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Biomedical subjects

A R Jonsen

Publications and source records attributed to A R Jonsen.

At least 73 records · Page 4Linked to original sources
PubMed1985

Artificial heart and assist devices: directions, needs, costs, societal and ethical issues.

A Working Group appointed by the Director of the National Heart, Lung, and Blood Institute (NHBLI) has reviewed the current status of mechanical circulatory support systems (MCSS), and has examined the potential need for such devices, their cost, and certain societal and ethical issues related to their use. The media have reported the limited clinical investigative use of pneumatically energized total artificial hearts (which actually replace the patient's heart) and left ventricular assist devices (which support or replace the function of the left ventricle by pumping blood from the left heart to the aorta with the patient's heart in place). However, electrically energized systems, which will allow full implantation, permit relatively normal everyday activity, and involve battery exchange or recharge two or three times a day, are currently approaching long-term validation in animals prior to clinical testing. Such long-term left ventricular assist devices have been the primary goal of the NHLBI targeted artificial heart program. Although the ventricular assist device is regarded as an important step in the sequence of MCSS development, the Working Group believes that a fully implantable, long-term, total artificial heart will be a clinical necessity and recommends that the mission of the targeted program include the development of such systems. Past estimates of the potential usage of artificial hearts have been reviewed in the context of advances in medical care and in the prevention of cardiovascular disease. In addition, a retrospective analysis of needs was carried out within a defined population. The resulting projection of 17,000-35,000 cases annually, in patients below age 70, falls within the general range of earlier estimates, but is highly sensitive to many variables. In the absence of an actual base of data and experience with MCSS, projection of costs and prognoses was carried out using explicit sets of assumptions. The total cost of a left ventricular assist device, its implantation and maintenance for a projected average of 4 1/2 years of survival might be approximately $150,000 (in 1983 dollars). The gross annual cost to society could fall in the range of $2.5-$5 billion. Ethical issues associated with use of the artificial heart are not unique. For individual patients these relate primarily to risk-benefit, informed consent, patient selection, and privacy. However, for society as a whole, the larger concern relates to the distribution of national resources.(ABSTRACT TRUNCATED AT 400 WORDS)

Assisted Circulation↗
PubMed1985

Dying right in theory and practice. What do we really know of terminal care?

Despite the widely held belief that hospices treat dying patients differently than conventional hospitals do, few systematic comparisons exist. We reviewed medical charts to study the terminal care practice at one hospital and two inpatient hospices. As expected, hospital patients had more diagnostic tests and higher laboratory charges than patients in either hospice did. Yet physicians' notes about patients' families or nonmedical aspects of illness were infrequent at all three institutions. Furthermore, analgesic use and the frequency of nurses' notes about nonmedical or family issues differed between hospices: sometimes one hospice, sometimes the other, resembled the hospital closely. Hence, some common assumptions about hospice care appear inaccurate. We believe that health professionals who attend dying patients--whether in hospitals or hospices--have an obligation to examine their terminal care practices critically and to develop standards appropriate for their institutions.

Adult↗
PubMed1984

What is extraordinary life support?

These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs Homer A. Boushey, Associate Professor of Medicine, and David G. Warnock, Associate Professor of Medicine, under the direction of Dr Lloyd H. Smith, Jr, Professor of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA 94143.

Aged↗
PubMed1983

The living will. Help or hindrance?

The living will is a statement that directs physicians to act in certain ways during a patient's terminal phase of illness. The physician is instructed not to take measures that would prolong the life of the patient. The living will is designed to promote patient autonomy while removing onerous decision making from physicians and the patients' families. Experience with the living will indicates that it can either help or hinder clinical decision making. When appropriately implemented, the living will can perform its intended functions. When vague in terminology or applied to patients with uncertain prognoses, the living will can promote medical staff confusion. Adequate communication between patient and physician can improve the utility of the living will. Other considerations affecting the applications of the living will are discussed in detail.

Aged↗
PubMed1983

Ethical crises and cultural differences.

Generalizations about patients without careful attention to their cultural background, their values and norms could lead to a number of ethical crises. The informed consent, disclosure of diagnosis and prognosis, and discussions of termination of treatment are reflections of Western cultural values. They represent respect for autonomy of clients and respect for openness in communications. For patients from other cultures such practices have different meanings that may violate their own values. The result of such conflict in practices and meanings can render the relationship between patients and health care personnel difficult at best and distrustful at worst.

Adult↗
PubMed1981

Conflicting duties to patients: the case of a sexually active hepatitis B carrier.

A hemodialysis nurse who is a hepatitis B carrier insists on continuing dialysis nursing and sexual relationships but refuses to inform her lovers. The implications of her stance pose an ethical problem for her physician: whether to keep confidentiality, whereby others may be exposed to her hepatitis, or to breach confidentiality in order to limit her patient care activities and to notify her lovers. Pertinent medical and epidemiologic facts, legal opinions, and ethical considerations are discussed. We propose that the physician's responsibility to keep in immediate patient's confidences outweighs the responsibility to protect others unless there is sound evidence for very certain, severe harm to specific others.

Adult↗
PubMed1980

Clinical decisions to limit treatment.

A case of a patient with gastrointestinal hemorrhage raises the question of limiting medical treatment. We analyze four reasons to limit treatment: Treatment is futile, the patient refuses treatment, the costs of treatment seem excessive, and the quality of life is judged unacceptable. For cases in which treatment is to be limited, we offer practical suggestions for compassionate and appropriate terminal care.

Aged↗
PubMed1980

Ethical decisions in the care of a patient terminally ill with metastatic cancer.

A case of a patient with metastatic cancer raises the issues of patient refusal of treatment, euthanasia, and unintended side effects of therapy. For each management dilemma, there are relevant ethical and legal considerations, justifications, and conclusions. In addition, psychological and social influences on the decision process tend to limit deliberation.

Decision Making↗