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Howe EG. Questions Care Providers Should Ask When They Have Ethical Discretion. J Clin Ethics 2023; 34:5-10. [PMID: 36940350 DOI: 10.1086/723705] [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: 03/22/2023]
Abstract
AbstractSince some care providers give colleagues' interests priority over patients' and families', they are at risk of imposing their bias on patients without knowing this. In this piece I discuss how the risk increases when care providers have greater discretion and how they can best avoid this risk. I discuss identifying these situations, assessing them, and then, based on what they have concluded, intervening and use their having inadequate resources, their seeing what patients want as futile, and their making decisions regarding surrogate decision makers as paradigmatic examples. As "remedies," I suggest that care providers share with patients their rationales, validate adaptive aspects of difficult behaviors, self-disclose, and sometimes even go beyond their usual clinical practices.
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Abstract
Experts have an obligation to make difficult decisions rather than offloading these decisions onto others who may be less well equipped to make them. This commentary considers this obligation through the lens of drafting critical care rationing protocols to address COVID-19-induced scarcity. The author recalls her own experience as a member of multiple groups charged with the generation of protocols for how hospitals and states should ration critical care resources like ventilators and intensive care unit beds, in the event that there would not be enough to go around as the COVID-19 pandemic intensified. She identifies several obvious lessons learned through this process, including the need to combat the pervasive effects of racism, ableism, and other forms of discrimination; to enhance the diversity, equity, and inclusion built into the process of drafting rationing protocols; and to embrace transparency, including acknowledging failings and fallibility. She also comes to a more complicated conclusion: Individuals in a position of authority, such as medical ethicists, have a moral obligation to embrace assertion, even when such assertions may well turn out to be wrong. She notes that when the decision-making process is grounded in legitimacy, medical ethics must have the moral courage to embrace fallibility.
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Affiliation(s)
- Karola V Kreitmair
- K.V. Kreitmair is assistant professor of bioethics, Department of Medical History and Bioethics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
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3
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Liu KY, Schneider LS, Howard R. The need to show minimum clinically important differences in Alzheimer's disease trials. Lancet Psychiatry 2021; 8:1013-1016. [PMID: 34087114 DOI: 10.1016/s2215-0366(21)00197-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/19/2021] [Accepted: 05/11/2021] [Indexed: 12/17/2022]
Abstract
Deciding on the smallest change in an outcome that constitutes a clinically meaningful treatment effect (ie, the minimum clinically important difference [MCID]) is fundamental to interpreting clinical trial outcomes, making clinical decisions, and designing studies with sufficient statistical power to detect any such effect. There is no consensus on MCIDs for outcomes in Alzheimer's disease trials, but the US Food and Drug Administration's consideration of aducanumab clinical trials data has exposed the uncertainty of the clinical meaning of statistically significant but small improvements. Although MCIDs for outcomes, including Clinical Dementia Rating-Sum of Boxes and Mini-Mental State Examination in Alzheimer's disease have been reported, the Food and Drug Administration's guidelines, drafted in 1989 to facilitate regulatory approval of substantially effective antidementia drugs, do not specify quantified minimum differences. Although it is important that regulatory requirements encourage drug development and approval, without MCIDs, sponsors are motivated to power trials to detect statistical significance for only small and potentially inconsequential effects on clinical outcomes. MCIDs benefit patients, family members, caregivers, and health-care systems and should be incorporated into clinical trials and drug development guidance for Alzheimer's disease.
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Affiliation(s)
- Kathy Y Liu
- Division of Psychiatry, University College London, London, UK.
| | - Lon S Schneider
- Department of Psychiatry and the Behavioral Sciences, and Department of Neurology, Keck School of Medicine, and Leonard Davis School of Gerontology of the University of Southern California, Los Angeles, CA, USA
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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4
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Davies EM, Bridges AJ, Chung EML. Does radiology require informed consent for radiation risk? Br J Radiol 2021; 94:20210620. [PMID: 34357789 PMCID: PMC8553186 DOI: 10.1259/bjr.20210620] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 11/05/2022] Open
Abstract
Recent trends in medical decision-making have moved from paternalistic doctor-patient relations to shared decision-making. Informed consent is fundamental to this process and to ensuring patients' ongoing trust in the health-care profession. It cannot be assumed that patients consent to the risk associated with medical exposures, unless they have been provided with the information to make that decision. This position is supported by both the legal and ethical framework around Radiation Protection detailed in this commentary.
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Affiliation(s)
- Elizabeth M Davies
- University
Hospitals of Leicester NHS Trust, Infirmary Square,
Leicester, England, United
Kingdom
| | - Andrew J Bridges
- University
Hospitals of Leicester NHS Trust, Infirmary Square,
Leicester, England, United
Kingdom
| | - Emma ML Chung
- University
Hospitals of Leicester NHS Trust, Infirmary Square,
Leicester, England, United
Kingdom
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5
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Kuczewski M, Wasson K, Hutchison PJ, Dilling DF. Putting ethics and clinical decision making before politics: requiring COVID-19 immunization for Solid Organ Transplantation (SOT) Candidates and their Support Team. J Heart Lung Transplant 2021; 41:17-19. [PMID: 34799246 PMCID: PMC8530775 DOI: 10.1016/j.healun.2021.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022] Open
Abstract
We recommend that vaccination for COVID-19 should be a requirement for waitlist activation for solid organ transplant (SOT). We also recommend that such vaccination be required of the primary member of the in-home support team. We argue that these requirements are consistent with current standard practices that draw on a well-established ethical framework. As a result, these recommendations should be easily received and are only controversial owing to the inflamed and politicized state of public discourse.
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Affiliation(s)
- Mark Kuczewski
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois.
| | - Katherine Wasson
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Paul J Hutchison
- Department of Internal Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Daniel F Dilling
- Lung Transplantation, Department of Internal Medicine, Loyola University Health System, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
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6
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Affiliation(s)
- Chandrasekar Gopalakrishnan
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Abstract
Machine learning (ML) algorithms are powerful prediction tools with immense potential in the clinical setting. There are a number of existing clinical tools that use ML, and many more are in development. Physicians are important stakeholders in the health care system, but most are not equipped to make informed decisions regarding deployment and application of ML technologies in patient care. It is of paramount importance that ML concepts are integrated into medical curricula to position physicians to become informed consumers of the emerging tools employing ML. This paradigm shift is similar to the evidence-based medicine (EBM) movement of the 1990s. At that time, EBM was a novel concept; now, EBM is considered an essential component of medical curricula and critical to the provision of high-quality patient care. ML has the potential to have a similar, if not greater, impact on the practice of medicine. As this technology continues its inexorable march forward, educators must continue to evaluate medical curricula to ensure that physicians are trained to be informed stakeholders in the health care of tomorrow.
