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Watson K, Paul M, Yanow S, Baruch J. Supporting, Not Reporting - Emergency Department Ethics in a Post- Roe Era. N Engl J Med 2022; 387:861-863. [PMID: 36053234 DOI: 10.1056/nejmp2209312] [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] [Indexed: 11/19/2022]
Affiliation(s)
- Katie Watson
- From the Departments of Medical Education, Medical Social Sciences, and Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.W.); the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and Harvard Medical School - both in Boston (M.P.); Women Help Women, Amsterdam (S.Y.); and the Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI (J.B.)
| | - Maureen Paul
- From the Departments of Medical Education, Medical Social Sciences, and Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.W.); the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and Harvard Medical School - both in Boston (M.P.); Women Help Women, Amsterdam (S.Y.); and the Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI (J.B.)
| | - Susan Yanow
- From the Departments of Medical Education, Medical Social Sciences, and Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.W.); the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and Harvard Medical School - both in Boston (M.P.); Women Help Women, Amsterdam (S.Y.); and the Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI (J.B.)
| | - Jay Baruch
- From the Departments of Medical Education, Medical Social Sciences, and Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago (K.W.); the Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, and Harvard Medical School - both in Boston (M.P.); Women Help Women, Amsterdam (S.Y.); and the Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, RI (J.B.)
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Lisak A, Efrat-Treister D, Glikson E, Zeldetz V, Schwarzfuchs D. The influence of culture on care receivers' satisfaction and aggressive tendencies in the emergency department. PLoS One 2021; 16:e0256513. [PMID: 34473754 PMCID: PMC8412260 DOI: 10.1371/journal.pone.0256513] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 08/09/2021] [Indexed: 02/04/2023] Open
Abstract
Introduction Reducing aggressive tendencies among care receivers in the emergency department has great economic and psychological benefits for care receivers, staff, and health care organizations. In a study conducted in a large multicultural hospital emergency department, we examined how cultural factors relating to ethnicity interact to enhance care receivers’ satisfaction and reduce their aggressive tendencies. Specifically, we explored how care receivers’ cultural affiliation, individual cultural characteristics, and the cultural situational setting interact to increase care receivers’ satisfaction and reduce their aggressive tendencies. Method Data were collected using survey responses from 214 care receivers. We use structural equation models and the bootstrap method to analyze the data. Results Care receivers’ openness to diversity (an individual cultural characteristic) was positively related to their satisfaction that was associated with lower aggressive tendencies, only when they were affiliated with a cultural minority group and when the cultural situational setting included language accessibility. Conclusion Our results demonstrate that cultural affiliation, individual cultural characteristics, and cultural situational setting can affect care receivers’ satisfaction and aggressive tendencies in a multicultural emergency department context. In particular, high cultural openness of care receivers, and making information accessible in their native language, increased satisfaction and reduced aggressive tendencies among cultural minority care receivers in our study.
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Affiliation(s)
- Alon Lisak
- Department of Management, Ben-Gurion University of the Negev, Be’er Sheva, Israel
- * E-mail:
| | - Dorit Efrat-Treister
- Department of Management, Ben-Gurion University of the Negev, Be’er Sheva, Israel
| | - Ella Glikson
- The Graduate School of Business Administration, Bar-Ilan University, Ramat Gan, Israel
| | - Vladimir Zeldetz
- Department of Emergency Medicine, Soroka University Medical Center, Be’er Sheva, Israel
| | - Dan Schwarzfuchs
- Department of Emergency Medicine, Soroka University Medical Center, Be’er Sheva, Israel
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Marinelli E, Busardò FP, Zaami S. Intensive and pharmacological care in times of COVID-19: A "special ethics" for emergency? BMC Med Ethics 2020; 21:117. [PMID: 33213445 PMCID: PMC7675378 DOI: 10.1186/s12910-020-00562-7] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The Authors have laid out an analysis of Italian COVID-19 confirmed data and fatality rates, pointing out how a dearth of health care resources in northern regions has resulted in hard, ethically challenging decisions in terms of granting patient access to intensive care units (ICU). MAIN TEXT Having to make such decisions certainly entails substantial difficulties, and that has led many health care professional to seek ethical guidance. The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has attempted to meet that growing need by a set of recommendations, applying "clinical soundness" as a beacon standard; that approach tends to prioritize patients with higher life expectancy, which could be characterized as a "moderately utilitarian" approach. Yet, such a selection has engendered daunting ethical quandaries. The authors believe it can only be warranted and acceptable if rooted in a transparent decision-making process and verifiable, reviewed criteria. Moreover, the authors have stressed how clinical experimentation in a pandemic setting is a subtext of great interest from an ethical perspective. In Italy, no drug therapy and trials were undertaken for COVID-19 patients for a rather long period of time. When the epidemic was already circulating, an intervention proved necessary on the system of administrative procedures, aimed at expediting the authorization and validation of protocols, then bogged down by bureaucracy. A new system has since been instituted by a government decree that was signed about one month after the first Covid-19 case was officially recorded in the country. Such a swift implementation, which took just a few weeks, is noteworthy and proves that clinical trials can be initiated in a timely fashion, even with a pandemic unfolding. The concerted, action of supportive care and RCTs is the only way to attain effective forms of treatments for COVID-19 and any other future outbreak. CONCLUSIONS The authors have arrived at the conclusion that the most effective and ethically sound response on the part of any national health care system would be to adequately reconfigure its organizational mechanisms, by making clinical trials and all related administrative procedures consistent with the current state of emergency.
