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PubMedDate not supplied

Who decides? An ethics case consult for Terri Schiavo.

What lessons might we take away as palliative care clinicians or ethics consultants? I might summarize as follows: As has been widely discussed elsewhere, the importance of advance directives, designation of proxy decision makers, and nuanced discussions with those potential proxies is of utmost importance--even for young adults. Be as clear as possible about diagnosis and prognosis. Rely on those with the greatest expertise and the least potential conflict of interest. Be honest about the limits of medical certainty and the diagnostic and prognostic possibilities. Separate reality from what loved ones or special interest advocates might wish were the reality. Efforts to resolve disputes among families or between families and care providers ought to remain private, and focus on the patient at hand rather than broader social or political agendas. Ethics committees or independent mediators work toward "win-win" outcomes and may help avoid the polarized, "winner-take-all" approach of litigation. Medical facts are not value-free and do not add up to a universally agreed-upon conclusion in the manner of a mathematical equation, but are viewed and interpreted through the lens of each participant's perspective. In the space of this essay, I can offer only a brief nod to the field of narrative ethics, but the interested reader will find a rich body of literature regarding this concept on which to base his or her own ethical conclusions regarding this case.

Adult↗
PubMed2006

Experts' attitudes towards medical futility: an empirical survey from Japan.

UNLABELLED: BACKGROUND The current debate about medical futility is mostly driven by theoretical and personal perspectives and there is a lack of empirical data to document experts and public attitudes towards medical futility. METHODS: To examine the attitudes of the Japanese experts in the fields relevant to medical futility a questionnaire survey was conducted among the members of the Japan Association for Bioethics. A total number of 108 questionnaires returned filled in, giving a response rate of 50.9%. Among the respondents 62% were healthcare professionals (HCPs) and 37% were non-healthcare professionals (Non-HCPs). RESULTS: The majority of respondents (67.6 %) believed that a physician's refusal to provide or continue a treatment on the ground of futility judgment could never be morally justified but 22.2% approved such refusal with conditions. In the case of physiologically futile care, three-quarters believed that a physician should inform the patient/family of his futility judgment and it would be the patient who could decide what should be done next, based on his/her value judgment. However more than 10% said that a physician should ask about a patient's value and goals, but the final decision was left to the doctor not the patient. There was no statistically significant difference between HCPs and Non-HCPs (p = 0.676). Of respondents 67.6% believed that practical guidelines set up by the health authority would be helpful in futility judgment. CONCLUSION: The results show that there is no support for the physicians' unilateral decision-making on futile care. This survey highlights medical futility as an emerging issue in Japanese healthcare and emphasizes on the need for public discussion and policy development.

Aged↗
PubMed2005

A cycle of terms implicit in the idea of medicine: Karen Ann Quinlan as a rhetorical icon and the transvaluation of the ethics of euthanasia.

In this article, I examine competing characterizations of Karen Ann Quinlan's life and the role these characterizations played in shaping public attitudes toward euthanasia and medicine in America. I discuss the reasons Quinlan's coma brought forth radically contrasted narratives about who she was by applying Burke's (1961) cycle of terms implicit in the idea of order. I compare the manner in which traditional life-sanctity advocates spoke about her with the narratives and counternarratives offered by the family and the social innovators who would challenge those traditionalist assumptions.

Attitude to Death↗
PubMed2006

Prediction of poor outcome within the first 3 days of postanoxic coma.

OBJECTIVE: To determine the optimal timing of somatosensory evoked potential (SSEP) recordings and the additional value of clinical and biochemical variables for the prediction of poor outcome in patients who remain comatose after cardiopulmonary resuscitation (CPR). METHODS: A prospective cohort study was conducted in 32 intensive care units including adult patients still unconscious 24 hours after CPR. Clinical, neurophysiologic, and biochemical variables were recorded 24, 48, and 72 hours after CPR and related to death or persisting unconsciousness after 1 month. RESULTS: Of 407 included patients, 356 (87%) had a poor outcome. In 301 of 305 patients unconscious at 72 hours, at least one SSEP was recorded, and in 136 (45%), at least one recording showed bilateral absence of N20. All these patients had a poor outcome (95% CI of false positive rate 0 to 3%), irrespective of the timing of SSEP. In the same 305 patients, neuron-specific enolase (NSE) was determined at least once in 231, and all 138 (60%) with a value >33 microg/L at any time had a poor outcome (95% CI of false positive rate 0 to 3%). The test results of SSEP and NSE overlapped only partially. The performance of all clinical tests was inferior to SSEP and NSE testing, with lower prevalences of abnormal test results and wider 95% CI of false positive rates. CONCLUSION: Poor outcome in postanoxic coma can be reliably predicted with somatosensory evoked potentials and neuron-specific enolase as early as 24 hours after cardiopulmonary resuscitation in a substantial number of patients.

