Ethics of organ procurement from the unrepresented patient population.

The shortage of organs for transplantation by its nature prompts ethical dilemmas. For example, although there is an imperative to save human life and reduce suffering by maximising the supply of vital organs, there is an equally important obligation to ensure that the process by which we increase the supply respects the rights of all stakeholders. In a relatively unexamined practice in the USA, organs are procured from unrepresented decedents without their express consent. Unrepresented decedents have no known healthcare wishes or advance care planning document; they also lack a surrogate. The Revised Uniform Anatomical Gift Act (RUAGA) of 2006 sends a mixed message about the procurement of organs from this patient population and there are hospitals that authorise donation. In addition, in adopting the RUAGA, some states included provisions that clearly allow organ procurement from unrepresented decedents. An important unanswered question is whether this practice meets the canons of ethical permissibility. The current Brief Report presents two principled approaches to the topic as a way of highlighting some of the complexities involved. Concluding remarks offer suggestions for future research and discussion.

Chaplain rounds: a chance for medical students to reflect on spirituality in patient-centered care.

OBJECTIVE: This study assesses the perceived impact of a required half-day with a hospital chaplain for first-year medical students, using a qualitative analysis of their written reflections. METHODS: Students shadowed chaplains at the UCLA hospital with the stated goal of increasing their awareness and understanding of the spiritual aspects of health care and the role of the chaplain in patient care. Participation in the rounds and a short written reflection on their experience with the chaplain were required as part of the first-year Doctoring course. RESULTS: The qualitative analysis of reflections from 166 students using grounded theory yielded four themes: (1) the importance of spiritual care, (2) the chaplain's role in the clinical setting, (3) personal introspection, and (4) doctors and compassion. CONCLUSIONS: Going on hospital rounds with a chaplain helps medical students understand the importance of spirituality in medicine and positively influences student perceptions of chaplains and their work.

Use of silicone materials to simulate tissue biomechanics as related to deep tissue injury.

OBJECTIVE: Deep tissue injury (DTI) is caused by prolonged mechanical loading that disrupts blood flow and metabolic clearance. A patient simulator that mimics the biomechanical aspects of DTI initiation, stress and strain in deep muscle tissue, would be potentially useful as a training tool for pressure-relief techniques and testing platform for pressure-mitigating products. As a step toward this goal, this study evaluates the ability of silicone materials to mimic the distribution of stress in muscle tissue under concentrated loading. METHODS: To quantify the mechanical properties of candidate silicone materials, unconfined compression experiments were conducted on 3 silicone formulations (Ecoflex 0030, Ecoflex 0010, and Dragon Skin; Smooth-On, Inc, Easton, Pennsylvania). Results were fit to an Ogden hyperelastic material model, and the resulting shear moduli (G) were compared with published values for biological tissues. Indentation tests were then conducted on Ecoflex 0030 and porcine muscle to investigate silicone's ability to mimic the nonuniform stress distribution muscle demonstrates under concentrated loading. Finite element models were created to quantify stresses throughout tissue depth. Finally, a preliminary patient simulator prototype was constructed, and both deep and superficial "tissue" pressures were recorded to examine stress distribution. RESULTS: Indentation tests showed similar stress distribution trends in muscle and Ecoflex 0030, but stress magnitudes were higher in Ecoflex 0030 than in porcine muscle. All 3 silicone formulations demonstrated shear moduli within the range of published values for biological tissue. For the experimental conditions reported in this work, Ecoflex 0030 exhibited greater stiffness than porcine muscle. CONCLUSION: Indentation tests and the prototype patient simulator trial demonstrated similar trends with high pressures closest to the bony prominence with decreasing magnitude toward the interfacial surface. Qualitatively, silicone mimicked the phenomenon observed in muscle of nonuniform stress under concentrated loading. Although shear moduli were within biological ranges, stress and stiffness values exceeded those of porcine muscle. This research represents a first step toward development of a preclinical model simulating the biomechanical conditions of stress and strain in deep muscle, since local biomechanical factors are acknowledged to play a role in DTI initiation. Future research is needed to refine the capacity of preclinical models to simulate biomechanical parameters in successive tissue layers of muscle, fat, dermis, and epidermis typically intervening between bone and support surfaces, for body regions at risk for DTI.

Influential factors for self-care in ambulatory care heart failure patients: a qualitative perspective.

Chronic heart failure is associated with debilitating symptoms, diminished quality of life and frequent hospitalizations. The literature suggests that effective everyday self-care decision-making can improve heart failure outcomes. This article focuses on the qualitative portion of a study of self-care decision-making in community-dwelling individuals attending a heart failure clinic. Semi-structured interviews conducted with 11 participants identified influences that enhance or impede self-care practices and their behavioural responses to them. Content analysis was used to examine predisposing attributes and enabling circumstances described in Connelly's Model of Self-Care in Chronic Illness. These interactive factors were either facilitators or barriers to self-care. The importance of individualizing patient teaching plans and frequent monitoring of factors likely to facilitate self-care were pivotal nursing implications that emerged from this study.