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Affiliation(s)
- Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Paolo Busardò
- Department of Excellence of Biomedical Sciences and Public Health, University Politecnica delle Marche, Ancona, Italy.
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
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Lavingia R, Raghavan R, Morain SR. Emergency-Only Hemodialysis Policies: Ethical Critique and Avenues for Reform. J Law Med Ethics 2020; 48:527-534. [PMID: 33021161 DOI: 10.1177/1073110520958877] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
An estimated 6,500 undocumented immigrants in the United States have been diagnosed with end-stage renal disease (ESRD). These individuals are ineligible for the federal insurance program that covers dialysis and/or transplantation for citizens, and consequently are subject to local or state policies regarding the provision of healthcare. In 76% of states, undocumented immigrants are ineligible to receive scheduled outpatient dialysis treatments, and typically receive dialysis only when presenting to the emergency center with severe life-threatening symptoms. 'Emergency-only hemodialysis' (EOHD) is associated with higher healthcare costs, higher mortality, and longer hospitalizations. In this paper, we present an ethical critique of existing federal policy. We argue that EOHD represents a failure of fiduciary and professional obligations, contributes to moral distress, and undermines physician obligations to be good stewards of medical resources. We then explore potential avenues for reform based upon policies introduced at the state level. We argue that, while reform at the federal level would ultimately be a more sustainable long-term solution, state-based policy reforms can help mitigate the ethical shortcomings of EOHD.
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Affiliation(s)
- Richa Lavingia
- Richa Lavingia, B.S., is a medical student at Baylor College of Medicine in Houston, TX and an M.P.H. student at the UTHealth School of Public Health in Houston, TX. She received her B.S. from Duke University in Durham, NC. Rajeev Raghavan, M.D., is an Associate Professor of Medicine at Baylor College of Medicine in Houston, TX. He received his B.S. from Case Western Reserve University in Cleveland, OH and his M.D. from Baylor College of Medicine in Houston, TX. He has published extensively on the experience and care of undocumented patients with kidney disease and is a national expert on this topic. Stephanie Morain, Ph.D., M.P.H., is an Assistant Professor in the Center for Medical Ethics and Health Policy. She received her A.B. from Lafayette College in Easton, PA, her M.P.H. from Columbia University's Mailman School of Public Health in New York, NY, her Ph.D. in Health Policy from Harvard University in Cambridge, MA, and completed her postdoctoral training at the Berman Institute for Bioethics at Johns Hopkins University in Baltimore, MD
| | - Rajeev Raghavan
- Richa Lavingia, B.S., is a medical student at Baylor College of Medicine in Houston, TX and an M.P.H. student at the UTHealth School of Public Health in Houston, TX. She received her B.S. from Duke University in Durham, NC. Rajeev Raghavan, M.D., is an Associate Professor of Medicine at Baylor College of Medicine in Houston, TX. He received his B.S. from Case Western Reserve University in Cleveland, OH and his M.D. from Baylor College of Medicine in Houston, TX. He has published extensively on the experience and care of undocumented patients with kidney disease and is a national expert on this topic. Stephanie Morain, Ph.D., M.P.H., is an Assistant Professor in the Center for Medical Ethics and Health Policy. She received her A.B. from Lafayette College in Easton, PA, her M.P.H. from Columbia University's Mailman School of Public Health in New York, NY, her Ph.D. in Health Policy from Harvard University in Cambridge, MA, and completed her postdoctoral training at the Berman Institute for Bioethics at Johns Hopkins University in Baltimore, MD
| | - Stephanie R Morain
- Richa Lavingia, B.S., is a medical student at Baylor College of Medicine in Houston, TX and an M.P.H. student at the UTHealth School of Public Health in Houston, TX. She received her B.S. from Duke University in Durham, NC. Rajeev Raghavan, M.D., is an Associate Professor of Medicine at Baylor College of Medicine in Houston, TX. He received his B.S. from Case Western Reserve University in Cleveland, OH and his M.D. from Baylor College of Medicine in Houston, TX. He has published extensively on the experience and care of undocumented patients with kidney disease and is a national expert on this topic. Stephanie Morain, Ph.D., M.P.H., is an Assistant Professor in the Center for Medical Ethics and Health Policy. She received her A.B. from Lafayette College in Easton, PA, her M.P.H. from Columbia University's Mailman School of Public Health in New York, NY, her Ph.D. in Health Policy from Harvard University in Cambridge, MA, and completed her postdoctoral training at the Berman Institute for Bioethics at Johns Hopkins University in Baltimore, MD
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5
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Abstract
Over the past year, our ethics service has had numerous consultations involving patients who use the emergency department for regular dialysis. Sometimes, they have access to outpatient hemodialysis that they forgo; other times, they've been "fired" from this kind of outpatient facility, and so the ED is their last option. In most of these cases, we're called because the patient is disruptive once admitted to the ICU and behavior plans haven't helped. But the call from a resident this March 2020 morning was different, the patient had end-stage renal disease and often missed hemodialysis, but he wasn't disruptive. "It's just that he comes in after using cocaine, and given scarcity with the coronavirus and ICU beds…." I have come to think that this is one of the more insidious effects of the pandemic: that there will be a resurgence of the view that some patients deserve health care by virtue of their compliant behavior and that those who are nonadherent don't.
