Informed Consent Challenges in Frail, Delirious, Demented, and Do-Not-Resuscitate Adult Patients

Considerations in geriatric dermatopathology

This review provides an overview of considerations in geriatric dermatopathology. The nuances of specimen collection and reporting in this population, including the importance of obtaining adequate tissue, providing detailed clinical information and ethical considerations surrounding specimen collection will be discussed. The histopathologic changes associated with aging and the morphologic features of common lesions related to photoaging are outlined followed by a discussion of common interpretation pitfalls, specifically entities at risk of overinterpretation and those related to hyper- and hypopigmentation. Finally, the recent literature is reviewed regarding special cases and what this implies for future research both in dermatology and dermatopathology.

Consent in Interventional Radiology-How Can We Make It Better?

Informed consent is an important part of the clinician-patient relationship. However, studies suggest consent practices tend to be limited in consistency and completeness. This may be particularly challenging for interventional radiology given more limited public awareness and the often fast-paced, dynamic nature of our practices. This article reviews these challenges as well as ideal consent practices and potential approaches to improve consent in interventional radiology.

The social construction of the patient-physician relationship in the clinical encounter: Media frames on shared decision making in Germany

The literature on healthcare management has noted that shared decision-making (SDM) - a practice of organizing joint decisions between healthcare professionals and patients - should improve healthcare outcomes through patient engagement and autonomy, fostering patient-centeredness. While SDM projects are implemented across Europe and the US, the diffusion of the practice remains partial, and its' conceptualization scattered. Healthcare management literature explores SDM on the underlying assumption that its limited diffusion results from an information problem, implying objective criteria and rational behavior. The purpose of this research is to study the social construction of SDM within the clinical setting and the underlying rationales using the case of one of the largest healthcare markets worldwide - Germany. To capture the complexity of SDM, a frame analysis is conducted on its medial representations. News media is both influential in shaping public opinion, as well as in generating public discourse. This analysis enables one to elaborate different facets of the construct of SDM, to capture inherent patterns of facilitating and obstructing aspects and to explore consequences for the diffusion of SDM. Three facilitating and three obstructive frames on the implementation of SDM were identified. The polarities of these frames range from the questioning of one's decision-making authority to the perception of individual competence and decision-making agency. Moreover, this study reflects on how physicians' and patients' role for SDM is conceived.

All the World Is a Nail: Why Are Surgeons Resistant to Learn How to Place Cholecystostomy Drains in Seriously Ill Patients With Acute Acalculous Cholecystitis?

Surgeons routinely provide palliative care, but often the technical procedure needed for the palliative intervention is beyond our training and comfort zone. This case is an example of surgical palliative care that utilizes image-guided techniques to provide optimal care. A frail elderly patient with multiple comorbidities who had been hospitalized for other diseases was diagnosed with acute acalculous cholecystitis. General surgery and gastroenterology were initially consulted, and the patient was referred to interventional radiology for a percutaneous cholecystostomy. The procedure was technically successful, and the patient's clinical status improved. A few days later, a follow-up cholecystogram showed a decompressed gallbladder, patent cystic duct, a common bile duct free of stones, and dilute contrast in the duodenum. After 2 weeks, the fistula tract was interrogated and found to be intact. The cholecystostomy tube was removed without incident. This case is presented as a call to action for surgeons to learn the skills required to place percutaneous cholecystostomies themselves and to add it to their surgical armamentarium.

Medical Malpractice Primer for Practicing Interventional Radiologists

Medical professional liability (MPL), also commonly referred to as medical malpractice, is a costly issue in health care today, accounting for roughly 2.4% of total health care expenditure in the United States. Almost all physicians currently in clinical practice will either be subject to a lawsuit themselves or work with someone who has. Given a lack of formal structured education about MPL in medicine for trainees, this review aims to define and discuss the relevant concepts in MPL as a reference for early career interventionalists to understand the current medicolegal environment and learn best practices to avoid litigation.

Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery

STUDY DESIGN

This study is a systematic review.

OBJECTIVE

Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery.

SUMMARY OF BACKGROUND DATA

Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%-24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available.

METHODS

A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015.

RESULTS

Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05).

CONCLUSIONS

An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed.

LEVEL OF EVIDENCE

Level II.