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Charles JA, Habibullah NK, Bautista S, Davis B, Joshi S, Hull SC. Planting the Seed for Blood Pressure Control: The Role of Plant-Based Nutrition in the Management of Hypertension. Curr Cardiol Rep 2024; 26:121-134. [PMID: 38526748 PMCID: PMC10990999 DOI: 10.1007/s11886-023-02008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 03/27/2024]
Abstract
PURPOSE OF REVIEW Hypertension results in significant morbidity, mortality, and healthcare expenditures. Fortunately, it is largely preventable and treatable by implementing dietary interventions, though these remain underutilized. Here, we aim to explore the role of healthy dietary patterns in hypertension management and describe approaches for busy clinicians to address nutrition effectively and efficiently with patients. RECENT FINDINGS DASH, Mediterranean, vegetarian, and vegan diets that include minimally processed, plant-based foods as core elements have consistently shown positive effects on hypertension. Recommendations that distill the most healthful components of these diets can significantly impact patient outcomes. Clinicians can harness evidence-based dietary assessment and counseling tools to implement and support behavioral changes, even during brief office visits. Healthful plant-based dietary patterns can often effectively prevent and treat hypertension. Clinicians may help improve patient outcomes by discussing evidence-based nutrition with their patients. Future work to promote infrastructural change that supports incorporating evidence-based nutrition into medical education, clinical care, and society at large can support these efforts.
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Affiliation(s)
- Justin A Charles
- Department of Family Medicine and Public Health, UC San Diego Health, San Diego, CA, USA.
| | | | - Saul Bautista
- Ethos Farm to Health/Ethos Primary Care, Long Valley, NJ, USA
| | - Brenda Davis
- Brenda Davis, Nutrition Consultations, Calgary, AB, Canada
| | - Shivam Joshi
- Department of Veterans Affairs, Orlando, FL, USA
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
- Program for Biomedical Ethics, Yale School of Medicine, New Haven, CT, USA
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2
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Zaidi D, Kirkpatrick JN, Fedson SE, Hull SC. Reply: Ethical and Moral Complexities of Left Ventricular Assist Device Deactivation: Embracing the Uncertainty. JACC Heart Fail 2024; 12:600. [PMID: 38448155 DOI: 10.1016/j.jchf.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 03/08/2024]
Affiliation(s)
- Danish Zaidi
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Savitri E Fedson
- Baylor College of Medicine, Houston, Texas, USA; Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sarah C Hull
- Yale School of Medicine, New Haven, Connecticut, USA.
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3
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Acquaye AGO, Hull SC. Ethics of identity concordance requests in patient-clinician encounters. J Natl Med Assoc 2023; 115:539-544. [PMID: 37880065 DOI: 10.1016/j.jnma.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/10/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
Systemic injustice has resulted in significant baseline inequality amongst populations according to gradients of privilege. What is the ethical approach to situations wherein equity may require differential treatment to correct for baseline disadvantages as a necessary means to its attainment? We explore this concept through the issue of patient requests for clinician identity concordance, when patients request a clinician who matches their race, ethnicity, or gender. Firstly, we discuss ethical grounds for refusing requests by exploring the balance between patient autonomy, a physician's obligation to not abandon one's patients, and the right of a clinician to be free from violence of any form. Next, we explore the ethics surrounding conditional acceptance through the frames of intent and clinical outcomes. We note the legacy of trauma experienced by marginalized patients at the hands of medicine and the abundance of data suggesting that identity concordance can mitigate disparities.
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Affiliation(s)
- Amber G O Acquaye
- Yale School of Medicine, 703 Whitney Ave, New Haven, Connecticut 06511 United States.
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, 15 York Street, PO Box 208017, New Haven, CT 06520-8017 United States; Program for Biomedical Ethics, Yale School of Medicine, 15 York Street, PO Box 208017, New Haven, CT 06520-8017 United States
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4
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Zaidi D, Kirkpatrick JN, Fedson SE, Hull SC. Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework. JACC Heart Fail 2023; 11:1481-1490. [PMID: 37768252 DOI: 10.1016/j.jchf.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/06/2023] [Accepted: 08/08/2023] [Indexed: 09/29/2023]
Abstract
Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.
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Affiliation(s)
- Danish Zaidi
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - James N Kirkpatrick
- Division of Cardiology, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Savitri E Fedson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA; Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA.