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Nau JY. [Not Available]. Rev Med Suisse 2020; 16:968-969. [PMID: 32374553] [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: 06/11/2023]
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Yuguero Torres O, Pérez Pérez RM. Emergency department patients who leave after voluntary discharge or without discharge: a challenge with ethical, medical, and legal implications. Emergencias 2019; 30:433-436. [PMID: 30638350] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Oriol Yuguero Torres
- Institut de Rercerca Biomèdica de Lleida (IRBLLEIDA), Lleida, España. Facultad de Medicina, Universidad de Lleida, Lleida, España. Servicio de Urgencias, Hospital Universitario Arnau de Vilanova de Lleida, España
| | - Rosa M Pérez Pérez
- Institut de Rercerca Biomèdica de Lleida (IRBLLEIDA), Lleida, España. Facultad de Medicina, Universidad de Lleida, Lleida, España. Servicio de Urgencias, Hospital Universitario Arnau de Vilanova de Lleida, España
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Ashby MA, Morrell B. To Your Good Health! Going to the Pub With Friends, Nursing Dying Patients, And 'ER' Receptionists: the Ubiquitous Rise of Risk Management and Maybe A 'Prudential' Bioethics? J Bioeth Inq 2019; 16:1-5. [PMID: 30968315 DOI: 10.1007/s11673-019-09912-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Michael A Ashby
- Cancer, Chronic Disease and Sub-Acute Stream, Royal Hobart Hospital, Tasmanian Health Service, University of Tasmania, Repatriation Centre, 90 Davey Street, Hobart, TAS, 7000, Australia.
- Medical Ethics and Death Studies, School of Medicine, College of Health and Medicine, University of Tasmania, Repatriation Centre, 90 Davey Street, Hobart, TAS, 7000, Australia.
| | - Bronwen Morrell
- Sydney Health Ethics, Faculty of Medicine and Health, University of Sydney, Level 1, Medical Foundation Building, K25, Sydney, NSW, 2006, Australia
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Wang H, Kline JA, Jackson BE, Laureano-Phillips J, Robinson RD, Cowden CD, d’Etienne JP, Arze SE, Zenarosa NR. Association between emergency physician self-reported empathy and patient satisfaction. PLoS One 2018; 13:e0204113. [PMID: 30212564 PMCID: PMC6136813 DOI: 10.1371/journal.pone.0204113] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 09/03/2018] [Indexed: 12/14/2022] Open
Abstract
Background Higher physician self-reported empathy has been associated with higher overall patient satisfaction. However, more evidence-based research is needed to determine such association in an emergent care setting. Objective To evaluate the association between physician self-reported empathy and after-care instant patient-to-provider satisfaction among Emergency Department (ED) healthcare providers with varying years of medical practice experience. Research design A prospective observational study conducted in a tertiary care hospital ED. Methods Forty-one providers interacted with 1,308 patients across 1,572 encounters from July 1 through October 31, 2016. The Jefferson Scale of Empathy (JSE) was used to assess provider empathy. An after-care instant patient satisfaction survey, with questionnaires regarding patient-to-provider satisfaction specifically, was conducted prior to the patient moving out of the ED. The relation between physician empathy and patient satisfaction was estimated using risk ratios (RR) and their corresponding 95% confidence limits (CL) from log-binomial regression models. Results Emergency Medicine (EM) residents had the lowest JSE scores (median 111; interquartile range [IQR]: 107–122) and senior physicians had the highest scores (median 119.5; IQR: 111–129). Similarly, EM residents had the lowest percentage of “very satisfied” responses (65%) and senior physicians had the highest reported percentage of “very satisfied” responses (69%). There was a modest positive association between JSE and satisfaction (RR = 1.04; 95% CL: 1.00, 1.07). Conclusion This study provides evidence of a positive association between ED provider self-reported empathy and after-care instant patient-to-provider satisfaction. Overall higher empathy scores were associated with higher patient satisfaction, though minor heterogeneity occurred between different provider characteristics.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, United States of America
- * E-mail:
| | - Jeffrey A. Kline
- Department of Emergency Medicine, University of Indiana School of Medicine, Indianapolis, IN, United States of America
| | - Bradford E. Jackson
- Center for Outcomes Research, John Peter Smith Health Network, and University of North Texas Health Science Center, School of Public Health, Fort Worth, TX, United States of America
| | - Jessica Laureano-Phillips
- Office of Clinical Research, John Peter Smith Health Network, Fort Worth, TX, United States of America
| | - Richard D. Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, United States of America
| | - Chad D. Cowden
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, United States of America
| | - James P. d’Etienne
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, United States of America
| | - Steven E. Arze
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, United States of America
| | - Nestor R. Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, Fort Worth, TX, United States of America
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Colaco KA, Courtright A, Andreychuk S, Frolic A, Cheng J, Kam AJ. Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, ethical, learning and resource needs. J Med Ethics 2018; 44:13-20. [PMID: 28751469 DOI: 10.1136/medethics-2016-103531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 03/12/2016] [Revised: 12/24/2016] [Accepted: 04/26/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments (EDs) in order to build ethics capacity and provide a foundation for the development of an ethics education programme. METHODS This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. RESULTS Of the 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress (16%), conflict management with patients or families (16%) and resource issues (15%). Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams (42%) was the most desired method. CONCLUSIONS Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists.