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Affiliation(s)
- Cornelius A James
- C.A. James is assistant professor, Departments of Internal Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kevin M Wheelock
- K.M. Wheelock is an internal medicine house officer, Yale School of Medicine, New Haven, Connecticut
| | - James O Woolliscroft
- J.O. Woolliscroft is professor, Departments of Internal Medicine and Learning Health Sciences, and Lyle C. Roll Professor of Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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Saeed F, Duberstein PR, Epstein RM, Lang VJ, Liebman SE. Frequency and Severity of Moral Distress in Nephrology Fellows: A National Survey. Am J Nephrol 2021; 52:487-495. [PMID: 34153971 PMCID: PMC10073901 DOI: 10.1159/000516575] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/02/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Moral distress is a negative affective response to a situation in which one is compelled to act in a way that conflicts with one's values. Little is known about the workplace scenarios that elicit moral distress in nephrology fellows. METHODS We sent a moral distress survey to 148 nephrology fellowship directors with a request to forward it to their fellows. Using a 5-point (0-4) scale, fellows rated both the frequency (never to very frequently) and severity (not at all disturbing to very disturbing) of commonly encountered workplace scenarios. Ratings of ≥3 were used to define "frequent" and "moderate-to-severe" moral distress. RESULTS The survey was forwarded by 64 fellowship directors to 386 fellows, 142 of whom (37%) responded. Their mean age was 33 ± 3.6 years and 43% were female. The scenarios that most commonly elicited moderate to severe moral distress were initiating dialysis in situations that the fellow considered futile (77%), continuing dialysis in a hopelessly ill patient (81%) and carrying a high patient census (75%), and observing other providers giving overly optimistic descriptions of the benefits of dialysis (64%). Approximately 27% had considered quitting fellowship during training, including 9% at the time of survey completion. CONCLUSION A substantial majority of nephrology trainees experienced moral distress of moderate to severe intensity, mainly related to the futile treatment of hopelessly ill patients. Efforts to reduce moral distress in trainees are required.
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Affiliation(s)
- Fahad Saeed
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Public Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Paul R. Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Ronald M. Epstein
- Division of Palliative Care, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Center for Communication and Disparities Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Valerie J Lang
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Hospital Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Scott E. Liebman
- Division of Nephrology, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Asom A. "I Can't Breathe"-COVID-19 Perspectives as a Black Trainee. Acad Med 2021; 96:781-782. [PMID: 33538468 PMCID: PMC8140627 DOI: 10.1097/acm.0000000000003962] [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] [Indexed: 06/12/2023]
Affiliation(s)
- Anase Asom
- Fourth-year medical student, University of Chicago Pritzker School of Medicine, Chicago, Illinois; ; Twitter:@anaseasom; ORCID: https://orcid.org/0000-0001-7049-1536
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Schiappacasse GV. Ethical Considerations in Chemotherapy and Vaccines in Cancer Patients in Times of the COVID-19 Pandemic. Curr Oncol 2021; 28:2007-2013. [PMID: 34073214 PMCID: PMC8161828 DOI: 10.3390/curroncol28030186] [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] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022] Open
Abstract
The COVID-19 situation is a worldwide health emergency with strong implications in clinical oncology. In this viewpoint, we address two crucial dilemmas from the ethical dimension: (1) Is it ethical to postpone or suspend cancer treatments which offer a statistically significant benefit in quality of life and survival in cancer patients during this time of pandemic?; (2) Should we vaccinate cancer patients against COVID-19 if scientific studies have not included this subgroup of patients? Regarding the first question, the best available evidence applied to the ethical principles of Beauchamp and Childress shows that treatments (such as chemotherapy) with clinical benefit are fair and beneficial. Indeed, the suspension or delay of such treatments should be considered malefic. Regarding the second question, applying the doctrine of double-effect, we show that the potential beneficial effect of vaccines in the population with cancer (or those one that has had cancer) is much higher than the potential adverse effects of these vaccines. In addition, there is no better and less harmful known solution.
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Affiliation(s)
- Guido V. Schiappacasse
- Oncology Department, Clinical Hospital of Viña del Mar, Limache Street 1741, Viña del Mar 2520000, Chile; ; Tel.: +56-959021201
- Oncology Department, Bupa Reñaca Clinic, Anabaena Street 336, Viña del Mar 2520000, Chile
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11
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Humbyrd CJ. Virtue Ethics in a Value-Driven World: Trolley Troubles. Clin Orthop Relat Res 2021; 479:669-670. [PMID: 32604158 PMCID: PMC8083800 DOI: 10.1097/corr.0000000000001383] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/04/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Casey Jo Humbyrd
- C. J. Humbyrd, Associate Professor of Orthopaedic Surgery and Chief, Foot and Ankle Division, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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12
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Wiebe E, Kelly M, McMorrow T, Tremblay-Huet S, Hennawy M. Assessment of capacity to give informed consent for medical assistance in dying: a qualitative study of clinicians' experience. CMAJ Open 2021; 9:E358-E363. [PMID: 33849985 PMCID: PMC8084565 DOI: 10.9778/cmajo.20200136] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD. METHODS This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide médicale à mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus. RESULTS The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer. INTERPRETATION The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD.
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MESH Headings
- Attitude of Health Personnel
- Canada
- Clinical Decision-Making/ethics
- Clinical Decision-Making/methods
- Codes of Ethics
- Euthanasia, Active, Voluntary/ethics
- Euthanasia, Active, Voluntary/legislation & jurisprudence
- Euthanasia, Active, Voluntary/psychology
- Guidelines as Topic
- Humans
- Informed Consent/standards
- Mental Competency
- Nurses
- Physicians
- Practice Patterns, Physicians'/ethics
- Practice Patterns, Physicians'/standards
- Professional Practice/statistics & numerical data
- Qualitative Research
- Right to Die/ethics
- Right to Die/legislation & jurisprudence
- Social Control, Formal/methods
- Suicide, Assisted/ethics
- Suicide, Assisted/legislation & jurisprudence
- Suicide, Assisted/psychology
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Affiliation(s)
- Ellen Wiebe
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Michaela Kelly
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Thomas McMorrow
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Sabrina Tremblay-Huet
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Mirna Hennawy
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
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13
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Affiliation(s)
- Joseph W. Kaempf
- Women and Children's ServicesProvidence St. Vincent Medical CenterProvidence Health SystemPortlandOregonUSA
| | - Kevin M. Dirksen
- Providence Center for Health Care EthicsProvidence St. Vincent Medical CenterProvidence Health SystemPortlandOregonUSA
| | - Nicholas J. Kockler
- Providence Center for Health Care EthicsProvidence St. Vincent Medical CenterProvidence Health SystemPortlandOregonUSA
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14
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Lee B, Kwon CY. Review of economic analysis of available interventions on idiopathic short stature: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24871. [PMID: 33607861 PMCID: PMC7899841 DOI: 10.1097/md.0000000000024871] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Idiopathic short stature (ISS) causes a high economic burden worldwide. As part of a research project that synthesizes economic evidence for Korean medicine treatment of ISS, we describe the methods that will be used for the comprehensive review of articles that analyze health-related economic evaluation for available interventions for ISS using a systematic review methodology. METHODS Eight electronic English, Korean, and Chinese databases will be searched from their inception until December 2020 to identify studies on the economic evaluation of available interventions on ISS, without language, study design, or publication status restrictions. From the included studies, the effectiveness, utility, and cost data will be collected as the outcome measures by two researchers independently. Descriptive analysis of individual studies will be conducted. If it is judged that the interventions and outcomes of the included studies are sufficiently homogeneous, we will attempt a quantitative synthesis through meta-analysis using Review Manager version 5.4 software (Cochrane, London, UK). RESULTS This study will summarize the evidence regarding the economic evaluation of available interventions for ISS. CONCLUSIONS The findings of this review will help clinicians and patients in evidence-based decision-making in clinical settings and help policy makers develop effective policies and distribute resources based on the available evidence.
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Affiliation(s)
- Boram Lee
- Clinical Medicine Division, Korea Institute of Oriental Medicine, 1672 Yuseongdae-ro, Yuseong-gu, Daejeon
| | - Chan-Young Kwon
- Department of Oriental Neuropsychiatry, Dong-eui University College of Korean Medicine, 62 Yangjeong-ro, Busanjin-gu, Busan, Republic of Korea
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15
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A R, Yue R, Chen B, Huang X. Moxibustion for the treatment of Alzheimer's disease: A protocol for a systematic reviews and meta-analysis. Medicine (Baltimore) 2021; 100:e24657. [PMID: 33578594 PMCID: PMC10545423 DOI: 10.1097/md.0000000000024657] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Alzheimer's disease (AD) occurs in the elderly and the early stage of aging, with early clinical manifestations of memory impairment, cognitive impairment, behavioral change and decline in language function, etc., and eventually loss of the ability to live independently, requiring 24-hour care, and a variety of complications. However, these complications are the direct cause of death in AD patients. With the acceleration of the aging process of society, the incidence of AD is increasing year by year, seriously threatening the physical health and quality of life of the elderly. There are many ways to treat AD, however, moxibustion is especially popular in China. Therefore, our systematic review aims to evaluate the efficacy and safety of moxibustion in the treatment of ADand to provide reliable evidence for clinical decision-makers. METHODS We will search electronic databases including PubMed, Embase, Cochrane Library, China Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Database (WF), and China Scientific Journals Database (VIP) from inception to January 2021. Two authors will independently screen the studies, extract data information, and assess methodological quality through the Cochrane risk of bias (ROB) tool. The RevmanV.5.3 software will be used for statistical analysis. RESULTS The results of this study will evaluate the current status of moxibustion therapy for AD, aiming to prove the effectiveness and safety of moxibustion therapy, and will be published in a peer-reviewed journal. CONCLUSION This systematic review will provide a credible evidence-based for moxibustion in the treatment of AD. INPLASY REGISTRATION NUMBER INPLASY202110021.
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Affiliation(s)
- Rigun A
- Jiangxi University of Traditional Chinese Medicine
| | - Ruizhen Yue
- Jiangxi University of Traditional Chinese Medicine
| | - Baoshan Chen
- Jiangxi University of Traditional Chinese Medicine
| | - Xianbao Huang
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, China
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16
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Abstract
The coronavirus disease 2019 (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals' suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals' risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score as a rationing strategy is necessary in order to assess its acceptability to older people as well as its potential for disparate impacts.
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Affiliation(s)
- Emma Grace Lewis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Breckons
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Richard P Lee
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Catherine Dotchin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
| | - Richard Walker
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
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17
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Howe EG. People with Differences of Sexual Development: Can We Do Better? J Clin Ethics 2021; 32:3-12. [PMID: 33656453] [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: 06/12/2023]
Abstract
This article discusses how careproviders of all types can help people with differences of sexual development (DSD): people with ambiguous genitalia, who used to be referred to as intersexed. Careproviders may be in a unique position to benefit these people by offering to discuss difficult issues that concern them, even when the discussions are brief. Specific interventions include learning about people with DSD, whether through the literature or in the clinic; treating them with optimal respect; raising difficult topics such as sex, fertility, and social stigma; encouraging them and helping them to meet others with DSD; and sharing the strengths that we can see that they have. We have come far, but have a long way to go.
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Affiliation(s)
- Edmund G Howe
- Programs in Medical Ethics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814 USA.
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18
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Abstract
The coronavirus disease 2019 pandemic presents significant challenges for health systems globally, including substantive ethical dilemmas that may pose specific concerns in the context of care for people with kidney disease. Ethical concerns may arise as changes in policy and practice affect the ability of all health professionals to fulfill their ethical duties toward their patients in providing best practice care. In this article, we briefly describe such concerns and elaborate on issues of particular ethical complexity in kidney care: equitable access to dialysis during pandemic surges; balancing the risks and benefits of different kidney failure treatments, specifically with regard to suspending kidney transplantation programs and prioritizing home dialysis, and barriers to shared decision-making; and ensuring ethical practice when using unproven interventions. We present preliminary advice on how to approach these issues and recommend urgent efforts to develop resources that will support health professionals and patients in managing them.
