Ethical decision-making in critical care in Hong Kong

OBJECTIVES

Biomedical ethics has assumed an increasingly important role in medicine over the past 30 yrs, and its development has served the important goal of protecting patients' rights and interests. However, medical ethics has evolved within a Western tradition, and conflict often arises when trying to apply Western medical ethics to patients from other cultures. Using Hong Kong as an example, this article reviews the nature and sources of cross-cultural conflict in the intensive care unit setting that often arises between physicians trained in Western medicine and patients from a Chinese cultural background.

DATA SOURCES

This article draws on the first author's experience as a critical care physician in Hong Kong, and on a review of the literature on cross-cultural interactions in medicine.

STUDY SELECTION

Studies were selected that contrasted the approaches of different cultures to common ethical dilemmas in medicine. Review articles examining the relationship between culture and ethics were also selected.

CONCLUSIONS

Hong Kong presents an interesting case study because of the coexistence of Western and Chinese medicine in a predominantly Chinese population that practices many Chinese cultural traditions. Whereas contemporary Western medical ethics focuses on individual rights, autonomy, and self-determination, traditional Chinese societies place greater emphasis on such community values as harmony, responsibility, and respect for parents and ancestors. Specific areas of cross-cultural conflict include: the role of the patient and family in medical decision-making; the disclosure of unfavorable medical information to critically ill patients; the discussion of advance directives or code status with patients; and the withholding or withdrawal of life support.

Production of S-(+)-2-phenylpropionic acid from (R,S)-2-phenylpropionitrile by the combination of nitrile hydratase and stereoselective amidase in Rhodococcus equi TG328

A new soil isolate, tentatively identified as Rhodococcus equi TG328, was found to be effective in the production of S-(+)-2-phenylpropionic acid from (R,S)-2-phenylpropionitrile. The conversion is catalysed by two enzymes. First, a nitrile hydratase converts the (R,S)-nitrile to (R,S)-2-phenylpropionamide. Second, a stereoselective amidase converts the S-(+)-amide to S-(+)-2-phenylpropionic acid. Conditions for optimal enzyme production and accumulation of S-(+)-2-phenylpropionic acid by resting cells were studied. The reaction of resting cells for 30 h at 10 degrees C with (R,S)-2-phenylpropionitrile resulted in the production of 100 g of S-(+)-2-phenylpropionic acid per litre of reaction mixture. The enantiometric excess of the purified S-(+)-2-phenylpropionic acid was 99.4%. The amount of S-(+)-2-phenylpropionic acid accumulated was enhanced by lower reaction temperatures. In addition, unreacted R-(-)-2-phenylpropionamide with 99.0% enantiometric excess was isolated.

Personalizing, not patronizing: the case for patient autonomy by unbiased presentation of management options in stage I testicular cancer

Testicular cancer (TC) is the most common neoplasm in males aged 15-40 years. The majority of patients have no evidence of metastases at diagnosis and thus have clinical stage I (CSI) disease [Oldenburg J, Fossa SD, Nuver J et al. Testicular seminoma and non-seminoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013; 24(Suppl 6): vi125-vi132; de Wit R, Fizazi K. Controversies in the management of clinical stage I testis cancer. J Clin Oncol 2006; 24: 5482-5492.]. Management of CSI TC is controversial and options include surveillance and active treatment. Different forms of adjuvant therapy exist, including either one or two cycles of carboplatin chemotherapy or radiotherapy for seminoma and either one or two cycles of cisplatin-based chemotherapy or retroperitoneal lymph node dissection for non-seminoma. Long-term disease-specific survival is ∼99% with any of these approaches, including surveillance. While surveillance allows most patients to avoid additional treatment, adjuvant therapy markedly lowers the relapse rate. Weighing the net benefits of surveillance against those of adjuvant treatment depends on prioritizing competing aims such as avoiding unnecessary treatment, avoiding more burdensome treatment with salvage chemotherapy and minimizing the anxiety, stress and life disruption associated with relapse. Unbiased information about the advantages and disadvantages of surveillance and adjuvant treatment is a prerequisite for informed consent by the patient. In a clinical scenario like CSI TC, where different disease-management options produce indistinguishable long-term survival rates, patient values, priorities and preferences should be taken into account. In this review, we provide an overview about risk factors for relapse, potential benefits and harms of adjuvant chemotherapy and active surveillance and a rationale for involving patients in individualized decision making about their treatment rather than adopting a uniform recommendation for all.