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5
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Hull SC, Chou JC, Yee LM, Yee D, Esserman L. A Truly Pro-Life Position Requires Access to Reproductive Health Care. J Womens Health (Larchmt) 2023; 32:1023-1026. [PMID: 37379465 DOI: 10.1089/jwh.2023.0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Affiliation(s)
- Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Josephine C Chou
- Division of Cardiovascular Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Douglas Yee
- Division of Hematology, Oncology, and Transplantation, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California, USA
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6
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Podoltsev NA, Wang R, Shallis RM, Stempel JM, Di M, Neparidze N, Zeidan AM, Huntington SF, Giri S, Hull SC, Gore SD, Ma X. Statin use, survival and incidence of thrombosis among older patients with polycythemia vera and essential thrombocythemia. Cancer Med 2023; 12:18889-18900. [PMID: 37702132 PMCID: PMC10557879 DOI: 10.1002/cam4.6528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/22/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Polycythemia vera (PV) and essential thrombocythemia (ET) are linked to increased risk of cardiovascular morbidity and mortality. In addition to the reduction in of arterial thrombotic events, statins may prevent venous thrombosis including among patients with cancer. As previous registry- and claims-based studies revealed that the use of statins may improve the survival of patients with various malignancies we evaluated their impact on outcomes of older adults with PV and ET. METHODS We identified 4010 older adults (aged 66-99 years at diagnosis) with PV (n = 1809) and ET (n = 2201) in a population-based cohort study using the Surveillance, Epidemiology, and End Results-Medicare database with median follow-up of 3.92 (interquartile range: 2.58-5.75) years. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) approaches were utilized to assess potential association between statins and overall survival. Multivariable competing risk models with death as a competing risk were used to evaluate possible relationship between statins and the incidence of thrombosis. RESULTS 55.8% of the patients used statins within the first year after PV/ET diagnosis, and statin use was associated with a 22% reduction in all-cause mortality (PSM: hazard ratio [HR] = 0.78, 95% confidence interval [CI]: 0.63-0.98, p = 0.03; IPTW: HR = 0.79, 95% CI: 0.64-0.97, p = 0.03). Statins also reduced the risk of thrombosis in this patient population (PSM: HR = 0.63, 95% CI: 0.51-0.78, p < 0.01; IPTW: HR = 0.57, 95% CI: 0.49-0.66, p < 0.01) as well as in PV and ET subgroups. CONCLUSIONS These findings suggest that it may be important to incorporate statins into the therapeutic strategy for older adults with PV and ET.
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Affiliation(s)
- Nikolai A. Podoltsev
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
- Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenConnecticutUSA
| | - Rory M. Shallis
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Jessica M. Stempel
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Mengyang Di
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Natalia Neparidze
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Scott F. Huntington
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
| | - Smith Giri
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Present address:
Division of Hematology and OncologyUniversity of Alabama School of MedicineBirminghamAlabamaUSA
| | - Sarah C. Hull
- Section of Cardiology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Steven D. Gore
- Section of Hematology, Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- Present address:
Investigational Drug Branch, Cancer Therapy Evaluation ProgramNational Cancer InstituteBethesdaMarylandUSA
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale UniversityNew HavenConnecticutUSA
- Department of Chronic Disease EpidemiologyYale School of Public HealthNew HavenConnecticutUSA
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7
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Hull SC, Thamman R. Turning Up the Ethical Gain: The Importance of Accurate Echocardiographic Assessment for Improved Cardiovascular Outcomes in Women. J Am Soc Echocardiogr 2023:S0894-7317(23)00159-1. [PMID: 36963470 DOI: 10.1016/j.echo.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine; Program for Biomedical Ethics, Yale School of Medicine.
| | - Ritu Thamman
- Division of Cardiology, University of Pittsburgh School of Medicine; Center for Bioethics and Health Law, University of Pittsburgh School of Medicine.
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8
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Werner KM, Mercurio MR, Shabanova V, Hull SC, Taylor SN. Pediatricians' Reports of Interaction with Infant Formula Companies. Breastfeed Med 2023; 18:219-225. [PMID: 36795978 DOI: 10.1089/bfm.2022.0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Introduction: Seventy percent of countries follow the World Health Organization International Code of Marketing Breast Milk Substitutes that prohibits infant formula companies (IFC) from providing free products to health care facilities, providing gifts to health care staff, or sponsoring meetings. The United States rejects this code, which may impact breastfeeding rates in certain areas. Objective: We aimed at gathering exploratory data about interactions between IFC and pediatricians. Methods: We distributed an electronic survey to U.S. pediatricians asking about practice demographics, interactions with IFC, and breastfeeding practices. Using the zip code of the practice, we obtained additional information from the 2018 American Communities Survey, including median income, percent of mothers who had graduated college, percent of mothers working, and racial and ethnic identity. We compared demographic data for those pediatricians who had a formula company representative visit versus not and those who had a sponsored meal versus not. Results: Of 200 participants, the majority reported a formula company representative visit to their clinic (85.5%) and receiving free formula samples (90%). Representatives were more likely to visit areas with higher-income patients (median = $100K versus $60K, p < 0.001). They tended to visit and sponsor meals for pediatricians at private practices and in suburban areas. Most of the reported conferences attended (64%) were formula company-sponsored. Conclusion: Interactions between IFC and pediatricians are prevalent and occur in many forms. Future studies may reveal whether these interactions influence the advice of pediatricians or the behavior of mothers who had planned to exclusively breastfeed.
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Affiliation(s)
- Kelly M Werner
- Division of Neonatology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mark R Mercurio
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA.,Program for Biomedical Ethics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Veronika Shabanova
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Biostatistics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah C Hull
- Program for Biomedical Ethics, Yale University School of Medicine, New Haven, Connecticut, USA.,Section of Cardiology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah N Taylor
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
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9
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Hull SC, Oen-Hsiao JM, Spatz ES. Practical and Ethical Considerations in Telehealth: Pitfalls and Opportunities. Yale J Biol Med 2022; 95:367-370. [PMID: 36187411 PMCID: PMC9511944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Telehealth has been a long-awaited advancement with the potential to improve efficiency, convenience, and quality in healthcare. However, as telehealth becomes integrated into routine clinical care, it is imperative to consider the practical and ethical implications that could undermine or devalue care delivery. The medical profession must ensure that it is implemented judiciously and with robust quality standards, guided by fair and equitable policies that balance patient autonomy with rigorous standards of care and access. Such a system must recognize the opportunity for more patient input as stakeholders to tailor care to their needs and preferences, while also acknowledging the risk of suboptimal care if convenience is prioritized over quality. More studies of optimal care models are needed to integrate data in terms of both stakeholder input and outcomes.
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Affiliation(s)
- Sarah C. Hull
- Section of Cardiovascular Medicine, Yale School of
Medicine, New Haven, CT, USA
- Program for Biomedical Ethics, Yale School of Medicine,
New Haven, CT, USA
- To whom all correspondence should be addressed:
Sarah C. Hull, MD, MBE, Assistant Professor of Clinical Medicine (Cardiology),
Associate Director, Program for Biomedical Ethics, Yale School of Medicine, New
Haven, CT; ; ORCID:
https://www.orcid.org/0000-0001-9125-410X
| | - Joyce M. Oen-Hsiao
- Section of Cardiovascular Medicine, Yale School of
Medicine, New Haven, CT, USA
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Yale School of
Medicine, New Haven, CT, USA
- Yale Center for Outcomes Research and Evaluation, New
Haven, CT, USA
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10
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Hull SC. Patient Communication: Take the Time to Do it Right. JACC Heart Fail 2022; 10:439-440. [PMID: 35654528 DOI: 10.1016/j.jchf.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Sarah C Hull
- Section of Cardiovascular Medicine, and Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA.
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11
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Havlik JL, Mercurio MR, Hull SC. The Case for Ethical Efficiency: A System That Has Run Out of Time. Hastings Cent Rep 2022; 52:14-20. [PMID: 35476354 DOI: 10.1002/hast.1351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The American health care system increasingly conflates physician "productivity" with true clinical efficiency. In reality, inordinate time pressure on physicians compromises quality of care, decreases patient satisfaction, increases clinician burnout, and costs the health care system a great deal in the long term even if it is financially expedient in the short term. Inadequate time to deliver care thereby conflicts with the core principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. We propose that the health care system adjust its focus to recognize the nonmonetary value of physician time while still realizing the need to deploy resources as effectively as possible, a concept we describe as "ethical efficiency."