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Affiliation(s)
| | - Jordan A Parsons
- Bristol Medical School, University of Bristol, Bristol, UK; Instituts für Geschichte und Ethik der Medizin, Martin-Luther-Universität Halle-Wittenberg, Halle, Germany
| | - Fergus J Caskey
- Bristol Medical School, University of Bristol, Bristol, UK; The Richard Bright Renal Unit, Southmead Hospital, North Bristol National Health Service Trust, Bristol, UK
| | - David C H Harris
- Centre for Transplantation and Renal Research, Westmead Institute for Medical Research, University of Sydney, Westmead, New South Wales, Australia
| | - Vivekanand Jha
- George Institute for Global Health India, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Manipal Academy of Higher Education (MAHE), Manipal, Karnataka, India
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19
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Chervenak FA, McCullough LB, Grünebaum A, Bornstein E, Sen C, Stanojevic M, Degtyareva M, Kurjak A. Professionally responsible advocacy for women and children first during the COVID-19 pandemic: guidance from World Association of Perinatal Medicine and International Academy of Perinatal Medicine. J Perinat Med 2020; 48:867-873. [PMID: 32769228 DOI: 10.1515/jpm-2020-0329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Received: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 01/21/2023]
Abstract
The goal of perinatal medicine is to provide professionally responsible clinical management of the conditions and diagnoses of pregnant, fetal, and neonatal patients. The New York Declaration of the International Academy of Perinatal Medicine, "Women and children First - or Last?" was directed toward the ethical challenges of perinatal medicine in middle-income and low-income countries. The global COVID-19 pandemic presents common ethical challenges in all countries, independent of their national wealth. In this paper the World Association of Perinatal Medicine provides ethics-based guidance for professionally responsible advocacy for women and children first during the COVID-19 pandemic. We first present an ethical framework that explains ethical reasoning, clinically relevant ethical principles and professional virtues, and decision making with pregnant patients and parents. We then apply this ethical framework to evidence-based treatment and its improvement, planned home birth, ring-fencing obstetric services, attendance of spouse or partner at birth, and the responsible management of organizational resources. Perinatal physicians should focus on the mission of perinatal medicine to put women and children first and frame-shifting when necessary to put the lives and health of the population of patients served by a hospital first.
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Affiliation(s)
- Frank A Chervenak
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Laurence B McCullough
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amos Grünebaum
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Eran Bornstein
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Cihat Sen
- Department of Perinatology, Cerrahpaşa Medical School, University of Istanbul, Istanbul, Turkey
| | - Milan Stanojevic
- Department of Neonatology, University Hospital "Sveti Duh", Zagreb, Croatia
| | - Marina Degtyareva
- Department of Neonatology, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Asim Kurjak
- Department of Obstetrics and Gynecology, University of Zagreb, Zagreb, Croatia
- University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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20
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Lam PT. Self-reflections after disbandment of palliative care unit during COVID-19 pandemic. Hong Kong Med J 2020; 26:463. [PMID: 33034296 DOI: 10.12809/hkmj208654] [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: 06/11/2023] Open
Affiliation(s)
- P T Lam
- Department of Medicine and Geriatrics, United Christian Hospital, Hong Kong
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21
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Dugerdil A, Deriaz J, Hurst-Majno S, Dominicé Dao M. [Ethical questions regarding the medical care of adults with disabilities]. Rev Med Suisse 2020; 16:1790-1795. [PMID: 32997448] [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
Medical care of adults with disabilities, especially those with intellectual disabilities, can be ethically difficult. Several questions arise frequently. Can we administer a life-saving treatment that could impact negatively the patient's quality of life when the patient isn't able to give consent? During this Covid-19 period, can the use of chemical or physical restraints be considered as mistreatment, whereas the aim is to protect others? These are situations where the ethical question holds a central role. Although each clinical situation is unique, this article highlights, through four clinical cases, the ethical principles that should guide physicians in their decision-making process.
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Affiliation(s)
| | | | - Samia Hurst-Majno
- Institut éthique histoire humanités, Faculté de médecine, Université de Genève, 1211 Genève 4
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22
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Aquino YSJ, Cabrera N. Hydroxychloroquine and COVID-19: critiquing the impact of disease public profile on policy and clinical decision-making. J Med Ethics 2020; 46:574-578. [PMID: 32647045 PMCID: PMC7371492 DOI: 10.1136/medethics-2020-106306] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 04/14/2020] [Revised: 06/17/2020] [Accepted: 06/26/2020] [Indexed: 05/04/2023]
Abstract
The controversy surrounding the use of hydroxychloroquine (HCQ), an antimalarial drug, for COVID-19 has raised numerous ethical and policy problems. Since the suggestion that HCQ has potential for COVID-19, there have been varying responses from clinicians and healthcare institutions, ranging from adoption of protocols using HCQ for routine care to the conduct of randomised controlled trials to an effective system-wide prohibition on its use for COVID-19. In this article, we argue that the concept of 'disease public profile' has become a prominent, if not the sole, determinant in decision-making across various healthcare responses to the pandemic. In the case of COVID-19, the disease's public profile is based on clinical and non-clinical factors that include contagiousness, clinical presentation and media coverage. In particular, we briefly examine the dangers of a heightened public profile in magnifying the inequality of diseases and undermining three key ethical concepts, namely (1) evidence-based practice, (2) sustainable allocation and (3) meaningful consent.
