Managing Bias in Palliative Care: Professional Hazards in Goals of Care Discussions at the End of Life.

BACKGROUND: In the setting of end-of-life care, biases can interfere with patient articulation of goals and hinder provision of patient-centered care. No studies have addressed clinician bias or bias management specific to goals of care discussions at the end of life. OBJECTIVES: To identify and determine the prevalence of palliative care clinician biases and bias management strategies in end-of-life goals of care discussions. DESIGN: A semistructured interview guide with relevant domains was developed to facilitate data collection. Participants were asked directly to identify biases and bias management strategies applicable to this setting. Two researchers developed a codebook to identify themes using a 25% transcript sample through an iterative process based on grounded theory. Inter-rater reliability was evaluated using Cohen κ. It was 0.83, indicating near perfect agreement between coders. The data approach saturation. SETTING/PARTICIPANTS: A purposive sampling of 20 palliative care clinicians in Middle Tennessee participated in interviews. RESULTS: The 20 clinicians interviewed identified 16 biases and 11 bias management strategies. The most frequently mentioned bias was a bias against aggressive treatment (n = 9), described as a clinician's assumption that most interventions at the end of life are not beneficial. The most frequently mentioned bias management strategy was self-recognition of bias (n = 17), described as acknowledging that bias is present. CONCLUSION: This is the first study identifying palliative care clinicians' biases and bias management strategies in end-of-life goals of care discussions.

A Medical Student Perspective on Physician-Assisted Suicide.

Physician-assisted suicide and euthanasia (PAS/E) has been increasingly discussed and debated in the public arena, including in professional medical organizations. However, the medical student perspective on the debate has essentially been absent. We present a medical student perspective on the PAS/E debate as future doctors and those about to enter the profession. We argue that PAS/E is not in line with the core principles of medicine and that the focus should be rather on providing high-quality end-of-life and palliative care.

Femoral remodeling around Charnley total hip arthroplasty is unpredictable.

BACKGROUND: There are two unusual remodeling patterns of the proximal femur around well-fixed Charnley total hip arthroplasties: cortical thinning leading to endosteal widening around the femoral component and hypertrophy of the distal femoral cortex. Previous studies have shown remodeling patterns are affected by stem design and occur early postoperatively. It is unclear if these changes are related to patient demographics or if they progress throughout the lifetime of the implant. QUESTIONS/PURPOSES: We determined if patient demographic variables influence remodeling patterns after cemented Charnley total hip arthroplasty and if the observed remodeling changes persist long-term. METHODS: We retrospectively reviewed the radiographs of 106 well-fixed Charnley femoral components. Using a novel digital edge detection program, we determined the femoral remodeling pattern and time-related changes in femoral dimensions. The minimum followup was 20 years (mean, 25.3 years; range, 19.5-37 years). RESULTS: We found no association between remodeling type and age at surgery, sex, preoperative diagnosis, body mass index, or postoperative activity level. There was also no association between initial implant alignment and remodeling type. Cortical thickening in the distal hypertrophy group was an early phenomenon occurring primarily within the first 2 years, whereas cortical thinning begins later and is a more progressive process. CONCLUSIONS: These data show remodeling after cemented Charnley total hip arthroplasty is not related to patient demographic variables; however, distal cortical hypertrophy can be predicted in the early postoperative period.