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12
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Tolchin B, Latham SR, Bruce L, Ferrante LE, Kraschel K, Jubanyik K, Hull SC, Herbst JL, Kapo J, Moritz ED, Hughes J, Siegel MD, Mercurio MR. Reflections on New Evidence on Crisis Standards of Care in the COVID-19 Pandemic. The Journal of Clinical Ethics 2021. [DOI: 10.1086/jce2021324358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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13
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Hull SC, Soufer A, Spatz ES, Baldassarre LA. Rationale and proposed framework for shared decision making in cardio-oncology. Cardiooncology 2021; 7:30. [PMID: 34425913 PMCID: PMC8380868 DOI: 10.1186/s40959-021-00118-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/12/2021] [Indexed: 12/24/2022]
Abstract
Physicians have a duty to present diagnostic and therapeutic choices with rational guidance that respects patient values and realizes patient goals. In cardio-oncology, we commonly encounter patients who understandably feel overwhelmed or feel that they have no favorable options, particularly in the context of advanced malignancy. Accordingly, a longitudinal multidisciplinary commitment to shared decision making (SDM) ensures that physicians and patients actively participate in this process to promote the best possible outcomes from the patient perspective. We propose a practical framework for approaching these difficult decisions in cardio-oncology drawing upon our experience in clinical practice.
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Affiliation(s)
- Sarah C Hull
- Section of Cardiovascular Medicine, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA. .,Program for Biomedical Ethics, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA.
| | - Aaron Soufer
- Section of Cardiovascular Medicine, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Erica S Spatz
- Section of Cardiovascular Medicine, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA.,Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Lauren A Baldassarre
- Section of Cardiovascular Medicine, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
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14
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Abstract
By convention, the ascending aorta is measured by echo from leading edge to leading edge. "Leading edge" connotes the edge of the aortic wall that is closest to the probe (at the top of the inverted "V" of the ultrasound image). By transthoracic echo (TTE), the leading edges are the outer anterior wall and inner posterior wall. By transesophageal echo (TEE), the leading edges are the outer posterior wall and inner anterior wall. Aortic measurements should be taken (by convention) in diastole (when the aorta is moving least). Simple TTE is 70 to 85% sensitive in diagnosing ascending aortic dissection. TEE sensitivity approaches 100%, though the tracheal carina imposes a blind spot on TEE, impeding visualization of distal ascending aorta and proximal aortic arch. While computed tomography angiography may be superior for defining full anatomic extent of aortic dissection, echocardiography is superior in assessing functional consequences such as mechanism and severity of aortic regurgitation, evidence of myocardial ischemia when complicated by coronary dissection, or evidence of tamponade physiology when pericardial effusion is present. Reverberation artifact can mimic a dissection flap. A true flap moves independently of the outer aortic wall which can be confirmed by M-mode. Color flow respects a true flap but does not respect a reverberation artifact. Assessment for bicuspid aortic valve (BAV) morphology should be done in systole, not diastole. In diastole, when the valve is closed, the raphé can make a bicuspid valve appear trileaflet. Doming in the parasternal long axis (PLAX) view and an eccentric closure line on PLAX M-mode should also raise suspicion for BAV.
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Affiliation(s)
- Krishna Upadhyaya
- Section of Cardiovascular Medicine, Columbia St. Mary's Hospital, Milwaukee, Wisconsin
| | - Ifeoma Ugonabo
- Division of Cardiovascular Diseases, University of Tennessee-Methodist, Knoxville, Tennessee
| | - Keyuree Satam
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Columbia St. Mary's Hospital, Milwaukee, Wisconsin
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15
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Tolchin B, Latham SR, Bruce L, Ferrante LE, Kraschel K, Jubanyik K, Hull SC, Herbst JL, Kapo J, Moritz ED, Hughes J, Siegel MD, Mercurio MR. Reflections on New Evidence on Crisis Standards of Care in the COVID-19 Pandemic. J Clin Ethics 2021; 32:358-360. [PMID: 34928864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Crisis standards of care have been widely developed by healthcare systems and states in the United States during the COVID-19 pandemic, and in some rare cases have actually been used to allocate medical resources. All publicly available U.S. crisis standards of care with a mechanism for allocating scarce resources make use of the Sequential Organ Failure Assessment (SOFA) score in hopes of assigning scarce resources to those patients who are more likely to survive. We reflect on the growing body of evidence suggesting that the SOFA score has limited accuracy in predicting mortality among patients hospitalized with COVID-19 and that the SOFA score systematically disfavors Black patients. Use of the SOFA score for allocating scarce resources may therefore result in Black patients with equal likelihood of survival being deprived of life-saving medical resources. There is also a risk of injustice for patients with non-COVID-19 diagnoses, for whom the SOFA score may be a more accurate prognostic score, but who might nevertheless be unfairly (de)prioritized when assessed alongside COVID-19 patients using the same scoring system. For these reasons we recommend that the SOFA score not be used for triage purposes during the COVID pandemic, and that a national effort be made to develop and empirically test crisis standards of care in advance of the next public health emergency.