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Affiliation(s)
- Yves S J Aquino
- Department of Philosophy, Macquarie University, Sydney, New South Wales, Australia
| | - Nicolo Cabrera
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
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23
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Fournier V, Bretonnière S, Spranzi M. Empirical research in clinical ethics: The 'committed researcher' approach. Bioethics 2020; 34:719-726. [PMID: 32125719 DOI: 10.1111/bioe.12742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 02/05/2019] [Revised: 12/09/2019] [Accepted: 02/06/2020] [Indexed: 06/10/2023]
Abstract
After the 'empirical turn' in bioethics, few specific approaches have been developed for doing clinical ethics research in close connection with clinical decision-making on a daily basis. In this paper we describe the 'committed researcher' approach to research in clinical ethics that we have developed over the years. After comparing it to two similar research methodological approaches, the 'embedded researcher' and 'deliberative engagement', we highlight its main features: it is patient-oriented, it is implemented by collegial and multidisciplinary teams, it uses an ethical grid to build the interview guide, and it is geared towards bringing the results to bear on the public debate surrounding the issue at stake. Finally, we position our methodological approach with respect to the 'is vs. ought' distinction. We argue that our 'commitment researcher' approach to clinical ethics research takes concerned people's life-building values as the main data, and compares them to the larger normative framework underlying the medical practice at stake.
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Affiliation(s)
| | | | - Marta Spranzi
- Clinical Ethics Centre, (AP-HP), Paris, France
- UVSQ, Versailles, France
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24
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Affiliation(s)
- Rachel Burman
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Ruth Cairns
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | | | - Robert Elias
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Victoria Metaxa
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Gareth Owen
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Hazel Polat
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Alex Ruck Keene
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
| | - Emer Sutherland
- Covid-19 Ethics Working Group, King's College Hospital, London, UK
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25
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Yao JS, Dee EC, Milazzo C, Jurado J, Paguio JA. Covid-19 in dementia: an insidious pandemic. Age Ageing 2020; 49:713-715. [PMID: 32584402 PMCID: PMC7337638 DOI: 10.1093/ageing/afaa136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022] Open
Affiliation(s)
- Jasper Seth Yao
- Hoboken University Medical Center, Hoboken, NJ 07030, USA
- Address correspondence to: Jasper Seth Yao. Tel: +639175369876 or +63287277619.
| | | | | | - Jerry Jurado
- Hoboken University Medical Center, Hoboken, NJ 07030, USA
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26
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Crimi C, Impellizzeri P, Campisi R, Nolasco S, Spanevello A, Crimi N. Practical considerations for spirometry during the COVID-19 outbreak: Literature review and insights. Pulmonology 2020; 27:438-447. [PMID: 32800783 PMCID: PMC7405879 DOI: 10.1016/j.pulmoe.2020.07.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background As the Coronavirus disease 2019 (COVID-19) is spreading worldwide, countries are dealing with different phases of the pandemic. Lately, scientific evidence has been growing about the measures for reopening respiratory outpatient services during the COVID-19 pandemic. We aim to summarize the key differences and similarities among recommendations by different national and international organizations. Methods We searched on Google and Pubmed for recently published National and International Recommendations/Guidelines/Position Papers from professional organizations and societies, offering a guidance to physicians on how to safely perform pulmonary function testing during COVID-19 pandemic. We also searched for spirometry manufacturers' operational indications. Results Indications on spirometry were released by the Chinese Task force, the American Thoracic Society, the European Respiratory Society, the Thoracic Society of Australia and New Zealand, the Société de Pneumologie de Langue Française, the Spanish Societies (Sociedad Espanola de Neumologia y Cirugia Toracica, Sociedad Espanola de Alergologia e Inmunologia Clinica, Asociacion de Especialistas en Enfermeria del trabajo, Asociacion de Enfermeria Comunitaria), the Sociedade Portuguesa de Pneumologia, the British Thoracic Society/Association for Respiratory Technology & Physiology, the Irish Thoracic Society, the Sociedad Uruguaya de Neumologia, the Italian Thoracic Society and the Italian Respiratory Society, Cleveland Clinic and Nebraska Medical Center. Detailed technical recommendations were found on manufacturers’ websites. We found several similarities across available guidelines for safely resuming pulmonary function services, as well as differences in criteria for selecting eligible patients for which spirometry is deemed essential and advice which was not homogenous on room ventilation precautions. Conclusions This study shows a synthesis of national/international guidelines allowing practicing physicians to adapt and shape the way to organize their outpatient services locally. There is generally good agreement on the importance of limiting pulmonary function testing to selected cases only. However, significant differences concerning the subsets of candidate patients, as well as on the management of adequate room ventilation, were observed.
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Affiliation(s)
- Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Via Santa Sofia, 78, Catania, Italy.
| | - Pietro Impellizzeri
- Department of Clinical and Experimental Medicine, Section of Respiratory Medicine, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Via Santa Sofia, 78, Catania, Italy.
| | - Raffaele Campisi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Via Santa Sofia, 78, Catania, Italy.
| | - Santi Nolasco
- Department of Clinical and Experimental Medicine, Section of Respiratory Medicine, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Via Santa Sofia, 78, Catania, Italy.
| | - Antonio Spanevello
- Istituti Clinici Scientifici Maugeri IRCCS, Via Crotto Roncaccio, 16, 21049 Tradate, VA, Italy.
| | - Nunzio Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Via Santa Sofia, 78, Catania, Italy; Department of Clinical and Experimental Medicine, Section of Respiratory Medicine, A.O.U. "Policlinico-Vittorio Emanuele", University of Catania, Via Santa Sofia, 78, Catania, Italy.
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27
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Scott IA. COVID-19 pandemic and the tension between the need to act and the need to know. Intern Med J 2020; 50:904-909. [PMID: 32881234 PMCID: PMC7436818 DOI: 10.1111/imj.14929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 05/22/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Ian A. Scott
- Internal Medicine and Clinical EpidemiologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
- School of Clinical MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
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28
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Christopher T Aquina
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Luke V Selby
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Stephanie DiFilippo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 395 West 12th Avenue, Suite 670, Columbus, OH 43210, USA.
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29
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Affiliation(s)
| | - John R Teerlink
- San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121-1545, USA; University of California San Francisco, San Francisco, CA, USA.
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30
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Abstract
The unprecedented COVID-19 pandemic has risen a number of clinical situations where the principles of the medical act, the singularity of the patient-physician relationship and the need for revitalizing the medical vocation have all become at front line. Original articles, viewpoints, and perspectives addressing these aspects have appeared in major medical journals. Never before but perhaps with AIDS in the eighties, a disease awakened such feelings of commitment in medicine. Herein, we discuss some of these very sensitive issues for physicians that emerged during the past months of global COVID-19 crisis.
