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Biomedical subjects

M Siegler

Publications and source records attributed to M Siegler.

At least 19 recordsLinked to original sources
PubMed2002

Is posthumous semen retrieval ethically permissible?

It is possible to retrieve viable sperm from a dying man or from a recently dead body. This sperm can be frozen for later use by his wife or partner to produce his genetic offspring. But the technical feasibility alone does not morally justify such an endeavour. Posthumous semen retrieval raises questions about consent, the respectful treatment of the dead body, and the welfare of the child to be. We present two cases, discuss these three issues, and conclude that such requests should generally not be honoured unless there is convincing evidence that the dead man would want his widow to carry and bear his child. Even with consent, the welfare of the potential child must be considered.

Adult↗
PubMed2001

Ethical considerations and rationale of adult-to-adult living donor liver transplantation.

Adult-to-adult living donor liver transplantation (ALDLT) is a reality; shortly after its introduction into clinical practice, it is being performed in approximately 50 centers throughout the United States and Europe. The quick development of ALDLT and some deaths among donors repropose old ethical dilemmas and confront the transplant community with new urgent problems. To minimize risks for recipients and, especially, donors, two key questions are addressed: (1) who can or should perform the procedure, and (2) what patient should undergo the procedure. The high risks taken by live donors undergoing a hemihepatectomy seem to be justified by the steadily increasing mortality of adult recipients waiting for transplantation. A comprehensive consent procedure is at the base of responsible decision making for both donors and recipients. In adherence to basic medical criteria, the autonomy of decision of donors and recipients may allow the extension of indications to patients not suitable to undergo transplantation with cadaveric grafts. The broadening of indications is appropriate only in centers with adequate experience and proven expertise in ALDLT. The medical community faces the duty of regulating ALDLT before external influences force undesired policy changes, particularly if not based on medical grounds. Individual centers and patients are ultimately responsible for the correct use of LDLT.

Adult↗
PubMed2001

Ethical issues identified by rehabilitation clinicians.

OBJECTIVES: To quantify systematically and to characterize the range of ethics issues affecting rehabilitation professionals' day-to-day clinical practice, and to assess the preferences of rehabilitation clinicians for ethics education. DESIGN: Survey of clinicians and admitting office personnel in an acute rehabilitation hospital with open-ended questions about the ethical issues they found most troubling in daily practice. SETTING: A 175-bed free-standing, urban rehabilitation hospital. PARTICIPANTS: A total of 411 clinicians and admitting office personnel, of whom 217 responded (53%) and generated a total of 547 ethics issues. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ethical issues were coded by 2 independent raters into 24 different categories and a reconciliation session was used to resolve discrepancies. RESULTS: The largest response (24%) was categorized as pressures resulting from health care reimbursement changes. The second most common problem (17%) involved conflicts among patients, physicians, team members, or families around goal setting. Difficulty assessing decision-making capacity was third (7%). The respondents favored discussion groups or interdisciplinary in-services and lectures over self-instructional materials as formats for ethics education. CONCLUSIONS: Ethical issues in the rehabilitation setting are common, and reflect both the dynamic nature of the health care environment and the team model of care. Ongoing, interactive educational interventions are warranted to address these issues.

Adult↗
PubMed2000

Paradoxes in cancer patients' advance care planning.

PURPOSE: To determine the frequency of advance care planning (ACP) in hospitalized cancer patients and to assess their reactions to a proposed policy in which medical housestaff would offer to discuss ACP at the time of hospital admission. METHODS: Structured interviews with 111 consecutively admitted cancer patients on the oncology inpatient service of a tertiary care medical center. RESULTS: We found that 69% (77/111) of patients had discussed their advance care preferences with someone, usually a family member, and 33% (37/111) had completed at least one formal advance directive (e.g., a living will or durable power of attorney for health care); 32% (36/111) had done both; and 30% (33/111) had done neither. However, only 9% (10/111) of patients reported having discussed their advance care preferences with their clinic oncologists and only 23% (23/101) of the remaining patients stated that they wished to do so. By contrast, 58% (64/110) of patients supported a policy in which medical housestaff would offer to discuss these advance care preferences as a part of the admission history. CONCLUSIONS: Our data suggest that while oncology inpatients frequently have ACPs that they discuss with family and/or document in formal advance directives, they rarely discuss or wish to discuss these ACPs with clinic oncologists. We also show that most of the reticent patients would nevertheless consider discussing the same ACPs with admitting housestaff on the day of hospital admission.

Journal Article↗
PubMed1999

Patients' priorities among treatment effects in head and neck cancer: evaluation of a new assessment tool.

BACKGROUND: Patients with head and neck cancer may face decisions between surgery or radiation (with or without chemotherapy) which involve significant trade-offs in functional outcomes. This preliminary investigation is designed to examine patients' priorities among the effects of treatments for head and neck cancer. METHODS: A new instrument designed to allow patients to rank personal priorities among 12 treatment effects was developed and tested. A cross section of patients (19) from pretreatment and posttreatment time periods and 23 controls participated. RESULTS: Preliminary findings indicate high individual variability, with some differences between groups according to treatment time. Differences between patients and controls are evident. We report test-retest reliability and the limitations of this new tool. CONCLUSIONS: The data suggest that measures of health state values should be conducted with patients rather than healthy volunteers. Patients' priorities may be influenced by treatment and some values may be more susceptible to change with experience of treatment effects. This new tool may provide insight into how patients' prioritize the anticipated and experienced effects of treatment for head and neck cancers.