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Affiliation(s)
- Benjamin Tolchin
- Yale New Haven Health System; Department of Neurology, Yale School of Medicine; Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System, New Haven, Connecticut USA.
| | - Stephen R Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, Connecticut USA
| | - Lori Bruce
- Interdisciplinary Center for Bioethics, Yale University, New Haven, Connecticut USA
| | - Lauren E Ferrante
- Yale New Haven Health System; Department of Neurology, Yale School of Medicine; Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System; Interdisciplinary Center for Bioethics, Yale University; Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New Haven, Connecticut USA
| | - Katherine Kraschel
- Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut USA
| | - Karen Jubanyik
- Yale New Haven Health System; Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut USA
| | - Sarah C Hull
- Yale New Haven Health System; Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine; Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut USA
| | - Jennifer L Herbst
- Quinnipiac University School of Law; Frank H. Netter, MD, School of Medicine at Quinnipiac University, North Haven, Connecticut USA
| | - Jennifer Kapo
- Yale New Haven Health System; Program in Palliative Care, Yale School of Medicine, New Haven, Connecticut USA
| | - Ernest D Moritz
- Yale New Haven Health System; Program in Palliative Care, Yale School of Medicine, New Haven, Connecticut USA
| | - John Hughes
- Yale New Haven Health System; Program for Biomedical Ethics, Yale School of Medicine; Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut USA
| | - Mark D Siegel
- Yale New Haven Health System; Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut USA
| | - Mark R Mercurio
- Yale New Haven Health System; Program for Biomedical Ethics, Yale School of Medicine; Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut USA
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16
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Hull SC. Echocardiographic Assessment of the Aorta: Tips and Pitfalls. Aorta (Stamford) 2020; 8:161-162. [PMID: 33761567 PMCID: PMC8043812 DOI: 10.1055/s-0040-1721750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
AbstractThis Yale Aortic Institute lecture provides “tips and pitfalls” regarding echocardiographic assessment of the aorta.
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Affiliation(s)
- Sarah C. Hull
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
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17
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Tolchin B, Latham SR, Bruce L, Ferrante LE, Kraschel K, Jubanyik K, Hull SC, Herbst JL, Kapo J, Moritz ED, Hughes J, Siegel MD, Mercurio MR. Developing a Triage Protocol for the COVID-19 Pandemic: Allocating Scarce Medical Resources in a Public Health Emergency. The Journal of Clinical Ethics 2020. [DOI: 10.1086/jce2020314303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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18
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Tolchin B, Hull SC, Kraschel K. Triage and justice in an unjust pandemic: ethical allocation of scarce medical resources in the setting of racial and socioeconomic disparities. J Med Ethics 2020; 47:medethics-2020-106457. [PMID: 33067315 DOI: 10.1136/medethics-2020-106457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/21/2020] [Accepted: 10/02/2020] [Indexed: 06/11/2023]
Abstract
Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change.