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Affiliation(s)
- Rafael Del Río
- Neurophysiology and Sleep Disorders Unit, Vithas International Hospital, Madrid, Spain
| | - Joaquín de Ojeda
- Department of Neurology, Infanta Sofia University Hospital, Madrid, Spain
| | - Vicente Soriano
- Department of Internal Medicine, UNIR Medical Center and Health Sciences School, Madrid, Spain
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31
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Affiliation(s)
- Peter B White
- Department of Orthoepaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Randy M Cohn
- Department of Orthoepaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, and the Berman Institute, Johns Hopkins University, Baltimore, Maryland
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32
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Stock PG, Wall A, Gardner J, Domínguez-Gil B, Chadban S, Muller E, Dittmer I, Tullius SG. Ethical Issues in the COVID Era: Doing the Right Thing Depends on Location, Resources, and Disease Burden. Transplantation 2020; 104:1316-1320. [PMID: 32569002 PMCID: PMC7340125 DOI: 10.1097/tp.0000000000003291] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 04/20/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Peter G. Stock
- University of California San Francisco, San Francisco, CA
| | - Anji Wall
- Baylor University Medical Center at Dallas, Dallas, TX
| | - James Gardner
- University of California San Francisco, San Francisco, CA
| | | | | | - Elmi Muller
- University of Cape Town, Cape Town, South Africa
| | - Ian Dittmer
- Auckland District Health Board (ADHB), Auckland, New Zealand
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33
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Abstract
Covid‐19 confronts us with tragic choices, in which every option is unacceptable. On the New York State Task Force on Life and the Law, I worked on guidelines for such situations. We did not envision the scale or character of Covid‐19. To minimize fear that the decisions made in these situations might be unfair, we all must know what guidelines or mandates inform them. Only with transparency about how decisions will be made, by whom, and according to what requirements can we have confidence that fairness prevails. We now face many related questions about process, goals, leadership, and trust. For example, how might ethical guidelines evolve as scientific understanding advances? Should guidelines vary with different venues? And if, as I have argued, judgment is necessary even with the best of guidelines, how can we prepare clinicians to make good judgments? Are there implications for better training of personnel in nonemergency times for what they might face in the worst of times?
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34
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Schoenborn NL, Massare J, Park R, Boyd CM, Choi Y, Pollack CE. Assessment of Clinician Decision-making on Cancer Screening Cessation in Older Adults With Limited Life Expectancy. JAMA Netw Open 2020; 3:e206772. [PMID: 32511720 PMCID: PMC7280953 DOI: 10.1001/jamanetworkopen.2020.6772] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
IMPORTANCE Despite clinical practice guidelines recommending against routine cancer screening in older adults with limited life expectancy, older adults are still frequently screened for breast, colorectal, and prostate cancers. OBJECTIVE To examine primary care clinicians' decision-making on stopping breast, colorectal, or prostate cancer screening in older adults with limited life expectancy. DESIGN, SETTING, AND PARTICIPANTS In qualitative interviews coupled with medical record-stimulated recall, clinicians from 17 academic and community clinics affiliated with a large health system were asked how they came to specific cancer screening decisions in 2 or 3 of their older patients with less than 10-year of estimated life expectancy, including patients with and without recent screening. Patients were surveyed by telephone. Data collection occurred between October 2018 and May 2019. MAIN OUTCOMES AND MEASURES Clinician interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed with qualitative content analysis to identify major themes. Patient surveys assessed perception of cancer screening decisions, importance of clinician recommendation, and willingness to stop screening. RESULTS Twenty-five primary care clinicians (mean [SD] age, 47.1 [9.7] years; 14 female [56%]) discussed 53 patients during medical record-stimulated recall, ranging from 2 to 3 patients per clinician; 46 patients and 1 caregiver (mean [SD] age 74.9 [5.4]; 31 female [66%]) participated in the survey. Clinician interviews revealed 5 major themes: (1) cancer screening decisions were not always conscious, deliberate decisions; (2) electronic medical record alerts were connected with less deliberate decision-making; (3) cancer screening was not binary and clinicians often considered other options to scale back screening without actually stopping; (4) in addition to patient characteristics, clinicians were influenced by patient request and anecdotal experiences; and (5) influences outside of the primary care clinician-patient dyad were important, such as from specialists and patients' family or friends. Patient surveys asked approximately 64 cancer screening decisions of 47 patients. Patients did not recall approximately half (31 of 64) of their cancer screening decisions. Among those with recent screening, the mean score for willingness to stop screening was 3.2 (95% CI 2.5-3.9) on a 5-point Likert scale (with 1 indicating "extremely unlikely" and 5 indicating "extremely likely"). In most screening decisions that involved specialists (13 of 16), patients valued specialists' recommendations over those of primary care clinicians. CONCLUSIONS AND RELEVANCE Cancer screening decision-making is complex. Study findings suggest that strategies that facilitate more deliberate decision-making may be important in cancer screening of older adults with limited life expectancy.
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Affiliation(s)
- Nancy L. Schoenborn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jacqueline Massare
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Reuben Park
- Department of Biology and Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia M. Boyd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Youngjee Choi
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Craig E. Pollack
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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35
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Bottino CJ. Rethinking race in medical decision making. Bioethics 2020; 34:447-449. [PMID: 32469091 DOI: 10.1111/bioe.12755] [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: 02/27/2020] [Accepted: 03/10/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Clement J Bottino
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts
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36
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Affiliation(s)
- Arnold Milstein
- Stanford Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA 94305-6015, USA.
| | - Eric J Topol
- Scripps Research Translational Institute, Scripps Research, La Jolla, CA, USA
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37
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Ecker JL, Minkoff HL. Laboring alone? Brief thoughts on ethics and practical answers during the coronavirus disease 2019 pandemic. Am J Obstet Gynecol MFM 2020; 2:100141. [PMID: 32427187 PMCID: PMC7228734 DOI: 10.1016/j.ajogmf.2020.100141] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/02/2020] [Accepted: 05/06/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Jeffrey L. Ecker
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Corresponding author: Jeffrey Ecker, MD.
| | - Howard L. Minkoff
- Maimonides Medical Center, SUNY Downstate Health Sciences University, Brooklyn, NY
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38
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Abstract
Prognostication is a vital aspect of decision making because it provides patients and families with information to establish realistic and achievable goals of care, is used in determining eligibility for certain benefits, and helps in targeting interventions to those likely to benefit. Prognostication consists of 3 components: clinicians use their clinical judgment or other tools to estimate the probability of an individual developing a particular outcome over a specific period of time; this prognostic estimate is communicated in accordance with the patient's information preferences; the prognostic estimate is interpreted by the patient or surrogate and used in clinical decision making.
