Current opinion in anaesthesiology
An exploration of the ethics, challenges and practical reality of treating family members. Hutchison & McConnell deploy models of virtue, utilitarianism, deontology and principlism in an accessible and applied way.
- Virtue ethics – behaving in the way we think is right; embodying courage.
- Utilitarianism – behaving so as to maximise the best outcomes for the greater number of people.
- Deontology – obeying the rules; following a duty to moral law.
- Principlism – balances beneficence, nonmaleficence, autonomy and justice.
They cautiously challenge the blanket prohibitions of many professional bodies against treating family members.
Well worth reading.
“Only by constantly questioning whether they are the correct person to deliver care can they hope to do right by both their relative and themselves.”
Boer, Touw and Loer describe the concept of continuous, remote vital sign monitoring and the current level of evidence for it's proposed benefit.
We know that...
- Post-operative complications occur in 25-40% of patients, making this the most important focus for improving perioperative outcomes.
- Failure to rescue is a common problem, and few postoperative patients actually experience sudden deterioration, instead hindsight shows a slow and steady decline leading to the critical event that generates an emergency response.
Continuous remote vital sign monitoring on surgical wards may improve early recognition of deterioration.
- Remote monitoring uses medical-grade biosensors wirelessly linked to a central receiver, integrated with an electronic patient record, allowing patients free movement.
- The handful of currently available systems monitor combinations of heart rate ± variability, ECG, respiratory rate, pulse oximetry, blood pressure, temperature, posture and activity.
- Continuous monitoring may then be integrated with systems that calculate an Early Warning Score, automatically notify staff of early deterioration, or in more advanced future systems, allow prediction of deterioration.
- Although feasible, all current systems suffer from practical and technical issues that can limit their sensitivity and specificity.
So, any real evidence?
- Evidence of benefit is still very patchy, although data suggests that automated notification of deterioration leads to earlier responses by treating teams, with small interventions, reducing the burden on rapid response / MET systems.
- No actual morbidity or mortality outcome data is yet available.
While the hope is that remote monitoring can improve patient safety, it could disingenuously be used to justify reduced ward staffing and hospital stay length by normalizing the risk of our current postoperative harm status quo.summary
Early warnings scores are designed to detect clinical deterioration and promote intervention at the earliest possible moment. Although the ultimate effects on patient outcomes are unclear, early warning scores are now legally mandated in several countries. Here, we review the performance of early warning scores in surgical and perioperative populations. ⋯ Early warning scores may facilitate protocolized escalation of care for patients at risk of adverse events and can be used in surgical and postoperative patients, but high nonevent rates and practical implementation problems can restrict their usefulness.
Currently, outcome data in ambulatory anesthesia are somewhat limited though results are quite good with low reported rates of mortality and major morbidity. As patient comorbidities and surgical invasiveness increase, identifying those patients at higher risk will help to focus quality improvement energy and research where most effective. Better data collection and analysis will refine patient and procedure selection and improve outcomes going forward. ⋯ Identifying high-risk ambulatory patients can help facilitate development of a strategy to triage these patients, optimize their conditions prior to surgery, and manage their care and disposition postoperatively. Inpatient surgery or admission should be considered for higher risk patients having high invasive surgery.