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Affiliation(s)
- Keith A Colaco
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Alanna Courtright
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Sandra Andreychuk
- Office of Clinical and Organizational Ethics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Andrea Frolic
- Office of Clinical and Organizational Ethics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ji Cheng
- Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - April Jacqueline Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Abstract
Care ethics as initiated by Gilligan, Held, Tronto and others (in the nineteen eighties and nineties) has from its onset been critical towards ethical concepts established in modernity, like 'autonomy', alternatively proposing to think from within relationships and to pay attention to power. In this article the question is raised whether renewal in this same critical vein is necessary and possible as late modern circumstances require rethinking the care ethical inquiry. Two late modern realities that invite to rethink care ethics are complexity and precariousness. Late modern organizations, like the general hospital, codetermined by various (control-, information-, safety-, accountability-) systems are characterized by complexity and the need for complexity reduction, both permeating care practices. By means of a heuristic use of the concept of precariousness, taken as the installment of uncertainty, it is shown that relations and power in late modern care organizations have changed, precluding the use of a straightforward domination idea of power. In the final section a proposition is made how to rethink the care ethical inquiry in order to take late modern circumstances into account: inquiry should always be related to the concerns of people and practitioners from within care practices.
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Affiliation(s)
- Frans Vosman
- Department of Care Ethics, University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD, Utrecht, The Netherlands
| | - Alistair Niemeijer
- Department of Care Ethics, University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD, Utrecht, The Netherlands.
- Department of Social Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
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Probst MA, Kanzaria HK, Schoenfeld EM, Menchine MD, Breslin M, Walsh C, Melnick ER, Hess EP. Shared Decisionmaking in the Emergency Department: A Guiding Framework for Clinicians. Ann Emerg Med 2017; 70:688-695. [PMID: 28559034 PMCID: PMC5834305 DOI: 10.1016/j.annemergmed.2017.03.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [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: 02/06/2017] [Revised: 03/22/2017] [Accepted: 03/27/2017] [Indexed: 01/27/2023]
Abstract
Shared decisionmaking has been proposed as a method to promote active engagement of patients in emergency care decisions. Despite the recent attention shared decisionmaking has received in the emergency medicine community, including being the topic of the 2016 Academic Emergency Medicine Consensus Conference, misconceptions remain in regard to the precise meaning of the term, the process, and the conditions under which it is most likely to be valuable. With the help of a patient representative and an interaction designer, we developed a simple framework to illustrate how shared decisionmaking should be approached in clinical practice. We believe it should be the preferred or default approach to decisionmaking, except in clinical situations in which 3 factors interfere. These 3 factors are lack of clinical uncertainty or equipoise, patient decisionmaking ability, and time, all of which can render shared decisionmaking infeasible. Clinical equipoise refers to scenarios in which there are 2 or more medically reasonable management options. Patient decisionmaking ability refers to a patient's capacity and willingness to participate in his or her emergency care decisions. Time refers to the acuity of the clinical situation (which may require immediate action) and the time that the clinician has to devote to the shared decisionmaking conversation. In scenarios in which there is only one medically reasonable management option, informed consent is indicated, with compassionate persuasion used as appropriate. If time or patient capacity is lacking, physician-directed decisionmaking will occur. With this framework as the foundation, we discuss the process of shared decisionmaking and how it can be used in practice. Finally, we highlight 5 common misconceptions in regard to shared decisionmaking in the ED. With an improved understanding of shared decisionmaking, this approach should be used to facilitate the provision of high-quality, patient-centered emergency care.
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Affiliation(s)
- Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA
| | - Elizabeth M Schoenfeld
- Department of Emergency Medicine, Baystate Medical Center/Tufts School of Medicine, Springfield, MA
| | - Michael D Menchine
- Department of Emergency Medicine, University of Southern California/Keck School of Medicine, Los Angeles, CA
| | | | | | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Erik P Hess
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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13
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Abstract
Two potentially lifesaving protocols, emergency preservation and resuscitation (EPR) and uncontrolled donation after circulatory determination of death (uDCDD), currently implemented in some U.S. emergency departments (EDs), have similar eligibility criteria and initial technical procedures, but critically different goals. Both follow unsuccessful cardiopulmonary resuscitation and induce hypothermia to "buy time": one in trauma patients suffering cardiac arrest, to enable surgical repair, and the other in patients who unexpectedly die in the ED, to enable organ donation. This article argues that to fulfill patient-focused fiduciary obligations and maintain community trust, institutions implementing both protocols should adopt and publicize policies to guide ED physicians to utilize either protocol for particular patients, in order to address the appearance of conflict of interest arising from the protocols' similarities. It concludes by analyzing ethical implications of incentives that may influence institutions to develop the expertise required for uDCDD but not EPR.
