Advance Directive as Ulysses Contract: The Application of Stopping of Eating and Drinking by Advance Directive.

Increased attention is being paid to "dementia directives," advance directives tailored to persons with dementia that outline what treatments an individual with dementia might wish to receive or forgo should they lose capacity. Particular focus has been placed on the request to have assisted oral feedings withheld, the so-called Stopping of Eating and Drinking by Advance Directive (SED by AD), the purpose of which is to hasten death. This article reviews the available literature regarding the practice of SED by AD and explores the clinical and ethical aspects as they present at the bedside. Our review aims to show that practical, clinically applicable ways to approach such requests must be developed in order to balance the fundamental principles at play.

Evaluation Tools for Interdisciplinary Palliative Care Learning Experiences: A Literature Review.

Background: An interdisciplinary palliative care team began exploring evaluation tools used to assess changes in the knowledge, skills, and attitudes of learners participating in clinical learning experiences on an interdisciplinary palliative care consult service. This article will review existing evaluation tools, examine the themes that emerge, discuss their strengths and limitations, and make recommendations for continued development in the field. Methods and Findings: A literature search was performed using the MEDLINE database. Search terms included combinations of the following: interdisciplinary education, assessment/evaluation, and palliative care or palliative care assessment/test. Four hundred eighty-seven articles were captured during the initial search. Articles that focused on student readiness for interdisciplinary education and team self-assessments of current interdisciplinary collaboration practices were excluded. Nine articles were included in the review. Evaluation tools varied in terms of learner type, assessment type, and frequency. No tool was comprehensive in the assessment of knowledge, skills, and attitudes or truly interdisciplinary. Conclusions: There is a lack of comprehensive and interdisciplinary evaluation tools in the published literature. Further research should be conducted to develop a tool that meets the needs of learners in clinical experiences within an interdisciplinary service.

Distressing Visions at the End of Life: Case Report and Review of the Literature.

There is a growing body of literature documenting dreams, visions, and other trans-personal communications that occur as part of the dying process, often called end-of-life dreams and visions (ELDVs) or deathbed communications (DBCs). This paper describes a unique case involving distressing visions at the end of life, provides a review of existing literature around ELDVs, and will provide a framework within which to approach the patient experiencing distressing ELDVs.

Use of intravenous acetaminophen (paracetamol) in a pediatric patient at the end of life: case report.

BACKGROUND: For the better part of 100 years, acetaminophen (or paracetamol as it is known outside of the United States) has been a common first-line analgesic in pediatrics and is typically well tolerated with minimal side effects. Its use as an anti-pyretic is also well-documented and thus it is used broadly for symptom control in the general pediatric population. DISCUSSION: In pediatric palliative care, acetaminophen is also used as an adjuvant to opioid therapy for pain as well as an anti-pyretic. For many pediatric patients near end-of-life, however, the ability to tolerate oral intake is diminished and rectal suppository administration can be distressing or contraindicated as in the setting of neutropenia, thus limiting use of acetaminophen by its usual routes. In Europe and Australia, an intravenous formulation of acetaminophen has been used for many years and has only recently become available in the United States. CONCLUSION: Here, we describe a case using intravenous acetaminophen in a pediatric patient at the end of life.

When the worst headache becomes the worst heartache!

BACKGROUND AND PURPOSE: Although a great deal of literature has been generated regarding left ventricular wall abnormalities, ECG changes and cardiac enzyme leaks associated with subarachnoid hemorrhage (SAH), there have been only a few reports of true transient left ventricular apical ballooning syndrome in patients with SAH. Several pathophysiological mechanisms have been proposed to explain the unusual features of this syndrome, such as multivessel coronary vasospasm, abnormalities in coronary microvascular function, and catecholamine-mediated cardiotoxicity. Summary of Case- A previously healthy 64-year-old woman with no history of vascular disease was found unresponsive at home. She was taken to the emergency room where a CT head revealed an SAH due to a ruptured aneurysm of the posterior communicating artery. On admission, an ECG showed deeply inverted T-waves and QT prolongation, typical of SAH. Cardiac troponin was measured at 1.2 ng/mL, and later increased to 3.7 ng/mL. A transthoracic echocardiogram on the next day revealed a large left ventricular wall abnormality, characteristic of apical ballooning with an ejection fraction of 25% to 30%. The patient remained hemodynamically stable and was started on low dose beta-blocker and angiotensin-converting enzyme inhibitor. She had an uneventful cardiac recovery within 5 days at which time a repeat transthoracic echocardiogram revealed a normal ejection fraction with no wall motion abnormality. CONCLUSIONS: This report adds to the growing list of "stressors" for Takotsubo cardiomyopathy. Clinicians should be aware of the existence and the typical clinical manifestations of this syndrome, which is increasingly recognized in various populations. In particular, neurologists should consider this syndrome in the differential diagnosis of ECG changes and apical wall motion abnormalities in patients with SAH. Prognosis is generally very good with full recovery in most patients; however, there may be increased morbidity associated in patients with SAH.

The ethics of access to online genetic databases: private or public?

With the sequencing of the human genome comes the promise of advances in medical science. For this promise to be fully realized, researchers must have access to information resulting from this landmark endeavor as well as from subsequent research initiatives. However, because genomic sequences are potential sources of profit for the biotechnology and pharmaceutical industries, many private companies seek to limit access to this information. Some argue that this will impede scientific progress and increase the cost of basic research, while others argue that the privatization of genetic information is needed to assure profits and generate the considerable funding necessary to bring therapeutic products to the market. In analyzing the arguments for both sides, we conclude that both private funding and public access to information are important in genetic research. Precedents for compromise are necessary, as is increased dialog between private and public interests in order to ensure continued advancements in genetic science and medicine.