Adult↗
PubMed1996

The Quinlan case revisited.

... The point is that although physicians and hospitals (and their legal counsel) certainly feared in the 1970s and still fear prosecution and civil liability (and perhaps to an unreasonable degree), neither the complex psychosocial and economic nor the equally complex philosophical questions surrounding stopping artificial life support were settled at the time of the Quinlan case, and they are still not settled today. Perhaps our legal history does not need to be revised all that much.

Brain Death↗
PubMed2002

Translating psychosocial insight into ethical discussions supportive of families in end-of-life decision-making.

A large number of Americans would rather rely on family and friends more than their physicians about end-of-life care and decisions. Moving beyond traditional clinical ethics and its dyadic focus on the physician-patient relationship, this article presents an approach to ethical decision-making at the end of life that is more inclusive of the patient's family and has the potential to advance social work practice in end-of-life care. Initial attention is given to how psychosocial and bioethical perspectives and practices interact to shape understanding of moral issues in end-of-life decisions. Morally relevant principles are then adapted from contextual therapy as being useful for including more of a family focus and viewing ethical decision-making at the end of life as a family process. Specifically, focus is on exploring the ethical dynamics of family systems that impact the decision-making process and translating psychosocial insight into ethical discussions that are supportive of families. The case of a patient with sudden and unexpected brain death and without advance directives demonstrates one family's unresolved grief and illustrates how its members were helped to reason morally about end-of-life choices. Contributions of a social worker and bioethicist are illustrated.

Adult↗
PubMed1991

Morality in flux: medical ethics dilemmas in the People's Republic of China.

The bioethical dilemmas receiving the most attention in China now relate to the two ends of life: birth and death. On one end are issues relating to reproductive technology, especially birth control and family planning; at the other end is euthanasia... More research and discussion among people from various fields is needed. Progress will be made one step at a time, and I recommend that we proceed now to win acceptance of brain death criteria; to make clear the distinctions between passive and active euthanasia,...to encourage the use of living wills; and to protect the interests of newborns who are not terminally ill, including those with mild defects. In the changing context of modernization, in which different and even incompatible value systems must coexist, it is best for us to approach the ethical dilemmas facing us with mutual respect and understanding.

Abortion, Eugenic↗
PubMed1999

The concept of the person and the value of life.

The concept of the person has come to be intimately connected with questions about the value of life. It is applied to those sorts of beings who have some special value or moral importance and where we need to prioritize the needs or claims of different sorts of individuals. "Person" is a concept designating individuals like us in some important respects, but possibly including individuals who are very unlike us in other respects. What are these respects and why are they important? This paper sets out to answer these questions and to develop a coherent and useful concept of the person.

Animal Rights↗
PubMed2004

Introduction.

Explore the source record for details and available documents.

Anencephaly↗
PubMedDate not supplied

The prognosis for changes in end-of-life care after the Schiavo case.

Americans have reached consensus that (1) people have a right to refuse life-sustaining medical interventions, and (2) interventions that can be terminated include artificial nutrition and hydration. The one unresolved issue is how to decide for mentally incompetent patients. Only about 20 percent of Americans have completed living wills, and data show that family members are poor at predicting patients' wishes for life-sustaining care. But despite court cases and national consensus that these are private and not legislative matters, the Schiavo case is unlikely to change practices except to increase the number of Americans who complete living wills.

Adult↗
PubMedDate not supplied

Terri Schiavo, Son Hudson, and 'nonbeneficial' medical treatments.

Two disputed cases about withholding life support (Terri Schiavo and Son Hudson) call for greater public discussion. Confusion arises from intermixing three kinds of cases: those (1) in which demanded treatment is physiologically futile, (2) involving competition for scarce resources, and (3) in which the treatment would likely achieve the patient's goals although the clinician perceives those goals to be valueless. This Perspective argues that clinicians should unilaterally refuse the first but do not have legitimate roles in blocking access to the second and third. Absent scarcity, patients should have access to effective life-prolonging treatments even if clinicians see no value in them.

Decision Making↗