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14
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Fins JJ, Knowlton SF. Care under the Influence. Hastings Cent Rep 2017; 47:8-9. [PMID: 28074588 DOI: 10.1002/hast.675] [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: 11/09/2022]
Abstract
A forty-year-old man is brought to the emergency room by his wife at five in the morning, two hours after he fell down the stairs at home, hitting his head and injuring his arm. He tells the ER physician that he got up to get a drink of water and tripped in the dark. His speech is slurred, and he smells strongly of alcohol. Lab results reveal elevated liver enzymes, and his blood alcohol level is 0.1. His medical history is unremarkable. When asked about his alcohol consumption, he says he usually has one or two drinks a night with dinner but that he drinks more on holidays and special occasions. He admits he had more to drink than usual last night because it had been a stressful day at work, but he is vague about how much he drank. His wife takes the ER physician aside and describes a very different situation. She says that her husband regularly has three or four drinks a night. She always goes to bed before he does and thinks he stays up later so he can continue to drink. She says that he often has no memory of conversations they had the night before and is concerned because he makes work-related calls at night. When asked what he does for a living, she hesitates, and then answers that he is an internist. He does not work at this hospital but works at one of its affiliated clinics. The ER doctor is concerned that his patient is an impaired physician. Yet when the admitting hospitalist, to whom he explains the situation, asks if he really wants to "go there," he shrugs his shoulders. "I suppose," she replies, "you might as well call an ethics consult."
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Bowman KF, O'Shea JT, Elliott RL. The long ER stay. J Med Assoc Ga 2017; 106:16-17. [PMID: 30251781] [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: 06/08/2023]
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16
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Abstract
I'd like to see a doorman at every emergency department to support often distraught people on arrival. It is about making people's lives easier and would also help lower aggression and violence against staff.
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Sevimli S, Karadas S, Dulger AC. Issues affecting health professionals during and after catastrophic earthquakes in Van-Turkey. J PAK MED ASSOC 2016; 66:129-134. [PMID: 26819153] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess physical and psycho-social problems faced by health professionals, and to analyse the ethical, legal and triage dimensions of disaster medical services. METHODS The descriptive study was conducted from November 2011 to March 2012 and comprised health professionals from two hospitals of Van, Turkey A specific questionnaire was designed and interviews were conducted face to face. SPSS 13 was used for statistical analysis. RESULTS Of the 430 health professionals who had experienced one or more earthquakes and were part of the study, 225(52.3%) were nurses and 205(47.7%) were doctors. There were 224(52%) women and 206(48%) men. Besides, 206(48) were below 31 years of age. Overall, 193(44.9%) participants experienced chaos, 83(19.3%) panic and fear, and 129(30%) despair. Only 20(4.7%) of them lived at home, while others lived in tents, containers, hospitals or cars during the emergency and continued to provide services despite social, economic and psychological problems. Triage was preferred by 339(78.8%) of the respondents. CONCLUSIONS Problems of health professionals were multi-dimensional and addressing them would make service delivery more effective.
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Affiliation(s)
- Sukran Sevimli
- Department of Medical History and Ethics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Sevdegul Karadas
- Department of Emergency Medicine, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Ahmet Cumhur Dulger
- Department of Gastroenterology, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
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Webster LB, Shirley JL. No Need to Object: Ethical Obligations for Interprofessional Collaboration in Emergency Department Discharge Planning. Annu Rev Nurs Res 2016; 34:183-198. [PMID: 26673382 DOI: 10.1891/0739-6686.34.183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Emergency departments (EDs) serve a wide range of patient needs. A crucial aspect of safe and effective care in the ED is to appropriately transition patients to the next level of care. In most EDs, this disposition planning is done exclusively by physicians, which has the potential to result in unacceptable harm. A virtue ethics approach demonstrates the need for explicit inclusion of nurses in disposition planning. In utilizing this approach, it is necessary to examine four focal virtues as they relate to the work of disposition planning and the moral character of the nurse. The virtues of prudence, trustworthiness, vigilance, and courage show that interprofessional collaboration is needed during disposition planning to promote patient safety, facilitate interprofessional relationships, and prevent moral distress. The majority of literature on disposition planning is empirical in nature; this chapter adds a normative argument and a motive for policy reform.
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Wang L, Haberland C, Thurm C, Bhattacharya J, Park KT. Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status. PLoS One 2015; 10:e0132758. [PMID: 26267816 PMCID: PMC4534408 DOI: 10.1371/journal.pone.0132758] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/17/2015] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES. METHODS Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge. RESULTS Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately. CONCLUSIONS Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.