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Affiliation(s)
- Benjamin Tolchin
- Neurology, Yale School of Medicine, New Haven, Connecticut, USA
- Epilepsy Center of Excellence, VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Adult Ethics Committee, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Sarah C Hull
- Cardiology, Yale School of Medicine, New Haven, Connecticut, USA
- Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Kraschel
- Solomon Center for Health Law & Policy, Yale Law School, New Haven, Connecticut, USA
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19
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Kirkpatrick JN, Hull SC, Fedson S, Mullen B, Goodlin SJ. Scarce-Resource Allocation and Patient Triage During the COVID-19 Pandemic: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 76:85-92. [PMID: 32407772 PMCID: PMC7213960 DOI: 10.1016/j.jacc.2020.05.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 11/29/2022]
Abstract
The COVID-19 pandemic and its sequelae have created scenarios of scarce medical resources, leading to the prospect that health care systems have faced or will face difficult decisions about triage, allocation, and reallocation. These decisions should be guided by ethical principles and values, should not be made before crisis standards have been declared by authorities, and, in most cases, will not be made by bedside clinicians. Do not attempt resuscitation and withholding and withdrawing decisions should be made according to standard determination of medical appropriateness and futility, but there are unique considerations during a pandemic. Transparent and clear communication is crucial, coupled with dedication to provide the best possible care to patients, including palliative care. As medical knowledge about COVID-19 grows, more will be known about prognostic factors that can guide these difficult decisions. Difficult decisions about triage and allocation have arisen in the COVID-19 pandemic. In a crisis, autonomy may become subordinate to maximize the number of lives saved. Fairness involves equal access to scarce resources, ignoring factors unrelated to prognosis and maximizing benefit. Transparent communication and palliative care are central to providing the best possible care to patients.
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Affiliation(s)
- James N Kirkpatrick
- Division of Cardiology and Department of Bioethics and Humanities, University of Washington, Seattle, Washington.
| | - Sarah C Hull
- Section of Cardiovascular Medicine, Program for Biomedical Ethics, Yale University, New Haven, Connecticut
| | - Savitri Fedson
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Section of Cardiology, Michael E DeBakey VA Medical Center, Houston, Texas
| | | | - Sarah J Goodlin
- Department of Geriatrics and Palliative Medicine, VAPORHCS, Oregon Health Sciences University, Patient-Centered Education and Research, Portland, Oregon
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20
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Tolchin B, Latham SR, Bruce L, Ferrante LE, Kraschel K, Jubanyik K, Hull SC, Herbst JL, Kapo J, Moritz ED, Hughes J, Siegel MD, Mercurio MR. Developing a Triage Protocol for the COVID-19 Pandemic: Allocating Scarce Medical Resources in a Public Health Emergency. J Clin Ethics 2020; 31:303-317. [PMID: 32991327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The coronavirus disease-2019 (COVID-19) has caused shortages of life-sustaining medical resources, and future waves of the virus may cause further scarcity. The Yale New Haven Health System developed a triage protocol to allocate scarce medical resources during the COVID-19 pandemic, with the primary goal of saving the most lives possible, and a secondary goal of making triage assessments and decisions consistent, transparent, and fair. We outline the process of developing the triage protocol, summarize the protocol itself, and discuss the major ethical challenges encountered, along with our answers to these challenges. These challenges include (1) the role of age and chronic comorbidities; (2) evaluating children and pregnant patients; (3) racial, ethnic, and socioeconomic disparities in health; (4) prioritization of healthcare workers; and (5) balancing clinical judgment versus protocolized assessments. We conclude with a review of the limitations of our protocol and the lessons learned. We hope that a robust public discussion of such protocols and the ethical challenges that they raise will result in the fairest possible processes, less need for triage, and more lives saved during future waves of the COVID-19 pandemic and similar public health emergencies.
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Affiliation(s)
- Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut USA.
| | - Stephen R Latham
- Yale Interdisciplinary Center for Bioethics, New Haven, Connecticut USA.
| | - Lori Bruce
- Yale Interdisciplinary Center for Bioethics, New Haven, Connecticut USA.
| | - Lauren E Ferrante
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut USA.
| | | | - Karen Jubanyik
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut USA.
| | - Sarah C Hull
- Program for Biomedical Ethics, Yale School of Medicine, New Haven, Connecticut USA.
| | | | - Jennifer Kapo
- Palliative Medicine, Yale School of Medicine, New Haven, Connecticut USA.
| | - Ernest D Moritz
- Adult Ethics Committee, Yale New Haven Health System, New Haven, Connecticut USA.
| | - John Hughes
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut USA.
| | - Mark D Siegel
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut USA.
| | - Mark R Mercurio
- Pediatrics and Program for Biomedical Ethics, Yale School of Medicine, in New Haven, Connecticut USA.
