Understanding Substance use Policies and Associated Ethical Concerns: A survey of Pediatric Transplant Centers.

Psychosocial risk factors, such as substance use, have been linked to poor post-transplant outcomes for solid organ transplant patients, including poor medication adherence, increased risk for rejection, and even graft failure. Despite universal consensus that substance use is an increasing problem among youth, many pediatric transplant centers do not have policies in place to address substance use and no universal guidelines exist regarding assessment during the pre-transplant evaluation in this population. An online survey was administered via REDCap™ and directed toward medical leaders (ie, medical and surgical directors) of national heart, kidney, and liver transplant centers. Questions examined the following: perspectives on the need for a universal transplant center policy on pediatric substance use, abuse, and dependence; timing and frequency of evaluation for substance use; specific substances which would elicit respondents' concerns; and ethical concerns surrounding substance use. Data were analyzed using descriptive statistics. Data were collected from 52 respondents from 38 transplant centers, with the majority (n = 40; 77%) reporting no substance use policy in place for pediatric transplant patients. However, many endorsed concerns if a pediatric patient was found to be using specific substances. Our findings further highlight the need for a universal substance use policy across pediatric solid organ transplant centers. The results from the distributed survey will help to provide guidelines and best practices when establishing a universal policy for substance use.

[Diagnostic Test Requests in the Family Medicine Consultation: An Ethical Perspective Concerning Requests for Maxillofacial Computerized Tomography Scan Prior to Dental Implants]. / A Transcrição de Exames na Consulta de Medicina Geral e Familiar: Perspetiva Ética Sobre o Caso do Pedido de Tomografia Computorizada Maxilofacial para Realização de Implantes Dentários.

In the Portuguese National Health Service, little attention has been paid to oral health care. The almost nonexistence of a dentistry network raises concern about accessibility to services, and justifies the need to call on a predominantly private provision of services. The coexistence between the public and private settings is not always easy, especially when services need to interact and actively collaborate in order to find answers to the patient's problems. Dental implant procedures and the need to perform a previous maxillofacial computerized tomography to study the bone bed where osseointegrated dental implants are placed are a common situation. The current governmental regulation, blinded to the clinical context, may limit the accessibility to the tests. Based on this scenario, we discuss the possible options from an ethical point of view, framing the patient's and the physician's perspective and the relation between both. We conclude that the medical decision can't be disregarded from the clinical evaluation, in the intimacy of the medical consultation. This is an ethical duty that overrules the administrative and bureaucratic constraints. A good management of this apparent dichotomy may enhance better health and greater empowerment for the patient.

A saúde oral tem sido pouco cuidada no contexto do Serviço Nacional de Saúde em Portugal. A quase inexistência de uma rede de medicina dentária levanta problemas de acessibilidade que condicionam a necessidade de complementar os serviços públicos com uma oferta predominantemente privada. Mas esta coexistência não é sempre fácil, sobretudo quando há necessidade dos serviços se cruzarem e colaborarem ativamente na resolução dos problemas do doente. Uma situação comum é a colocação de implantes dentários e a necessidade de realizar uma tomografia computorizada maxilofacial prévia para estudo de leito para colocação de implantes dentários osteointegrados, onde a aplicação de regulação governamental desenquadrada do contexto clínico pode condicionar a acessibilidade aos tratamentos. Com base neste cenário, discutem-se as opções do ponto de vista ético, na perspetiva do doente, do médico e da relação entre ambos. Conclui-se que a decisão médica não pode ser desenquadrada de uma avaliação clínica que apenas o ambiente de intimidade da consulta médica pode proporcionar. É um imperativo ético que se sobrepõe aos constrangimentos administrativos e burocráticos e que se bem gerido é potenciador de uma melhor saúde e de maior capacitação da pessoa.

Ethical issues in the psychosocial assessment of bariatric surgery candidates.

Psychosocial evaluation is recommended prior to bariatric surgery. Practice guidelines have been published on assessment methods for bariatric surgery candidates, but they have not emphasized ethical issues with this population. This review outlines ethical and professional considerations for behavioral healthcare providers who conduct pre-surgical assessments of bariatric surgery candidates by merging ethical principles for mental health professionals with current practices in pre-surgical assessments. Issues discussed include the following: (a) establishing and maintaining competence, (b) obtaining informed consent, (c) respecting confidentiality, (d) avoiding bias and discrimination, (e) avoiding and addressing dual roles, (f) selecting and using psychological tests, and (g) acknowledging limitations of psychosocial assessments.

Best practices in the pediatric pretransplant psychosocial evaluation.

Assessment of psychosocial functioning is an often-included component of the pretransplant evaluation process. This study reviews several domains of assessment that have been related to post-transplant outcomes across solid organ transplant populations. These include evaluation of patient and family past adherence, knowledge about the transplantation process, and their neurocognitive, psychological, and family functioning. To date, few comprehensive pretransplant evaluation measures have been standardized for use with children; however, several assessment measures used to evaluate the aforementioned domains are reviewed throughout the study. Additionally, this article discusses some developmental, illness-specific, and cultural considerations in conducting the psychosocial evaluation. We also discuss ethical issues specific to the pediatric psychosocial evaluation. