore, it is necessary to define the rights and obligations of anesthesiologists and experts in resuscitation, to master the normative acts regulating the standards of medical care and to obey strictly the fixed-by-law rights of patients.