When pharmacists refuse to dispense prescriptions.
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Female↗
Biomedical subjects
Katrina A Bramstedt
Publications and source records attributed to Katrina A Bramstedt.
Living liver donor mortality: where do we stand?
OBJECTIVE: To explore the use of medical journals, lay media, registries, and transplant center websites to discuss living liver donor mortality. METHODS: To study the incidence of and circumstances relating to living liver donor death, medical journals and lay print media were searched to create a case summary of worldwide living liver donor deaths. The United Network for Organ Sharing (UNOS) and European Liver Transplant Registry (ELTR) were also queried for information regarding living liver donor deaths. Lastly, the Websites of United States transplant centers offering living liver donation were reviewed to identify whether or not death was stated as a donor risk. RESULTS: Literature review revealed 14 living liver donor deaths. One of the five deaths occurring in the United States had been reported to UNOS. One of the 14 cases had been reported only in lay literature, and another only in the ELTR. In at least five cases, surgical complications were not the cause of donor death. Among the 62 transplant center Websites, only 12 centers (19%) specifically mentioned death as a donation risk. Eight of these 12 centers (67%) mentioned death in terms of percent mortality risk; however, risk rates spanned a 10-fold range from 0.2% to 2%. CONCLUSION: Potential living liver donors are best served by accurate information about donor mortality. Access to such data is difficult and these individuals would benefit by a worldwide living liver donor registry and peer-reviewed publication of donor mortality.
Adult↗
Protecting human subjects in neurosurgical trials: the challenge of psychogenic dystonia.
The discomfort and suffering of medically refractory organic dystonia has lead to the pursuit of new potential treatment interventions, namely, pallidotomy and deep brain stimulation (DBS). The risks inherent in surgical procedures require a heightened awareness to the need for protecting the welfare of research subjects participating in surgical trials. To this end, excluding patients who are not appropriate candidates is a key part of the trial process. We argue that psychogenic dystonia, a condition that is both difficult to diagnose and difficult to treat, should be an exclusion criterion for DBS therapy, and neurosurgery in general. However, since there exists no definitive test for psychogenic dystonia, researchers must determine fair and just criteria for excluding patients whose dystonia is suspected to be primarily psychogenic.
Clinical Trials as Topic↗
Use of the internet by United States heart transplant centers to promote transparency in the process of patient selection.
Organ transplantation is an ethically complex technology, in part because organs are very scarce and supply does not meet demand. Organ allocation must use a process that is fair, and the process should be open for public review and revision. We explored the transparency of the heart transplant patient selection process in the United States terming transparency as hospital use of their transplant program Web site to disclose their policies to potential patients. The Web sites of all heart transplant centers belonging to the U.S. Organ Procurement and Transplantation Network were reviewed for content pertaining to patient selection criteria for placement on the transplant waiting list. All 132 heart transplant centers have a Web site that discusses their transplant program; however, 84% (n = 111) do not publish their medical listing criteria on their Web site. Only 15% (n = 20) expressly indicate the requirement for a psychosocial evaluation. Few centers (n = 9) utilize their Web site to discuss use of a formal data review committee to decide which patients to list for transplantation. In order to demystify and correct false assumptions about the transplant listing process, wait listing criteria should be transparent to the public and Internet disclosure can facilitate this end. Our findings lay the foundation for future prospective studies.
Heart Transplantation↗
The dilemma of alcohol use by potential living liver donors.
Previous and current alcohol use by potential living liver donors presents ethical challenges for donor selection committees. Discussing these challenges, we offer guidelines for selection and management of these individuals. Donor safety and welfare should be the primary concern, thus relapse potential during the postdonation period for those with a history of alcohol dependence or abuse is of importance, especially because of the potentially severe consequences of mixing pain relievers (eg, acetaminophen) and alcohol during liver regeneration. Psychosocial and chemical dependency evaluations are critical for potential living donors as well as recipients.
Adult↗
Evaluating patients with a criminal history.
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Crime↗
Is it ethical to prioritize patients for organ allocation according to their values about organ donation?