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Affiliation(s)
- Emily J Martin
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, 757 Westwood Plaza Suite 7501, Los Angeles, CA 90095, USA.
| | - Eric Widera
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA; San Francisco Veterans Affairs Health Care System, 4150 Clement Street, Box 181G, San Francisco, CA 94121, USA. https://twitter.com/EWidera
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39
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Periman LM, Perez VL, Saban DR, Lin MC, Neri P. The Immunological Basis of Dry Eye Disease and Current Topical Treatment Options. J Ocul Pharmacol Ther 2020; 36:137-146. [PMID: 32175799 PMCID: PMC7175622 DOI: 10.1089/jop.2019.0060] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 12/29/2019] [Indexed: 12/13/2022] Open
Abstract
Homeostasis of the lacrimal functional unit is needed to ensure a well-regulated ocular immune response comprising innate and adaptive phases. When the ocular immune system is excessively stimulated and/or immunoregulatory mechanisms are disrupted, the balance between innate and adaptive phases is dysregulated and chronic ocular surface inflammation can result, leading to chronic dry eye disease (DED). According to the Tear Film and Ocular Surface Society Dry Eye Workshop II definition, DED is a multifactorial disorder of the ocular surface characterized by impairment and loss of tear homeostasis (hyperosmolarity), ocular discomfort or pain, and neurosensory abnormalities. Dysregulated ocular immune responses result in ocular surface damage, which is a further contributing factor to DED pathology. Several therapeutics are available to break the vicious circle of DED and prevent chronic disease and progression, including immunosuppressive agents (steroids) and immunomodulators (cyclosporine and lifitegrast). Given the chronic inflammatory nature of DED, each of these agents is commonly used in clinical practice. In this study, we review the immunopathology of DED and the molecular and cellular actions of current topical DED therapeutics to inform clinical decision making.
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Affiliation(s)
| | - Victor L. Perez
- Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Daniel R. Saban
- Duke Eye Center, Duke University School of Medicine, Durham, North Carolina
| | - Meng C. Lin
- School of Optometry, Clinical Research Center, University of California, Berkeley, California
| | - Piergiorgio Neri
- The Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Vincent JL, Creteur J. Ethical aspects of the COVID-19 crisis: How to deal with an overwhelming shortage of acute beds. Eur Heart J Acute Cardiovasc Care 2020; 9:248-252. [PMID: 32347745 PMCID: PMC7196891 DOI: 10.1177/2048872620922788] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/09/2020] [Indexed: 11/23/2022]
Abstract
The current outbreak of SARS-CoV-2 has and continues to put huge pressure on intensive care units (ICUs) worldwide. Many patients with COVID-19 require some form of respiratory support and often have prolonged ICU stays, which results in a critical shortage of ICU beds. It is therefore not always physically possible to treat all the patients who require intensive care, raising major ethical dilemmas related to which patients should benefit from the limited resources and which should not. Here we consider some of the approaches to the acute shortages seen during this and other epidemics, including some guidelines for triaging ICU admissions and treatments.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Belgium
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Abstract
The ethical dilemmas and predominant frameworks surrounding decision making for critically ill newborns have evolved substantially over the last 40 years. A shared decision-making approach is now favored, involving an exchange of information between parents and clinicians that emphasizes parental values and preferences, resulting in a personalized approach to decision making. In this review, we summarize the history of clinical decision making with a focus on the NICU, highlight different models of decision making, describe the advantages and current limitations of shared decision making, and discuss the ongoing and future challenges of decision making in the NICU amidst medical innovations and emerging technologies.
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Affiliation(s)
- Anne Sullivan
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
| | - Christy Cummings
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA
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Müller BS, Donner-Banzhoff N, Beyer M, Haasenritter J, Müller A, Seifart C. Regret among primary care physicians: a survey of diagnostic decisions. BMC Fam Pract 2020; 21:53. [PMID: 32183738 PMCID: PMC7079478 DOI: 10.1186/s12875-020-01125-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/10/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Experienced and anticipated regret influence physicians' decision-making. In medicine, diagnostic decisions and diagnostic errors can have a severe impact on both patients and physicians. Little empirical research exists on regret experienced by physicians when they make diagnostic decisions in primary care that later prove inappropriate or incorrect. The aim of this study was to explore the experience of regret following diagnostic decisions in primary care. METHODS In this qualitative study, we used an online questionnaire on a sample of German primary care physicians. We asked participants to report on cases in which the final diagnosis differed from their original opinion, and in which treatment was at the very least delayed, possibly resulting in harm to the patient. We asked about original and final diagnoses, illness trajectories, and the reactions of other physicians, patients and relatives. We used thematic analysis to assess the data, supported by MAXQDA 11 and Microsoft Excel 2016. RESULTS 29 GPs described one case each (14 female/15 male patients, aged 1.5-80 years, response rate < 1%). In 26 of 29 cases, the final diagnosis was more serious than the original diagnosis. In two cases, the diagnoses were equally serious, and in one case less serious. Clinical trajectories and the reactions of patients and relatives differed widely. Although only one third of cases involved preventable harm to patients, the vast majority (27 of 29) of physicians expressed deep feelings of regret. CONCLUSION Even if harm to patients is unavoidable, regret following diagnostic decisions can be devastating for clinicians, making them 'second victims'. Procedures and tools are needed to analyse cases involving undesirable diagnostic events, so that 'true' diagnostic errors, in which harm could have been prevented, can be distinguished from others. Further studies should also explore how physicians can be supported in dealing with such events in order to prevent them from practicing defensive medicine.
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Affiliation(s)
- Beate S. Müller
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Strasse 4, 35043 Marburg, Germany
| | - Martin Beyer
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jörg Haasenritter
- Department of General Practice / Family Medicine, University of Marburg, Karl-von-Frisch-Strasse 4, 35043 Marburg, Germany
| | - Angelina Müller
- Institute of General Practice, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Carola Seifart
- Department of Pneumology, and Ethics Commission, University of Marburg, Baldingerstrasse, 35032 Marburg, Germany
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Helou MA, DiazGranados D, Ryan MS, Cyrus JW. Uncertainty in Decision Making in Medicine: A Scoping Review and Thematic Analysis of Conceptual Models. Acad Med 2020; 95:157-165. [PMID: 31348062 PMCID: PMC6925325 DOI: 10.1097/acm.0000000000002902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
PURPOSE The practice of medicine is rarely straightforward. Data used to facilitate medical decision making may be conflicting, ambiguous, or scarce, and providing optimal care requires balancing clinicians' expertise and available evidence with patients' preferences. To explore uncertainty in decision making across disciplines, the authors performed a scoping review and thematic analysis of the literature to formulate a model describing the decision-making process in medicine under uncertain conditions. METHOD In 2016, the authors performed a comprehensive search of key databases using a combination of keywords and controlled vocabulary. They identified and reviewed 3,398 records. After applying their inclusion and exclusion criteria to the titles and abstracts and then full texts, 19 articles were selected. The authors applied a qualitative thematic analysis to these articles, using codes to extract themes related to uncertainty in decision making. RESULTS The 19 articles spanned 6 fields of study and 5 disciplines within the health sciences. The thematic analysis revealed 6 main themes: recognition of uncertainty, classification of uncertainty, stakeholder perspectives, knowledge acquisition, decision-making approach, and evaluation of the decision-making process. CONCLUSIONS Based on the themes that emerged from their thematic analysis of the literature characterizing the effects of uncertainty and ambiguity on the decision-making process, the authors developed a framework depicting the interplay between these themes with a visual representation of the decision-making process under uncertain conditions. Future research includes further development and validation of this framework to inform medical school curricula.
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Affiliation(s)
- Marieka A Helou
- M.A. Helou is assistant professor, Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: https://orcid.org/0000-0002-8650-5901. D. DiazGranados is assistant professor, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: https://orcid.org/0000-0002-0624-7093. M.S. Ryan is associate professor, Department of Pediatrics, and assistant dean for clinical medical education, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: https://orcid.org/0000-0003-3266-9289. J.W. Cyrus is assistant professor, Tompkins-McCaw Library for the Health Sciences, Virginia Commonwealth University School of Medicine, Richmond, Virginia; ORCID: https://orcid.org/0000-0001-5331-5151
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Wong J, Duane PG, Ingraham NE. A case series of patients who were do not resuscitate but underwent cardiopulmonary resuscitation. Resuscitation 2020; 146:145-146. [PMID: 31790757 PMCID: PMC7243352 DOI: 10.1016/j.resuscitation.2019.11.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 11/16/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jennifer Wong
- Division of Pulmonary and Critical Care, Department of Medicine, Minneapolis Veterans Affairs Health Care System and the University of Minnesota, Minneapolis, MN, United States.
| | - Peter G Duane
- Division of Pulmonary and Critical Care, Department of Medicine, Minneapolis Veterans Affairs Health Care System and the University of Minnesota, Minneapolis, MN, United States.
| | - Nicholas E Ingraham
- Division of Pulmonary and Critical Care, Department of Medicine, Minneapolis Veterans Affairs Health Care System and the University of Minnesota, Minneapolis, MN, United States.
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Kaebnick GE. Editorial Trends. Hastings Cent Rep 2019; 49:2. [PMID: 30790312 DOI: 10.1002/hast.967] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
I was recently asked to report on editorial trends in the Hastings Center Report, past and future. What I reported is that HCR has been going in two seemingly contrasting directions. One has to do with moral decision-making in clinical ethics-the core theme in bioethics for fifty years, but still developing. A second editorial trend is treatment of larger social and political issues that bear on health, such as public health interventions and access to health care. I could also have noted a continuing stream of pieces on emerging technologies, from whole-genome screening for newborns to artificial intelligence in clinical diagnoses to the so-called de-extinction of extinct animals and plants through various genetic and reproductive tricks. This January-February 2019 issue of HCR reflects all these trends.
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Abstract
Although decision-making algorithms are not new to medicine, the availability of vast stores of medical data, gains in computing power, and breakthroughs in machine learning are accelerating the pace of their development, expanding the range of questions they can address, and increasing their predictive power. In many cases, however, the most powerful machine learning techniques purchase diagnostic or predictive accuracy at the expense of our ability to access "the knowledge within the machine." Without an explanation in terms of reasons or a rationale for particular decisions in individual cases, some commentators regard ceding medical decision-making to black box systems as contravening the profound moral responsibilities of clinicians. I argue, however, that opaque decisions are more common in medicine than critics realize. Moreover, as Aristotle noted over two millennia ago, when our knowledge of causal systems is incomplete and precarious-as it often is in medicine-the ability to explain how results are produced can be less important than the ability to produce such results and empirically verify their accuracy.
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Abstract
Transplantation programs commonly rely on clinicians' judgments about patients' social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients' personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation.
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Singhal S. Do No Harm: The Hippocratic Oath. Natl Med J India 2019; 32:375. [PMID: 33380638 DOI: 10.4103/0970-258x.303624] [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] [Indexed: 06/12/2023]
Affiliation(s)
- Sunny Singhal
- Room Number 3095A, Department of Geriatric Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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49
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Affiliation(s)
- Nikola Biller-Andorno
- From the Institute of Biomedical Ethics and History of Medicine, University of Zurich, and the Collegium Helveticum - both in Zurich, Switzerland (N.B.-A.); and the Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany (A.B.)
| | - Armin Biller
- From the Institute of Biomedical Ethics and History of Medicine, University of Zurich, and the Collegium Helveticum - both in Zurich, Switzerland (N.B.-A.); and the Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany (A.B.)
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Navin MC, Wasserman JA, Haimann MH. Treatment Over Objection-Moral Reasons for Reluctance. Mayo Clin Proc 2019; 94:1936-1938. [PMID: 31537308 DOI: 10.1016/j.mayocp.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 07/15/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Jason Adam Wasserman
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI
| | - Mark H Haimann
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI
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