Thoracic surgery clinics
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Thoracic surgery clinics · Nov 2005
ReviewPostoperative futile care: stopping the train when the family says "keep going".
All surgeons must take risks when providing medical care. No guarantees of protection from a lawsuit exist in any guise. Concerning postoperative futile care, the stakes are high when withdrawal of support seems to be indicated but the surrogate believes in sanctity-of-life and demands continued aggressive care. ⋯ If so, "do what's right" is not just to "stop the train." It also consists of a range of clinical activities, including effective communication, emotional care, and pursuing a fair and open negotiation process established by the institution. Properly conducted, "stopping the train" should incur no greater risk for professional liability than any other challenging procedure that surgeons perform. Withdrawal of futile care should be considered as a procedure, and as such, the skills to deliver it should be mastered like any other.
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HIPAA regulations have been seen by many physicians as providing innumerable administrative hoops that require jumping through with no clear benefit for individual patients. Although this article has not comprehensively explored the requirements of HIPAA regulations, it has focused on the issues of "incidental disclosures" that are so important to the daily interactions of physicians and patients. Through the use of illustrative cases, it has been shown that HIPAA regulations frequently are based on well-accepted ethical principles. ⋯ As Lo and colleagues have very appropriately pointed out: In the context of inadvertent disclosure, the legal risks of good practice are very low. Physicians should work with risk managers and practice administrators to develop policies that promote good communication in patient care, while taking appropriate steps to protect patient privacy. By adopting such an approach to HIPAA, physicians can abide by the regulations while maintaining high ethical standards and minimizing the impact of the new requirements on physician-patient relationships.
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The causal relationship between GERD and esophageal adenocarcinoma, although unclear just a few decades ago, now is established fairly well. The physiologic changes and the biocellular alterations of the damaged esophageal mucosa are documented better. Despite this knowledge, the dramatic increase in the incidence of esophageal cancer cannot be explained. ⋯ During regular endoscopic follow-up, multilevel circumferential biopsies should document the evolution of the histologic changes in the lower esophagus and at the gastroesophageal junction of these patients. It is the only method available to document the appearance of dysplasia. It still is unclear if medicine or surgery provides the best quality of life and the best protection against the development of dysplasia and the possible progression toward adenocarcinoma formation when intestinal metaplasia is present in the esophagus.
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Smokers have a significantly greater risk of complications during and after operations. Cigarette smoke has significant effects on cardiac function, circulation, and respiratory function. ⋯ Smoking cessation programs that employ advice, support groups, nicotine replacement therapy, or some anti-depressants have been used successfully in many situations and should be used to discourage smoking preoperatively. Further research is needed, however, to clarify the best approach to smoking cessation for surgical patients.
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Although data are limited for preoperative pulmonary rehabilitation, benefit can be inferred largely from studies done on COPD and pulmonary rehabilitation because of the similarity of patient populations. Although underlying lung function is unchanged, patients who undergo preoperative pulmonary rehabilitation seem to experience an enhanced quality of life and increased functional capacity. ⋯ Although pulmonary rehabilitation works to benefit patients anticipating surgery, it also represents a valuable treatment alternative to patients who are poor surgical candidates. Pulmonary rehabilitation seems to be a cost-effective, benign intervention with no adverse effects and should remain an essential component of patient management before lung transplantation, LVRS, lung resection, and potentially any other elective thoracic surgical procedure.