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Affiliation(s)
- Louise Wang
- School of Medicine, Stanford University, Stanford, CA, United States of America
| | - Corinna Haberland
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Cary Thurm
- Children’s Hospital Association, Overland Park, KS, United States of America
| | - Jay Bhattacharya
- Center for Health Policy/ Primary Care Outcomes Research, Stanford University, Stanford, CA, United States of America
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States of America
- Department of Economics, Stanford University, Stanford, CA, United States of America
| | - K. T. Park
- Center for Health Policy/ Primary Care Outcomes Research, Stanford University, Stanford, CA, United States of America
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, United States of America
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Human rights breaches found in Northern Ireland. Nurs Stand 2015; 29:8. [PMID: 26036366 DOI: 10.7748/ns.29.40.8.s5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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21
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McClelland M. Ethics: Harm in the Emergency Department -- Ethical Drivers for Change. Online J Issues Nurs 2015; 20:14. [PMID: 26882433] [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: 06/05/2023]
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Biros MH, Dickert NW, Wright DW, Scicluna VM, Harney D, Silbergleit R, Denninghoff K, Pentz RD. Balancing ethical goals in challenging individual participant scenarios occurring in a trial conducted with exception from informed consent. Acad Emerg Med 2015; 22:340-6. [PMID: 25716051 PMCID: PMC7272239 DOI: 10.1111/acem.12602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/21/2014] [Accepted: 10/22/2014] [Indexed: 11/27/2022]
Abstract
In 1996, federal regulations were put into effect that allowed enrollment of critically ill or injured patients into Food and Drug Administration (FDA)-regulated clinical trials using an exception from informed consent (EFIC) under narrowly prescribed research circumstances. Despite the low likelihood that a legally authorized representative (LAR) would be present within the interventional time frame, the EFIC regulations require the availability of an informed consent process, to be applied if an LAR is present and able to provide prospective consent for patient enrollment into the trial. The purpose of this article is to describe a series of unanticipated consent-related questions arising when a potential surrogate decision-maker appeared to be available at the time of patient enrollment into a trial proceeding under EFIC.
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Affiliation(s)
- Michelle H Biros
- The Department of Emergency Medicine Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
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Venkat A, Wolf L, Geiderman JM, Asher SL, Marco CA, McGreevy J, Derse AR, Otten EJ, Jesus JE, Kreitzer NP, Escalante M, Levine AC. Ethical issues in the response to Ebola virus disease in US emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine. J Emerg Nurs 2015; 41:e5-e16. [PMID: 25770003 PMCID: PMC7119323 DOI: 10.1016/j.jen.2015.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 11/01/2022]
Abstract
The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.
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Affiliation(s)
- Arvind Venkat
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI.
| | - Lisa Wolf
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Joel M Geiderman
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Shellie L Asher
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Catherine A Marco
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Jolion McGreevy
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Arthur R Derse
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Edward J Otten
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - John E Jesus
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Natalie P Kreitzer
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Monica Escalante
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
| | - Adam C Levine
- Pittsburgh, PA; Des Plaines, IL; Los Angeles, CA; Albany, NY; Dayton, OH; Boston, MA; Milwaukee, WI; Cincinnati, OH; Wilmington, DE; Providence, RI
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Bayley C. System Failure: No Surgeon To Be Found. Narrat Inq Bioeth 2015; 5:271-277. [PMID: 26752582 DOI: 10.1353/nib.2015.0066] [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: 06/05/2023]
Abstract
A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians to treat emergencies.
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25
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Wagner JM, Dahnke MD. Nursing Ethics and Disaster Triage: Applying Utilitarian Ethical Theory. J Emerg Nurs 2014; 41:300-6. [PMID: 25510208 DOI: 10.1016/j.jen.2014.11.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/30/2014] [Accepted: 11/03/2014] [Indexed: 11/17/2022]
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26
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VandenBerg SD. The arithmetic of gestalt. CAN J EMERG MED 2014; 16:257-258. [PMID: 24852591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Abstract
The emergency department (ED) serves as the primary gateway for acute care and the source of health care of last resort. Emergency physicians are commonly expected to rapidly assess and treat patients with a variety of life-threatening conditions. However, patients do refuse recommended therapy, even when the consequences are significant morbidity and even mortality. This raises the ethical dilemma of how emergency physicians and ED staff can rapidly determine whether patient refusal of treatment recommendations is based on intact decision-making capacity and how to respond in an appropriate manner when the declining of necessary care by the patient is lacking a basis in informed judgment. This article presents a case that illustrates the ethical tensions raised by the refusal of life-sustaining care in the ED and how such situations can be approached in an ethically appropriate manner.
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Affiliation(s)
- Elaine Chang
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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29
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Svandra P. [The ethical approach applied to the TV series ER]. Rev Infirm 2013:31-33. [PMID: 23776983] [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: 06/02/2023]
Abstract
The television series ER presents an opportunity to reflect on ethical dilemmas. This article discusses the example of an episode in which a patient suffering from an incurable disease, unable to express his views clearly, has a tracheotomy performed on him without the consent of the team or his health care proxy.
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30
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Walker A. Perverse incentives. Tenn Med 2013; 106:7-8. [PMID: 23691865] [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: 06/02/2023]
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31
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Tang M. Application of a medicolegal approach in clinical stalemates. J Med Ethics 2012; 38:645-646. [PMID: 22923440 DOI: 10.1136/medethics-2012-100620] [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: 06/01/2023]
Affiliation(s)
- Michael Tang
- Yale School of Public Health, Yale University, New Haven, CT 06520-8034, USA.
