New horizons (Baltimore, Md.)
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To review the literature addressing the issue of a U.S. Food and Drug Administration (FDA) moratorium on use of the pulmonary artery catheter (PAC). ⋯ An FDA moratorium on the use of the PAC is not indicated.
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Victims of out-of-hospital cardiac arrest in most communities are not the beneficiaries of an optimal healthcare system response capable of providing survivors who live to hospital discharge. The public at large, including family members and bystander witnesses of cardiac arrest, must be expected to participate in this optimal response capability. ⋯ Emergency medical services systems need to devise innovative approaches to rapid provision of automated external defibrillation, in many cases no doubt outside the boundaries of traditional means of delivery of this intervention. Finally, it is likely that targeted responders among the public will be participants in a public access defibrillation approach to dealing with sudden cardiac death.
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Researchers face a number of constraints to human resuscitation research. To overcome these constraints we must first recognize them and then work to develop solutions. The constraints include history, which tends to create a standard-of-care aura around practices that have not been confirmed by valid research. ⋯ Currently, human resuscitation research does not rank high on the funding priority list of our major funding agencies. This requires an organized approach to generate funding support and requires strong, coherent research proposals. Despite these constraints, we face many opportunities to improve survival from cardiopulmonary emergencies.
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End-of-life decisions in the ICU are often complex and emotionally charged. Intensivists can correct the physiologic abnormalities of acute and chronic illness with drugs and technology, and prolong life in many situations. ⋯ Studies on do-not-resuscitate orders, and advanced and delayed directives comprise a portion of this work. This article contains a brief summary of selected research evidence on these difficult end-of-life issues.
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Healthcare reform continues to move forward, with the influence of managed care increasing in most areas of the United States. Strategies for cost containment are being considered to limit marginally beneficial health care, including futile-care policies, capitation, preset limits on health care, and guidelines for writing do-not-resuscitate (DNR) orders. Recent studies which attempted to improve communication between patients and physicians have failed to improve the quality of end-of-life care offered by healthcare providers. ⋯ Moreover, approximately 0.5% of all ICU care could be limited should DNR orders be written earlier in a patient's hospital or ICU stay. In addition, a shift from open-format ICUs to semiclosed units managed by qualified critical care physician directors would reduce the number of patients with futile or failed cardiopulmonary resuscitation, and increase the number of patients having care withheld or withdrawn after failed ICU therapy. Such a change would result in more substantial savings.