PubMed Health⌕ Search

Biomedical subjects

Stephen Streat

Publications and source records attributed to Stephen Streat.

11 recordsLinked to original sources
PubMed2005

Pro/con ethics debate: when is dead really dead?

Contemporary intensive care unit (ICU) medicine has complicated the issue of what constitutes death in a life support environment. Not only is the distinction between sapient life and prolongation of vital signs blurred but the concept of death itself has been made more complex. The demand for organs to facilitate transplantation promotes a strong incentive to define clinical death in a manner that most effectively supplies that demand. We consider the problem of defining death in the ICU as a function of viable organ availability for transplantation.

Attitude to Death↗
PubMed2004

Clinical review: moral assumptions and the process of organ donation in the intensive care unit.

The objective of the present article is to review moral assumptions underlying organ donation in the intensive care unit. Data sources used include personal experience, and a Medline search and a non-Medline search of relevant English-language literature. The study selection included articles concerning organ donation. All data were extracted and analysed by the author. In terms of data synthesis, a rational, utilitarian moral perspective dominates, and has captured and circumscribed, the language and discourse of organ donation. Examples include "the problem is organ shortage", "moral or social duty or responsibility to donate", "moral responsibility to advocate for donation", "requesting organs" or "asking for organs", "trained requesters", "pro-donation support persons", "persuasion" and defining "maximising donor numbers" as the objective while impugning the moral validity of nonrational family objections to organ donation. Organ donation has recently been described by intensivists in a morally neutral way as an "option" that they should "offer", as "part of good end-of-life care", to families of appropriate patients. In conclusion, the review shows that a rational utilitarian framework does not adequately encompass interpersonal interactions during organ donation. A morally neutral position frees intensivists to ensure that clinical and interpersonal processes in organ donation are performed to exemplary standards, and should more robustly reflect societal acceptability of organ donation (although it may or may not "produce more donors").

Critical Care↗
PubMed2003

Drotrecogin alfa (recombinant human activated protein C) in severe sepsis--a New Zealand viewpoint.

AIM: Sepsis is a serious and increasing worldwide intensive care problem. In response to intensivists' concerns over the benefits, risks and financial implications of the use of drotrecogin alfa (recombinant human activated protein C), the first adjunctive therapy for sepsis licensed in New Zealand, the New Zealand Region of the Australian and New Zealand Intensive Care Society (ANZICS) requested an advisory statement from a working party of New Zealand intensivists. METHODS: We reviewed (a) the PROWESS study of drotrecogin alfa recombinant; (b) the submission made by the sponsoring company to the FDA; (c) recent discussions and an economic evaluation of the use of the agent; (d) Australian pharmaceutical benefits scheme positive recommendations; (e) guidelines produced by the Eli Lilly Australian Advisory Board; (f) Australian hospital decisions on availability; and (g) New Zealand pricing and payment arrangements. We then formulated suggested New Zealand guidelines. RESULTS: We recommend that hospital pharmacy and therapeutics committees review the agent now. If the agent is made available for use, we recommend that: (a) specialists prescribing the agent be required to contribute clinical data to a national register of patients, (b) patients considered for treatment should first be treated with all appropriate surgical and medical therapy for severe sepsis with high illness severity in an intensive care unit by an intensivist; (c) patients considered for treatment should not have severe comorbidity or predetermined treatment limitations or contraindications to the agent in the original phase III study; and (d) patients should be considered only if seen to be not clearly improving after a six-hour period of intensive treatment. Once a decision has been made to treat with drotrecogin alfa, treatment should commence as soon as possible and within 24 hours of meeting criteria. Although the agent is recommended for use in adults, it may be reasonable to treat some older children. CONCLUSIONS: Despite high cost and moderate benefit, it may be reasonable to treat highly selected New Zealand patients with drotrecogin alfa.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2003

Ethics roundtable debate: should a sedated dying patient be wakened to say goodbye to family?

Intensivists have the potential to maintain vital signs almost indefinitely, but not necessarily the potential to make moribund patients whole. Current ethical and legal mandates push patient autonomy to the forefront of care plans. When patients are incapable of expressing their preferences, surrogates are given proxy. It is unclear how these preferences extend to the very brink of inevitable death. Some say that patients should have the opportunity and authority to direct their death spiral. Others say it would be impossible for them to do so because an inevitable death spiral cannot be effectively palliated. Humane principles dictate they be spared the unrelenting discomfort surrounding death. The present case examines such a patient and the issues surrounding a unique end-of-life decision.

Beneficence↗
PubMed2003

Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life.

CONTEXT: End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care. OBJECTIVE: To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models. DESIGN: Ethnographic study of three critical care units. SETTING: University hospitals in the United States and New Zealand. SUBJECTS: Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends. MEASUREMENTS AND MAIN RESULTS: Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families. CONCLUSIONS: End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.

Attitude of Health Personnel↗
PubMed2003

Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life--Updated.

CONTEXT: End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care. OBJECTIVE: To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models. DESIGN: Ethnographic study of three critical care units. SETTING: University hospitals in the United States and New Zealand. SUBJECTS: Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends. MEASUREMENTS AND MAIN RESULTS: Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families. CONCLUSIONS: End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.

Anthropology, Cultural↗
PubMed2002

Liver transplantation in New Zealand: the first four years.

AIM: To summarise the transplant-related activity of the New Zealand Liver Transplant Unit over the first four years. METHODS: The records of all patients assessed for liver transplantation between 1 December 1997 and 30 December 2001 were examined. Listing criteria, demographics, waiting time, transplant-hospitalisation details and long-term outcome for those who underwent liver transplantation were recorded. RESULTS: One hundred and eighty six patients over 14 years of age (acute liver failure 28, chronic liver disease 158) were assessed and 150 were listed for liver transplantation. Fifteen died waiting, 13 were de-listed (6 for cancer progression) and 14 remain listed. One hundred and nine liver transplants (including 1 combined heart-liver, 1 sequential liver-bone marrow and 5 re-transplants) were performed on 104 patients (13 acute liver failure, 96 chronic liver failure or hepatocellular carcinoma). The median waiting time was 2 days (range 0 5) for acute liver failure and 62 days (range 0 320) for other patients. Median age at transplant was 50 years (range 14-70); 73 patients (66%) were male; 71 (65%) were European; 13 (12%) Maori; 12 (11%) Pacific Islander; and 8 (7%) Asian. Median duration of surgery was 480 minutes (range 300 720 minutes); red cell transfusion 5 units (0 32); intensive care and total hospital stays were 2 (range 1 17) and 11 days (range 6 91). One transplanted patient died in hospital, 1- and 3-year patient survival was 94% and 87% and corresponding graft survival was 91% and 83%. Ninety three transplanted patients (89%) are alive. Of the 92 patients at least three months post-transplant, 62 (67%) were employed. CONCLUSION: Liver transplantation is now established in New Zealand as treatment of choice for acute and chronic liver failure and small hepatocellular carcinoma. Excellent outcomes have been attained in those transplanted to date. Reduction in waiting list mortality will require identification of and investment in strategies that will expand the donor organ availability.

Chronic Disease↗