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21
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Campelia GD, Barg FK, Kirkpatrick JN, Hull SC. Care Labor in VAD Therapy: Some Feminist Concerns. Perspect Biol Med 2019; 62:640-656. [PMID: 31761798 DOI: 10.1353/pbm.2019.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Ventricular assist device (VAD) care offers a distinctive lens through which we can explore unjust gender norms. This is a resource-intensive intervention, one in which increasingly sophisticated technology brings with it the need for more long-term care. This care work is demanding, involving device maintenance, medication and appointment management, household work, and emotional support. Most patients eligible for receiving VADs are men, so it is not surprising that it is more often women who are responsible for the care of patients with VADs. Still, there is room to question why so much of this labor is expected of and taken on by female caregivers, when it could be shared with male caregivers and even patients themselves. To the extent that gender difference in the distribution of this labor is avoidable and inequitable, it becomes in part a disparity resulting from unjust social norms. In order to unpack some of this injustice, the authors utilize empiric data and theoretical work in feminist ethics to articulate some of the mechanisms of the gender disparity in VAD care labor and to offer communitarian decision-making and redistribution of care labor as potential routes toward greater justice for women with respect to VAD therapy.
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Barg FK, Kellom K, Ziv T, Hull SC, Suhail-Sindhu S, Kirkpatrick JN. LVAD-DT: Culture of Rescue and Liminal Experience in the Treatment of Heart Failure. Am J Bioeth 2017; 17:3-11. [PMID: 28112612 DOI: 10.1080/15265161.2016.1265162] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of this article is to investigate how cultural meanings associated with the left ventricular assist device (LVAD) inform acceptance and experience of this innovative technology when it is used as a destination therapy. We conducted open-ended, semistructured interviews with family caregivers and patients who had undergone LVAD-DT procedures at six U.S. hospitals. A grounded theory approach was used for the analysis. Thirty-nine patients and 42 caregivers participated. Participants described a sense of obligation to undergo the procedure because of its promise for salvation. However, once the device was implanted, patients described being placed into a liminal state of being neither sick nor healthy, with no culturally scripted role. Consideration of end-of-life decisions was complicated by the uncertainties about how patients with LVADs die. Pre-implantation communications among patient, family, and clinicians should take into account the impact of the technology on meaning, identity, and patient experience.
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Affiliation(s)
- Frances K Barg
- a Perelman School of Medicine at the University of Pennsylvania
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23
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Chokshi S, Jacox J, Hull SC, Sanft T. The Heartaches of Cancer Therapy: Acute and Late Cardiotoxicity in Cancer Survivors. Oncology (Williston Park) 2016; 30:1095-1098. [PMID: 27987202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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24
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Kirkpatrick JN, Kellom K, Hull SC, Henderson R, Singh J, Coyle LA, Mountis M, Shore ED, Petrucci R, Cronholm PF, Barg FK. Caregivers and Left Ventricular Assist Devices as a Destination, Not a Journey. J Card Fail 2015; 21:806-15. [DOI: 10.1016/j.cardfail.2015.05.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 05/28/2015] [Accepted: 05/29/2015] [Indexed: 01/14/2023]
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25
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Goldenberg AJ, Hull SC, Wilfond BS, Sharp RR. Patient perspectives on group benefits and harms in genetic research. Public Health Genomics 2010; 14:135-42. [PMID: 20938159 DOI: 10.1159/000317497] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 06/21/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is unclear how the possible effects of genetic research on socially identifiable groups may impact patient willingness to donate biological samples for future genetic studies. METHODS Telephone interviews with patients at 5 academic medical centers in the U.S. examined how patients' beliefs about benefits and harms to ones racial or ethnic group shape decisions to participate in genetic research. RESULTS Of the 1,113 patients who responded to questions about group harms and benefits, 61% of respondents indicated that potential benefits to their own racial or ethnic group would be a big or moderate part of their decision to donate a sample for genetic research. 63% of black respondents and 57% of white respondents indicated that they were 'very' or 'moderately concerned' about genetic research findings being used to discriminate against people by race or ethnicity. 64% of black and 34% of white respondents reported that their willingness to donate a blood sample would be substantially reduced due to these concerns. CONCLUSION Our findings suggest that a key factor in many patients' decisions to donate samples for genetic research is how those studies may impact identifiable racial and ethnic groups. Given the importance of these considerations to many patients, our study highlights a need to address patients' concerns about potential group benefits and harms in the design of future research studies and DNA biobanks.
