"Farewell" to Prognosis in Shared Decision-Making.

Whether because of a cultural pattern or personal preference, palliative care clinicians encounter persons approaching the end of life who wish to limit or forego prognostic information relating to their situation. This scenario has received attention in a recent motion picture as well as a newly available advance directive modification-the Prognosis Declaration form. The ordinary expectation for end-of-life shared decision-making with a capable person is clinician disclosure of the best effort at prognostic assessment. The optimal match between the expressed values, goals, and preferences of the person with available clinician expertise is hopefully achieved. For the clinician, a person's choice to modify information disclosure and participation in shared decision-making represents a significant challenge of balancing key ethical principles of intervention with tolerance and compassion for these different preferences. Attention to communication strategies that elicit and appropriately reassess individual information and decision-making wishes, flexibility in information disclosure patterns with capable persons and their representatives, and recognition that a respect for autonomy includes the choice to opt out can approach this challenge while providing compassionate and ethical end-of-life care.

The Death Debate: Penumbra Conundrum.

Determination and declaration of death by neurologic criteria, brain death, is an established and legally accepted clinical practice with profound implications. Concerns regarding the accuracy of this diagnosis raise important clinical, ethical, and legal issues. A recent magazine article highlights these concerns by describing a poignant example of a patient meeting accepted clinical and ancillary testing criteria for brain death in the setting of post cardiac arrest hypoxic ischemic encephalopathy (CA-HIE). With continuation of ventilatory and nutritional support, this patient not only survived but over time demonstrated findings that were no longer consistent with brain death. Offered here is a review of the course of events described in the article, an overview of the variable clinical implications of CA-HIE and their relationship to the diagnosis of brain death, a proposed pathophysiologic correlation, and recommendations for palliative clinicians providing consultation with regard to goals of care and intervention options in cases of CA-HIE with severe neurologic injury.

A cargo-sorting DNA robot.

Two critical challenges in the design and synthesis of molecular robots are modularity and algorithm simplicity. We demonstrate three modular building blocks for a DNA robot that performs cargo sorting at the molecular level. A simple algorithm encoding recognition between cargos and their destinations allows for a simple robot design: a single-stranded DNA with one leg and two foot domains for walking, and one arm and one hand domain for picking up and dropping off cargos. The robot explores a two-dimensional testing ground on the surface of DNA origami, picks up multiple cargos of two types that are initially at unordered locations, and delivers them to specified destinations until all molecules are sorted into two distinct piles. The robot is designed to perform a random walk without any energy supply. Exploiting this feature, a single robot can repeatedly sort multiple cargos. Localization on DNA origami allows for distinct cargo-sorting tasks to take place simultaneously in one test tube or for multiple robots to collectively perform the same task.

Compiler-aided systematic construction of large-scale DNA strand displacement circuits using unpurified components.

Biochemical circuits made of rationally designed DNA molecules are proofs of concept for embedding control within complex molecular environments. They hold promise for transforming the current technologies in chemistry, biology, medicine and material science by introducing programmable and responsive behaviour to diverse molecular systems. As the transformative power of a technology depends on its accessibility, two main challenges are an automated design process and simple experimental procedures. Here we demonstrate the use of circuit design software, combined with the use of unpurified strands and simplified experimental procedures, for creating a complex DNA strand displacement circuit that consists of 78 distinct species. We develop a systematic procedure for overcoming the challenges involved in using unpurified DNA strands. We also develop a model that takes synthesis errors into consideration and semi-quantitatively reproduces the experimental data. Our methods now enable even novice researchers to successfully design and construct complex DNA strand displacement circuits.

Acute lung injury and acute respiratory distress syndrome requiring tracheal intubation and mechanical ventilation in the intensive care unit: impact on managing uncertainty for patient-centered communication.

