Intensive care ethics in evolution

The ethics of treating the seriously and critically ill have not been static throughout the ages. Twentieth century medicine has inherited from the nineteenth century a science which places an inappropriate weight on diagnosis over prognosis and management, combined with a seventeenth century duty to prolong life. However other earlier ethical traditions, both Hippocratic and Christian, respected both the limitations of medicine and emphasised the importance of prognosis. This paper outlines some of the historical precedents for the treatment of the critically ill, and also how the current paradigm limits clinical practice and causes ethical tensions. An understanding that other paradigms have been ethically acceptable in the past allows wider consideration and acceptance of alternatives for the future. However future alternatives will also have to address the role of technology, given its importance in this area of medicine.     

Caring animals and care ethics

Biology & Philosophy - Historical explanations in evolutionary biology are commonly characterized as narrative explanations. Examples include explanations of the evolution of particular traits...     

Defining priorities for improving end-of-life care in Canada

Background

High-quality end-of-life care should be the right of every Canadian. The objective of this study was to identify aspects of end-of-life care that are high in priority as targets for improvement using feedback elicited from patients and their families.

Methods

We conducted a multicentre, cross-sectional survey involving patients with advanced, life-limiting illnesses and their family caregivers. We administered the Canadian Health Care Evaluation Project (CANHELP) questionnaire along with a global rating question to measure satisfaction with end-of-life care. We derived the relative importance of individual questions on the CANHELP questionnaire from their association with a global rating of satisfaction, as determined using Pearson correlation coefficients. To determine high-priority issues, we identified questions that had scores indicating high importance and low satisfaction.

Results

We approached 471 patients and 255 family members, of whom 363 patients and 193 family members participated, with response rates of 77% for patients and 76% for families. From the perspective of patients, high-priority areas needing improvement were related to feelings of peace, to assessment and treatment of emotional problems, to physician availability and to satisfaction that the physician took a personal interest in them, communicated clearly and consistently, and listened. From the perspective of family members, similar areas were identified as high in priority, along with the additional areas of timely information about the patient’s condition and discussions with the doctor about final location of care and use of end-of-life technology.

Interpretation

End-of-life care in Canada may be improved for patients and their families by providing better psychological and spiritual support, better planning of care and enhanced relationships with physicians, especially in aspects related to communication and decision-making.Although a “quality death” is an espoused right of Canadians,¹ for many dying patients and their families, it is not achieved. Recent reviews and observational studies describe considerable dissatisfaction with end-of-life care, indicating that there are still opportunities for improvement.^2–5Ideally, initiatives aimed at improving end-of-life care would be informed by the experiences and expectations of patients and their family members. However, such efforts are often hampered by inadequate definitions of quality of care and by suboptimal tools for measurement.^6–8 In a recent, large cross-sectional survey, the Canadian Researchers at the End of Life Network defined what matters most to seriously ill patients as they approach the end of life.⁹ Both patients and their family members reported that it was extremely important that they have trust and confidence in the physicians caring for them or their loved ones.⁹ Avoidance of unwanted life-support measures, effective communication, continuity of care, and feelings of life completion were also rated as highly important.⁹ We used these comprehensive ratings of importance to develop and validate a novel questionnaire to measure satisfaction with end-of-life care.¹⁰ Using this questionnaire, we formally evaluated the care received at the end of life in several Canadian centres.By targeting initiatives for change at gaps in quality, we can address the highest priorities for improving end-of-life care in Canada. Our objective was to identify high-priority areas for improvement in the care of patients with advanced, life-limiting diseases and in the perceived quality of that care by their families. We identified these areas by focusing on care-related issues that had been rated as important by patients and their family members but were rated low on the questionnaire measuring satisfaction with end-of-life care.     