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Affiliation(s)
- A J Goldenberg
- Department of Bioethics, Case Western Reserve University, Cleveland, Ohio, USA
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26
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Abstract
Vaccination policy in the case of human papillomavirus (HPV) has remained a constant source of controversy ever since Gardasil, Merck's vaccine against HPV, received US Food and Drug Administration approval in the summer of 2006. This controversy has centered on the risks and benefits of vaccinating girls and women in rich and poor nations alike. However, despite all of the attention created by this important policy question, relatively little has been focused on another key public health question: should boys be vaccinated against HPV as well? If herd immunity against the most carcinogenic strains of HPV could be more rapidly and efficiently achieved by vaccinating everyone at risk for being a carrier, it logically follows that vaccine policy should expand to include boys and men.
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Affiliation(s)
- Sarah C Hull
- Center for Bioethics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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27
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Abstract
BACKGROUND Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation. OBJECTIVE To identify strategies used by physicians in dealing with ethical difficulties in their practice. DESIGN, SETTING, AND PARTICIPANTS National survey of internists, oncologists, and intensive care specialists by computer assisted telephone interviews (n = 344, response rate = 64%). As part of this survey, we asked physicians to tell us about a recent ethical dilemma they had encountered in their medical practice. Transcripts of their open-ended responses were analysed using coding and analytical elements of the grounded theory approach. MAIN MEASUREMENTS Strategies and approaches reported by respondents as part of their account of a recent ethical difficulty they had encountered in their practice. RESULTS When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients' wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent's integrity and that of the group of decision makers could also compete with each other. CONCLUSION In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process.
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Affiliation(s)
- S A Hurst
- Department of Clinical Bioethics, National Institutes of Health, Bethesda, MD, USA.
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Abstract
This article critiques an advertisement in a theatre playbill by a bio-technology company for its commercial test for the BRCA1 and BRCA2 genetic mutation, which may indicate a higher risk for breast and ovarian cancer. The advertisement targets a vulnerable audience attending a play about one woman's isolated and painful death from ovarian cancer. It promotes a product with incomplete and at times incorrect information, and it misguides women by suggesting that they contact the company directly about this test, rather than encouraging them to talk to their health care providers about genetic testing and their personal risk of breast cancer. In an era in which more genetic tests will be integrated into clinical practice, we can expect an increase in direct-to-consumer marketing for such tests. This advertisement is an example of what we need to be on guard against.
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Affiliation(s)
- S C Hull
- Bioethics Section, Medical Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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Abstract
BACKGROUND Institutional review boards (IRBs) are given discretion to interpret and apply the federal regulations governing the protection of human subjects in research. OBJECTIVE To determine the extent of the variability among different IRBs on their approved research practices and informed consent forms within the context of a multicenter trial that used a common protocol. DESIGN Descriptive analysis of survey information and informed consent forms. SETTING AND PARTICIPANTS Sixteen IRBs from the institutions participating in a multicenter trial comparing lower vs. traditional tidal volume ventilation in patients with acute lung injury. MEASUREMENTS Analysis of survey information on IRBs' approved research practices. Analysis of informed consent forms for the presence and the adequacy of description of each basic element of informed consent specified in the federal regulations. Reading levels of informed consent forms. MAIN RESULTS Surveys and IRB-approved consent forms were obtained from all of the contacted IRBs (n = 16). Variability was observed among several of the research practices; one IRB waived the requirement for informed consent, five IRBs permitted telephone consent, and three IRBs allowed prisoners to be enrolled. Three consent forms contained all of the basic elements of informed consent outlined in the federal regulations, and 13 forms had varying numbers of these elements absent (six forms without one element, four without two, one without three, and two without four). Reading levels of the consent forms ranged from grades 8.2 to 13.4 (mean +/- sd was 11.6 +/- 1.2 grade level). CONCLUSIONS Within a multicenter trial, IRBs reviewing a common protocol varied in several of their approved research practices and in the extent to which the basic elements of informed consent were included in their consent forms.
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Affiliation(s)
- H Silverman
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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Hull SC, Prasad K. Reading between the lines: direct-to-consumer advertising of genetic testing. Hastings Cent Rep 2001; 31:33-5. [PMID: 11478123 PMCID: PMC4809519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
A case study in the kinds of problems to expect from this increasingly popular marketing tactic.
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Hull SC, Kass NE. Adults with cystic fibrosis and (in)fertility: how has the health care system responded? J Androl 2000; 21:809-13. [PMID: 11105906 PMCID: PMC4819317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- S C Hull
- Bioethics Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892-1156, USA.
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