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32
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Evans M. Pushing the limit. Minnesota probe of Accretive's collection practices raises new questions on hospital billing policies. Mod Healthc 2012; 42:6-1. [PMID: 22667032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The collection practices of hospitals once again grabbed the spotlight, with a report from Minnesota Attorney General Lori Swanson, left, that raises questions about aggressive techniques used by Accretive Health at Fairview Health Services in Minneapolis. While Fairview has already ended its contract with Accretive, a number of large systems still use the Chicago-based billing company.
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33
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Greene J. Organ donation in the emergency department; a missed opportunity? Ann Emerg Med 2012; 59:A19-A21. [PMID: 22553856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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34
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Dauvrin M, Lorant V, Sandhu S, Devillé W, Dia H, Dias S, Gaddini A, Ioannidis E, Jensen NK, Kluge U, Mertaniemi R, Puigpinós i Riera R, Sárváry A, Straßmayr C, Stankunas M, Soares JJF, Welbel M, Priebe S. Health care for irregular migrants: pragmatism across Europe: a qualitative study. BMC Res Notes 2012; 5:99. [PMID: 22340424 PMCID: PMC3315408 DOI: 10.1186/1756-0500-5-99] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [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: 11/22/2011] [Accepted: 02/16/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health services in Europe face the challenge of delivering care to a heterogeneous group of irregular migrants (IM). There is little empirical evidence on how health professionals cope with this challenge. This study explores the experiences of health professionals providing care to IM in three types of health care service across 16 European countries. RESULTS Semi-structured interviews were conducted with health professionals in 144 primary care services, 48 mental health services, and 48 Accident & Emergency departments (total n = 240). Although legal health care entitlement for IM varies across countries, health professionals reported facing similar issues when caring for IM. These issues include access problems, limited communication, and associated legal complications. Differences in the experiences with IM across the three types of services were also explored. Respondents from Accident & Emergency departments reported less of a difference between the care for IM patients and patients in a regular situation than did respondents from primary care and mental health services. Primary care services and mental health services were more concerned with language barriers than Accident & Emergency departments. Notifying the authorities was an uncommon practice, even in countries where health professionals are required to do this. CONCLUSIONS The needs of IM patients and the values of the staff appear to be as important as the national legal framework, with staff in different European countries adopting a similar pragmatic approach to delivering health care to IM. While legislation might help to improve health care for IM, more appropriate organisation and local flexibility are equally important, especially for improving access and care pathways.
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Affiliation(s)
- Marie Dauvrin
- Fonds de la Recherche Scientifique-FNRS, rue d'Egmont 5, 1000 Bruxelles, Belgium
- Institute of Health and Society IRSS, Université catholique de Louvain, Clos Chapelle aux Champs 30 B1.30.15, 1200 Bruxelles, Belgium
| | - Vincent Lorant
- Institute of Health and Society IRSS, Université catholique de Louvain, Clos Chapelle aux Champs 30 B1.30.15, 1200 Bruxelles, Belgium
| | - Sima Sandhu
- Unit for Social and Community Psychiatry, London and the Barts School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London E13 8SP, UK
| | - Walter Devillé
- International and Migrant Health, NIVEL (Netherlands Institute for Health Services Research), Otterstraat 118-124, PO Box 1568, 3500, BN Utrecht, The Netherlands
| | - Hamidou Dia
- Etablissement public de santé Maison Blanche, 3-5 rue Lespagnol, 75020 Paris, France
| | - Sónia Dias
- Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira, 96, 1349-008, Lisbon, Portugal
| | - Andrea Gaddini
- Laziosanità ASP Public Health Agency for the Lazio Region, Via S. Costanza 53, 00185 Rome, Italy
| | - Elisabeth Ioannidis
- Department of Sociology, National school of Public Health, 196 Alexandras avenue, Athens 11521, Greece
| | - Natasja K Jensen
- Danish Research Centre for Migration, Ethnicity and Health (MESU), Section for Health Services Research, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, DK-1014 Copenhagen, Denmark
| | - Ulrike Kluge
- Clinic for Psychiatry and Psychotherapy, Charité - University Medicine Berlin, CCM, Charitéplatz 1, 10117 Berlin, Germany
| | - Ritva Mertaniemi
- Department for mental health and substance abuse services, National Institute for Health and Welfare (THL), P.O.B. 30, FIN-00271 Helsinki, Finland
| | | | - Attila Sárváry
- Faculty of Health, University of Debrecen, Sóstói út 2-4, 4400 Nyíregyháza, Hungary
| | - Christa Straßmayr
- Ludwig Boltzmann Institute for Social Psychiatry, Lazarettgasse 14A-912, 1090 Vienna, Austria
| | - Mindaugas Stankunas
- School of Public Health, Griffith University, Gold Coast Campus, Southport, Queensland 4222, Australia
- Department of Health Management, Lithuanian University of Health Sciences, A. Mickeviciaus 9, Kaunas 44307, Lithuania
| | - Joaquim JF Soares
- Department of Public Health Sciences, Section of Social Medicine, Karolinska Institutet, SE- 171 76 Stockholm, Sweden
- Department of Public Health Sciences, Mid Sweden University, SE-851 70 Sundsvall, Sweden
| | - Marta Welbel
- Institute of Psychiatry and Neurology, Ul. Sobieskiego 9, 02-957 Warsaw, Poland
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, London and the Barts School of Medicine and Dentistry, Queen Mary University of London, Newham Centre for Mental Health, London E13 8SP, UK
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Affiliation(s)
- Daniel K Sokol
- Department of Primary Care and Public Health, Charing Cross Campus, Imperial College London, London W6 8RF, UK.