A Phase II Study of Intermittent Sunitinib in Previously Untreated Patients With Metastatic Renal Cell Carcinoma

Purpose

Sunitinib is a standard initial therapy in metastatic renal cell carcinoma (mRCC), but chronic dosing requires balancing toxicity with clinical benefit. The feasibility and clinical outcome with intermittent sunitinib dosing in patients with mRCC was explored.

Patients and Methods

Patients with treatment-naïve, clear cell mRCC were treated with four cycles of sunitinib (50 mg once per day, 4 weeks of receiving treatment followed by 2 weeks of no treatment). Patients with a ≥ 10% reduction in tumor burden (TB) after four cycles had sunitinib held, with restaging scans performed every two cycles. Sunitinib was reinitiated for two cycles in those patients with an increase in TB by ≥ 10%, and again held with ≥ 10% TB reduction. This intermittent sunitinib dosing continued until Response Evaluation Criteria in Solid Tumors-defined disease progression while receiving sunitinib, or unacceptable toxicity occurred. The primary objective was feasibility, defined as the proportion of eligible patients who underwent intermittent therapy.

Results

Of 37 patients enrolled, 20 were eligible for intermittent therapy and all patients (100%) entered the intermittent phase. Patients were not eligible for intermittent sunitinib because of progressive disease (n = 13), toxicity (n = 1), or consent withdrawal (n = 3) before the end of cycle 4. The objective response rate was 46% after the first four cycles of therapy. The median increase in TB during the periods off sunitinib was 1.6 cm (range, −2.9 to 3.4 cm) compared with the TB immediately before stopping sunitinib. Most patients exhibited a stable sawtooth pattern of TB reduction while receiving sunitinib and TB increase while not receiving sunitinib. Median progression-free survival to date is 22.4 months (95% CI, 5.4 to 37.6 months) and median overall survival is 34.8 months (95% CI, 14.8 months to not applicable).

Conclusion

Periodic extended sunitinib treatment breaks are feasible and clinical efficacy does not seem to be compromised.

Whose death is it, anyway?

As medicine has increasingly gained the power to prolong life in the face of devastating illness, patients have increasingly become concerned about maintaining some control over how and when death arrives. Competent patients have the legal right to refuse treatment, but critically ill patients are frequently unable to participate in decision making. Advance directives were designed to help patients establish the level of care they would receive if they were to be rendered incompetent; yet, as the case discussed in this essay shows, even a valid advance directive does not guarantee that unwanted medical interventions will not be forced on us. The problem of physicians ignoring their patients' wishes goes beyond issues of communication and reflects an ongoing ambivalence about power and control in the physician-patient relationship. Unfortunately, many physicians find it easier to define success in terms of life and death than to try to determine what sort of existence is meaningful to an individual patient.

Physician virtues and communicating with patients

The growth of profit-driven medicine and managed care as well as the increasingly technologic focus of Western medicine have stimulated much reflection on the fundamental values of the medical profession and on the meaning of being a "good doctor." Many patients and many in the medical community have grown concerned about the fate of the doctor-patient relationship. In practicing medicine, physicians must be guided both by the basic principles of biomedical ethics and by Beauchamp's and Childress's four fundamental virtues: compassion, trustworthiness, discernment, and moral integrity. In addition, physicians must make the commitment to develop strong communication skills, for it is through communicating with patients that we forge a relationship with them and make them feel cared for. Good communication skills not only improve patient satisfaction and facilitate resolving the difficult ethical problems that arise in critical care but have also been shown to improve certain health outcomes. Unfortunately, studies have repeatedly shown physicians to have poor communication skills. In this article we identify key elements in preserving medicine's "covenant of trust" and in establishing good communication and rapport in critical care settings. We identify specific obstacles to good communication and propose strategies for overcoming them.