Miracles of modern medicine/casualties of modern medicine.

The author uses an autoethnographic account of a close friend's emergency cardiac surgery, and its disastrous outcome, to explore and critique the contemporary search for medical "miracles" and the patchwork and inequitable system of medical reimbursement in the United States.

Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary.

OBJECTIVE: The purpose of the conference was to provide clinical practice guidance in end-of-life care in the ICU via answers to previously identified questions relating to variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of healthcare providers, the use of imprecise and insensitive terminology and incomplete documentation in the medical record. PARTICIPANTS: Presenters and jury were selected by the sponsoring organizations (American Thoracic Society, European Respiratory Society, European Society of Intensive Care Medicine, Society of Critical Care Medicine, Société de Réanimation de Langue Française). Presenters were experts on the question they addressed. Jury members were general intensivists without special expertise in the areas considered. Experts presented in an open session to jurors and other healthcare professionals. EVIDENCE: Experts prepared review papers on their specific topics in advance of the conference for the jury's reference in developing the consensus statement. CONSENSUS PROCESS: Jurors heard experts' presentations over 2 days and asked questions of the experts during the open sessions. Jury deliberation with access to the review papers occurred for 2 days following the conference. A writing committee drafted the consensus statement for review by the entire jury. The 5 sponsoring organizations reviewed the document and suggested revisions to be incorporated into the final statement. CONCLUSIONS: Strong recommendations for research to improve end-of-life care were made. The jury advocates a shared approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honor decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the team, to decide on the reasonableness of the planned action. If a conflict cannot be resolved, an ethics consultation may be helpful. The patient must be assured of a pain-free death. The jury subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double-effect" should not detract from the primary aim to ensure comfort.

Stories, moral judgment, and medical care in an intensive care unit.

A division of labor exists between nurses and doctors in a surgical intensive care unit. Nurses perform a culturally identified feminine expressive role, caring about patients as well as for them. Doctors perform a culturally identified masculine instrumental role, concerned with curing patients' bodies. The nurses are interested in the patients' stories; the doctors attempt to ignore the stories to concentrate on returning patients to function. Based on the patient's story, however, the nurses make severe judgments as to moral worth. Such judgments can impair medical care. Must doctors, then, disregard patients' stories? In other words, must they limit themselves to caring for patients' bodies, attempting to ignore the individuals, situated in a web of social relationships, who inhabit those bodies?

Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003.

The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.

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.

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.