Because the supply of deceased donor organs fails to meet demand, patients needing a transplant frequently have lengthy waits or die while waiting. In an effort to reduce waiting times, the concept of "preferred status" has emerged. In the United States, preferred status has taken the form of a community of individuals called LifeSharers. Using directed donation, this group aims to facilitate priority organ allocation to its members-people who have agreed to be organ donors. Such preferred status programs increase societal awareness about organ donation and transplantation, but they are not without ethical controversy, as some term them "clubs." In the case of LifeSharers, the potential to increase the pool of deceased donor organs is a worthy goal that would benefit the community of patients awaiting transplantation, not just LifeSharers members.
Attitude to Health↗
Supporting organ transplantation in non-resident aliens within limits.
It is common knowledge that the supply of cadaveric organs does not meet demand. This shortage is often used as ethical argument against transplantation in Non-Resident Aliens; however, this fact in isolation does not present a comprehensive picture of organ allocation in USA. Even though approximately 153 cadaveric livers, kidneys, and hearts are transplanted into Non-Resident Aliens each year, roughly another 85 livers, kidneys and hearts are recovered as usable for transplantation but are not transplanted due to inability to find a recipient. These organs are also unable to be exported due to logistics or lack of patient matching. Because usable, recovered allografts are discarded on a yearly basis, there is no justification to use "allograft scarcity" as argument against transplantation in Non-Resident Aliens. Further, consistent with other countries, a system of two waiting lists which allocates organs to US Residents with the first right of refusal (with Non-Resident Aliens having to access organs refused by or not matched to US Residents) is ethically appropriate. Justification for this two-list system lies in deconstructing "who" is the transplant community, and who are "guests" of the transplant community.
Cadaver↗
When death is the outcome of informed refusal: dilemma of rejecting ventricular assist device therapy.
Refusal of treatment can have fatal consequences for heart failure patients who could otherwise benefit from ventricular assist device therapy. Ethical dilemmas arise when treatment refusals seem based on unsound reasoning by patients. Using a clinical case from our medical center, we explored the complex ethical issues associated with patient refusal of ventricular assist device therapy due to the patient's perception of large device size as compared to other mechanical heart technologies. Early on, the medical team must assess a patient's refusal of therapy by reflecting on the decisionmaking capacity of the patient to determine whether such refusal is truly "informed," and all incidents of informed refusal should be clearly documented in the patient's chart.
Adult↗
To do or not to do living donor hepatectomy in Jehovah's Witnesses: single institution experience of the first 13 resections.
Living donor liver transplantation has come to be an acceptable alternative to deceased donor transplants. Several ethical issues related to living donation have been raised in the face of reported perioperative morbidity and mortality. We report our experience in 13 consecutive Jehovah's Witness (JW) donor hepatectomies. From June 1999 to April 2004, 13 adult JW donors underwent donor hepatectomies at the USC-University Hospital. Nine donors underwent right lobectomy with a 62% mean volume of the liver resected. Four donors underwent a left lateral segmentectomy with a mean volume of 17.8%. Cell scavenging techniques, acute normovolemic hemodilution and fractionated products were used. The mean hospital stay was 6.2 days. All donors are alive and well at a median follow-up time of 3 years and 4 months. Live liver donation can be done safely in JW population if performed within a comprehensive bloodless surgery program.
Adolescent↗
When families complicate patient care: a case study with guidelines for approaching ethical dilemmas.
Using a case example, the authors explore several ethical dilemmas that can erupt as the consequence of patient family members attempting to influence the patient care plan. In an effort to avoid the engulfing of medical, financial, and personnel resources, the authors offer guidelines to prevent such cases from spiraling out of control.
Aged↗
When microchip implants do more than drug delivery: blending, blurring, and bundling of protected health information and patient monitoring.