Health care ethics and health law in the Dutch discussion on end-of-life decisions: a historical analysis of the dynamics and development of both disciplines

Over the past three or four decades, the concept of medical ethics has changed from a limited set of standards to a broad field of debate and research. We define medical ethics as an arena of moral issues in medicine, rather than a specific discipline. This paper examines how the disciplines of health care ethics and health care law have developed and operated within this arena. Our framework highlights the aspects of jurisdiction (Abbott) and the assignment of responsibilities (Gusfield). This theoretical framework prompted us to study definitions and changing responsibilities in order to describe the development and interaction of health care ethics and health law. We have opted for the context of the Dutch debate about end-of-life decisions as a relevant case study. We argue that the specific Dutch definition of euthanasia as 'intentionally taking the life of another person by a physician, upon that person's request' can be seen as the result of the complex jurisdictional process. This illustrates the more general conclusion that the Dutch debate on end-of-life decisions and the development of the two disciplines must be understood in terms of mutual interaction.     

Educating primary care clinicians about health disparities

Background

Primary care research has recently garnered greater attention at the national level. Yet, primary care (i.e., family medicine, internal medicine, pediatrics, and obstetrics and gynecology) departments within academic institutions struggle to develop and sustain strong research frameworks.

Methods

This paper discusses a successful model that was developed in the department of family medicine at the University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine.

Results

Overall, the framework revolves around three core values: training future primary care researchers, providing resources to emerging and junior faculty members, and creating a partnership with the community and clinicians to conduct primary care clinical research.

Conclusion

Significant effort is required to establish a successful research framework in family medicine. The framework presented herein serves as an example for other departments to use and adapt in developing their research division.     

Learning from different cultures--a cultural diversity project in end-of-life care

In January 1997, Midwest Bioethics Center (MBC) launched PATHWAYS to Improve End-of-Life Care, a three-year multifaceted community initiative to improve care of the dying in the Kansas City metropolitan area. Pathways focused on professional education and development, institutional reform, and public engagement, using thirteen different strategies to accomplish dozens of projects. Ultimately, more than 2,000 professionals and other community leaders were involved and more than 600 organizations participated. This article describes a cultural diversity project on end-of-life care that developed from this program.     

Bioethics for clinicians: 15. Quality end-of-life care

A physician who receives a call from the emergency department to see a patient with heart failure will have a clear framework within which to approach this problem. The thesis of this article is that physicians do not have an analogous conceptual framework for approaching end-of-life care. The authors present and describe a framework for end-of-life care with 3 main elements: control of pain and other symptoms, the use of life-sustaining treatments and support of those who are dying and their families. This 3-part framework can be used by clinicians at the bedside to focus their effort in improving the quality of end-of-life care.     

The spiritual strength story in end-of-life care: two case studies

In this article I analyze two brief case studies to propose that a "spiritual strength story" has five defining characteristics: (1) it is brief; (2) it is ontological; (3) it uses symbols and metaphors; (4) it is a "big story" or meta-narrative with a positive spiritual and/or religious focus that informs other narrative data; and (5) most conspicuously of all, it repeats. Cultivating awareness of the "spiritual strength" narrative type can help to improve the quality of inter-professional patient-centered care teamwork and understanding, especially in regard to the reflexive, embodied, and relational aspects of palliative and end-of-life care.     

The Kansas City palliative care curriculum--medical schools improve end-of-life training

Midwest Bioethics Center believes that encouraging palliative care training in the school milieu is one of the keys to achieving lasting improvement in end-of-life care. Therefore, a cooperative venture to increase palliative care education in medical schools was among the first strategies envisioned in the Center's PATHWAYS initiative. Its implementation, no less than its goal, requires both time and effort.     

Business leaders begin to rally in support of public health care system

There appears to be growing concern among Canada''s business leaders about the future of Canada''s health care system. At a recent meeting in Montebello, Que., that was cosponsored by the CMA and several Canadian corporations, some business representatives said Canada''s publicly funded system gives them a competitive edge in an increasingly global market.     

Privacy and disclosure in medical genetics examined in an ethics of care

The progress of genetic knowledge magnifies existing ethical problems in medical genetics. Among the most troubling types of problems -- for medicine, patients, and the larger society -- are those of privacy and disclosure. Examples of the range of problems involving privacy and disclosure are: 1) disclosure of false paternity to an unsuspecting husband; 2) disclosure of a patient's genetic make-up to his or her unknowing spouse; 3) disclosure of information, against a patient's wishes, to relatives at genetic risk; 4) disclosure of ambiguous test results; 5) disclosure of adventitious nonmedical information, e.g., fetal sex; and 6) disclosure to institutional third parties, such as employers and insurers....