A case of acute lung injury (ALI) progressing to acute respiratory distress syndrome (ARDS) requiring tracheal intubation and mechanical ventilation (ETMV) is presented. The palliative medicine service was asked to address concerns expressed by the patient's spouse reflecting uncertainty regarding outcome expectations. Acknowledging and confronting the uncertainties of a critical illness is an essential component of patient-centered communication. Addressing and managing uncertainty for the case scenario requires consideration of both short- and long-term outcomes including mortality, ventilator independence, and adverse effects on quality of life for survivors. In this paper, ALI/ARDS requiring ETMV in the ICU was used as a focal point for preparing a prognostic assessment incorporating these issues. This assessment was based on a review of recently published literature regarding mortality and ventilator independence of survivors for adult patients receiving ETMV for ALI/ARDS in the ICU. In the studies reviewed, long-term survival reported at 60 days to 1 year was 50-73% with greater than 84% of the survivors in each study breathing independently. Selected articles discussing outcomes other than mortality or recovery of respiratory function, particularly quality of life implications for ALI/ARDS survivors, were also reviewed. A case of of ALI/ARDS requiring ETMV in the ICU is used to illustrate the situation of an incapacitated critically ill patient where the outcome is uncertain. Patient-centered communication should acknowledge and address this uncertainty. Managing uncertainty consists of effectively expressing a carefully formulated prognostic assessment and using sound communication principles to alleviate the distress associated with the uncertain outcome probabilities.

Avian botulism and avian chlamydiosis in wild water birds, Benton Lake National Wildlife Refuge, Montana, USA.

In 1999, the U.S. Geological Survey (USGS) National Wildlife Health Center, Madison, Wisconsin, conducted a diagnostic investigation into a water bird mortality event involving intoxication with avian botulism type C and infection with avian chlamydiosis at the Benton Lake National Wildlife Refuge in Montana, USA. Of 24 carcasses necropsied, 11 had lesions consistent with avian chlamydiosis, including two that tested positive for infectious Chlamydophila psittaci, and 12 were positive for avian botulism type C. One bird tested positive for both avian botulism type C and C. psittaci. Of 61 apparently healthy water birds sampled and released, 13 had serologic evidence of C. psittaci infection and 7 were, at the time of capture, shedding infectious C. psittaci via the cloacal or oropharyngeal route. Since more routinely diagnosed disease conditions may mask avian chlamydiosis, these findings support the need for a comprehensive diagnostic investigation when determining the cause of a wildlife mortality event.

Acute renal failure requiring renal replacement therapy in the intensive care unit: impact on prognostic assessment for shared decision making.

A 69-year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. For this patient, ARF requiring RRT in the ICU was used as a focal point for preparing a prognostic assessment. A prognostic assessment should include the outcomes of most importance to a discussion of goals of care: mortality risk and survivor functional status, in this case including renal recovery. A systematic review of the literature was conducted to document published data regarding these outcomes for adult patients receiving RRT for ARF in the ICU. Forty-one studies met the inclusion criteria. The combined mean values for short-term mortality, long-term mortality, renal-function recovery of short-term survivors, and renal-function recovery of long-term survivors were 51.7%, 68.6%, 82.0%, and 88.4%, respectively. This case example illustrates a process for formulating and expressing a prognostic assessment for an ICU patient requiring RRT for ARF. Data from the literature review provide baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication.

Caring for children with learning disabilities who present problem behaviours: a maternal perspective.

The theoretical cognitive model of stress and coping provides a structure to obtain and analyse maternal perceptions of caring for children with learning disabilities who present severe problem behaviours. The Family Fund database identified 18 families who met the sample criteria of children aged five years to 15 years with severe to moderate learning disability presenting severe problem behaviour. Physical aggression was reported to be the primary behavioural problem for 13 of the children. Interviews undertaken with the main carer of the child at their home were taped and transcribed. The data were analysed using grounded theory techniques which identified 'secondary stressors' for the parent. These were social isolation, conflict, limitation of lifestyle and self-blame. It is proposed that the amalgamated impact of these can weaken parents' coping resources and, therefore, may prove to be as significant to the negative association with maternal wellbeing as the problem behaviour.