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Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med 2011; 59:177-87. [PMID: 21855170 DOI: 10.1016/j.annemergmed.2011.06.012] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [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: 02/28/2011] [Revised: 05/18/2011] [Accepted: 06/16/2011] [Indexed: 11/19/2022]
Abstract
Decisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the "greatest good for the greatest number" to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.
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Affiliation(s)
- John L Hick
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA.
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Tomlinson T. The not-so-tell-tale heart. Hastings Cent Rep 2011; 41:7-11. [PMID: 21495503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Abstract
At the time of this writing, a widely publicized, waived-consent trial is underway. Sponsored by Northfield Laboratories, Inc. (Evanston, IL) the trial is intended to evaluate the emergency use of PolyHeme®, an oxygen-carrying resuscitative fluid that might prevent deaths from uncontrolled bleeding. The protocol allows patients in hemorrhagic shock to be randomized between PolyHeme® and saline in the field and, still without consent, randomized between PolyHeme® and blood after arrival at an emergency department. The Federal regulations that govern the waiver of consent restrict its applicability to circumstances where proven, satisfactory treatments are unavailable. Blood-the standard treatment for hemorrhagic shock-is not available in ambulances but is available in hospitals. The authors argue that the in-hospital stage of the study fails to meet ethical and regulatory standards.
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Affiliation(s)
- Nancy S Jecker
- University of Washington School of Medicine, Seattle, WA 98195-7120, USA.
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Janvier A. Case study. Just another test? Commentary. Hastings Cent Rep 2010; 40:14. [PMID: 20166511] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Fuertes C, Trujillo E, Pinillos M, Balanzó X, Miró O, Burillo-Putzé G. [Attention to diversity in emergency care]. An Sist Sanit Navar 2010; 33 Suppl 1:149-161. [PMID: 20508686] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The immigrant population in general uses the health services less frequently than the native population. No significant differences are found between immigrants and natives in the use of emergency services. However, the perception of professionals who attend to the emergency services is that there is a greater use of these services by the immigrant population. Perhaps this is because difficulties of language and cultural understanding might require more effort and time in the care given to the immigrant patient. The doctor, who treats the immigrant population, as well as tourists and Spanish overseas voluntary workers, must become familiar with a series of pathologies, some of which might be exceptional among the native Spanish population, but which are endemic on some of the countries of origin of the immigrant population, frequently due to their lower socio-economic development. Some aspects to bear in mind in treating the immigrant patient might be as follows: avoiding the risk of minimising psychic complaints and explaining them away to uprootedness; if a diet or medicine is to be prescribed, the type of food and religious beliefs of the patient's country should be taken into account. The level of respect and the capacity to detect religious and cultural differences in relation to health care are fundamental tasks that the health professionals must assume with the greatest commitment in order to achieve care that is culturally appropriate in the face of diversity.
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Affiliation(s)
- C Fuertes
- Centro de Salud Txantrea, Servicio Navarrode Salud-Osasunbidea
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Bonifacio HJ. Case study. Just another test? Commentary. Hastings Cent Rep 2010; 40:13-14. [PMID: 20169651] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Affiliation(s)
- Ari Z Zivotofsky
- Bar-Ilan University, Gonda Brain Science Center, Ramat-Gan, Israel.
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Soldini M, Anastasi S. [Triage in the emergency department. Practical and ethical issues]. Clin Ter 2009; 160:223-232. [PMID: 19756326] [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: 05/28/2023]
Abstract
Triage is a complex and dynamic decisional process composed of sequential actions and necessary evaluations in order to establish the priority of access to medical attention in emergency care. In the Triage not only medical-biological knowledge is important but also the methods that together are inspired by ethical models. Following the historical considerations and after having brought out the methods and practice used in various countries and also having underlined the personal experience of the Emergency Department of the Emergency Department of the University Policlinic of the "Sapienza" University of Rome (Italy), the biggest hospital in Europe, the authors emphasized the nursing care in the "triage" and support the necessity of an adequate training period not only to acquired the technical knowledge required but also the psychological and social interaction as well as moral and practical competence. By "practical" we intend it to be explicitly a dimension in which moral competence has been acquired in using concrete first person action in a virtuous way towards the betterment of the sick person using the best modes of justice.
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Affiliation(s)
- M Soldini
- Dipartimento di Oftalmologia, Servizio di Cardiologia e Medicina Interna, Sapienza Università di Roma, Italia.
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When can staff divulge patient's HIV status? Warn patients of specific risks. What if HIPAA conflicts with your state's law? ED Manag 2008; 20:127-9. [PMID: 18998359] [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: 05/27/2023]
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