The Journal of clinical ethics
-
Review
The ethical and clinical importance of measuring consciousness in continuously sedated patients.
Continuous sedation at the end of life is a practice that has attracted a great deal of attention. An increasing number of guidelines on the proposed correct performance of the practice have been drafted. All of the guidelines stress the importance of using sedation in proportion to the severity of the patient's symptoms, thus to reduce the patient's consciousness no more than is absolutely necessary. ⋯ Other techniques, such as EEG (electroencephalography) derivatives, may score better on reliability and invasiveness. Yet these have so far never been compared to sedation scale scores for patients receiving continuous sedation at the end of life. Therefore, we conclude that, for both clinical and ethical reasons, research into the efficiency and applicability of other techniques, such as derivatives of EEG, are urgently needed.
-
Medical professionalism has been developing in the Peoples' Republic of China as one way to better address perennial and new challenges in healthcare in an ever-changing society. Among many recent developments in this area is promotion by the national Chinese Medical Doctor Association of the principles and values contained in the international document, "Medical Professionalism in the New Millennium: A Physician Charter." ⋯ Based on responses to the survey, Chinese physicians strongly support the majority of the fundamental principles and responsibilities of medical professionalism, including dedication, altruism, social justice, self-regulation, and informed consent. However, their support for the primacy of patients' welfare as a general principle, and the physician's responsibility to report medical errors and incompetent colleagues, is relatively low. To help advance medical professionalism in the People's Republic of China, professional development programs and medical ethics education should not only emphasize the general principles involved, but also formulate guidelines on how these principles can be carried out in practice.
-
This issue's "Legal Briefing" column covers recent legal developments involving total brain failure. Death determined by neurological criteria (DDNC) or "brain death" has been legally established for decades in the United States. But recent conflicts between families and hospitals have created some uncertainty. ⋯ Because of the similarity to medical futility disputes, some court cases on this topic were reviewed in a prior "Legal Briefing" column. But a more systematic review is now warranted. I categorize recent legal developments into the following nine categories: (1) History of Determining Death by Neurological Criteria, (2) Legal Status of Determining Death by Neurological Criteria, (3) Legal Duties to Accommodate Family Objections, (4) Protocols for Determining Death by Neurological Criteria, (5) Court Cases Seeking Physiological Support after DDNC, (6) Court Cases Seeking Damages for Intentionally Premature DDNC, (7) Court Cases Seeking Damages for Negligently Premature DDNC, (8) Court Cases Seeking Damages for Emotional Distress, (9) Pregnancy Limitations on DDNC.
-
We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients' ages ranged from 14 to 85. ⋯ In cases we characterized as finite-goal accommodation, a "reasonable accommodation" strategy proved effective in balancing stakeholders' interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the "reasonable accommodation" approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases.
-
Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of the checklist at a large academic medical system (Cleveland Clinic). ⋯ Despite these limitations, to the authors' knowledge this is the first investigation of the use of a checklist systematically to improve quality in ethics consultation. Importantly, our findings shed light on ways this checklist can be used to improve ethics consultation, including its use as an educational tool. The authors hope to test the checklist with consultants in other healthcare systems to explore its usefulness in different healthcare environments.