Activities of Daily Living↗
PubMed1999

A prisoner with chronic myeloid leukemia.

The health care received by prisoners in the area of tissue and organ transplantation is not well discussed or documented. We encountered a prisoner with newly diagnosed chronic myelogenous leukemia who was a candidate for allogeneic bone marrow transplantation and had two HLA-identical siblings who were willing to donate bone marrow. Based on humanitarian, constitutional, and ethical considerations, we suggest that the prisoner (patient) should receive the same health care as individuals who are not incarcerated and that the costs of care should play no greater role for prisoners than for other members of society.

Adult↗
PubMed1999

Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic?

OBJECTIVE: To assess whether physicians would be more likely to override a do-not-resuscitate (DNR) order when a hypothetical cardiac arrest is iatrogenic. DESIGN: Mailed survey of 358 practicing physicians. SETTING: A university-affiliated community teaching hospital. PARTICIPANTS: Of 358 physicians surveyed, 285 (80%) responded. MEASUREMENTS AND MAIN RESULTS: Each survey included three case descriptions in which a patient negotiates a DNR order, and then suffers a cardiac arrest. The arrests were caused by the patient's underlying disease, by an unexpected complication of treatment, and by the physician's error. Physicians were asked to rate the likelihood that they would attempt cardiopulmonary resuscitation for each case description. Physicians indicated that they would be unlikely to override a DNR order when the arrest was caused by the patient's underlying disease (mean score 2.55 on a scale from 1 "certainly would not" to 7 "certainly would"). Physicians reported they would be much more likely to resuscitate when the arrest was due to a complication of treatment (5.24 vs 2. 55; difference 95% confidence interval [CI] 2.44, 2.91; p <.001), and that they would be even more likely to resuscitate when the arrest was due to physician error (6.32 vs 5.24; difference 95% CI 0. 88, 1.20; p <.001). Eight percent, 29%, and 69% of physicians, respectively, said that they "certainly would" resuscitate in these three vignettes (p <.001). CONCLUSIONS: Physicians may believe that DNR orders do not apply to iatrogenic cardiac arrests and that patients do not consider the possibility of an iatrogenic arrest when they negotiate a DNR order. Physicians may also believe that there is a greater obligation to treat when an illness is iatrogenic, and particularly when an illness results from the physician's error. This response to iatrogenic cardiac arrests, and its possible generalization to other iatrogenic complications, deserves further consideration and discussion.

Advance Directive Adherence↗
PubMed1999

Unilateral do-not-attempt-resuscitation orders and ethics consultation: a case series.

OBJECTIVE: To describe the role of an ethics consultation service in unilaterally withholding cardiopulmonary resuscitation. DESIGN: Retrospective case series of 31 ethics consultations regarding unilateral do-not-attempt-resuscitation orders between 1992 and 1996. SETTING: A large, urban, academic medical center. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, physicians' rationale for withholding cardiopulmonary resuscitation, ethics consultants' recommendations, and patient outcomes were measured. The consultation service agreed with the medical team's intent to withhold cardiopulmonary resuscitation in 25 cases, but a unilateral do-not-attempt-resuscitation order was written in only seven of these. In 17 cases, the disagreement between the physician and the patient or surrogate over code status was resolved in a conference organized by the ethics service. CONCLUSIONS: The process of ethics consultation is useful in resolving disagreements over withholding cardiopulmonary resuscitation and other treatment and can frequently result in a consensus. Hospital policies that permit unilateral treatment limitation should be based on a model that is process-based and that encourages interdisciplinary participation in decision-making, such as that recently proposed by the Houston Task Force.

Academic Medical Centers↗
PubMed1998

Dialysis decision making in Canada, the United Kingdom, and the United States.

This study was designed to determine the extent to which differences in criteria for dialysis patient selection and availability of financial resources cause the wide variation in acceptance rates for dialysis in Canada, the United Kingdom, and the United States. We also sought to determine whether there is agreement among nephrologists in the three countries on which patients should not be offered dialysis. We used a cross-sectional survey of all members of the Canadian Society of Nephrology and the Renal Association of Great Britain, and a randomized sample of 800 members of the American Society of Nephrology. Five case vignettes were presented asking for yes/no decisions on offering or not offering dialysis, together with ranking of factors considered important. We also inquired about dialysis resources and physician demographics. We compared responses by country. More nephrologists from the United Kingdom returned responses (83%) than Canadian (53%) or American (36%) nephrologists. American nephrologists offered dialysis more than Canadian or British nephrologists (three of five cases; P < 0.04 to P < 0.001) and ranked patient/family wishes (three of five cases; P < 0.057 to P < 0.0001) and fear of lawsuit (P < 0.04 to P = 0.0012) higher than British or Canadian nephrologists. Canadian and British nephrologists reported their perception of patients' quality of life as a reason to provide (P = 0.0019) or not provide (P = 0.068 to P = 0.0026) dialysis more often than their American counterparts. Despite these differences, nephrologists from each country did not differ by more than 30% on any decision and ranked factors almost identically. Ten percent and 12% of Canadian and British nephrologists, respectively, but only 2% of American nephrologists, reported refusing dialysis due to lack of resources (P < 0.0001). We conclude that the wide variation in dialysis acceptance rates in the three countries is somewhat influenced by differences in patient selection criteria and withholding of dialysis by nephrologists based on financial constraints, but that other factors, such as differences in rates of patient nonreferral for dialysis, contribute more significantly to the variation. Generally agreed on practice guidelines for dialysis patient selection appear possible.

Adult↗