Although currently in the research stage, scientists argue that drug-releasing microchip implants are on the horizon for future patients. This paper presents ethical reflection on these implants and identifies specific areas of concern; namely, patient monitoring and tracking, and patient privacy and confidentiality. It is foreseeable that drug delivery chips could be multifunctional with the overt or covert addition of sensors that monitor more than just the bloodstream concentrations of prescribed drugs (e.g., cotinine and alcohol in non-compliant patients, patient location via radio frequency or global positioning satellite). Similarly, it is foreseeable that these chips could be embedded with a patient's protected health information that could potentially be accessed and used by unauthorized persons. While drug delivery microchips are theoretically convenient and accurate for dosing, and might offer faster drug delivery with fewer side effects, ethical issues loom and should be contemplated now, while the technology is still under development.
Computers↗
Saying "good-bye": ethical issues in the stewardship of bed spaces.
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Aged↗
Surrogate consent for live organ donation.
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Humans↗
Now we lay them down to sleep: ethical issues with the use of pharmacologic coma for adult status epilepticus.
The use of pharmacologic coma (PC) to treat status epilepticus (SE) is not always successful, and there are no guidelines for the duration of PC in an attempt to achieve seizure control. Using clinical cases, we explore three concepts: (1) SE as a terminal condition; (2) PC resulting in permanent unconsciousness; and (3) use of PC for extended periods. Regarding a patient's Advance Directive/Living Will, these three concepts can pose ethical complexities for the medical team due to the notions of unconsciousness, cognitive appreciation, and life support being relevant to both PC therapy as well as these documents. We argue that when PC therapy is not reversing the patient's clinical course and only offering to sustain organic life, it is ethically appropriate to discontinue such therapy and provide the patient comfort care. If PC therapy is only expected to sustain organic life, it is ethically appropriate not to offer it.
Adult↗
Elective inactivation of total artificial heart technology in non-futile situations: inpatients, outpatients and research participants.
Total artificial heart technology as a potential clinical therapy raises the issue of elective device inactivation in both futile and non-futile situations. This article explores elective device inactivation in non-futile situations. In reply to such requests for inactivation, the medical team should reflect on the individual's decision-making capacity, the clinical appropriateness of the therapy, and the setting of the request (clinical research vs. clinical practice). A decision-making flowchart is presented as a guide for managing inactivation requests. In the research setting, current U.S. federal regulations are murky as to the matter of study withdrawal made by participants who lack decision-making capacity. This compared with clear legal and ethical approaches in the non-research setting (clinical practice).
Clinical Trials as Topic↗
Shopping for a transplant: when noncompliant patients seek wait listing at multiple hospitals.
United Network for Organ Sharing policy allows patients to be listed for a transplant at multiple hospitals. This strategy can sometimes lessen the transplant waiting time for patients because waiting times vary geographically. We explore the ethical dilemma of "shopping for a transplant" by presenting the case of a patient with an addictive disorder who was listed for liver transplantation at one hospital on the east coast of the United States and was seeking listing at 2 additional hospitals in midwestern United States, when marijuana use was suspected by 1 of the latter 2 facilities. Although the transplant team at this facility deferred listing the patient, the team's bioethicist posed the concept of a duty to notify the facility where the patient was already listed for transplantation about any confirmed substance abuse, in an effort to prevent a scarce resource from being allocated to an individual who is noncompliant.
Confidentiality↗
A pilot study of health education via a nurse-run telephone self-management programme for elderly people with osteoarthritis.
We conducted a pilot study of a nurse-run telephone self-management programme for elderly people with osteoarthritis (OA). Thirty-two subjects, aged 60 years or more, with a diagnosis of OA were recruited from two hospital rheumatology clinics and were randomized to a control or intervention group. The intervention group received six weekly mailings of OA health education modules, a relaxation audio-tape and six weekly 45 min follow-up telephone self-management sessions. There was a 100% compliance rate in the intervention group, and all subjects completed baseline and three-month interviews; one subject in each group was lost to six-month follow-up. There were no significant differences in self-management between the control and intervention groups. However, at three months there were improvements in the intervention group (relative to baseline) on some outcome measures. The results suggest that the telephone may be a useful tool for reinforcing health-promoting activities for patients.
Aged↗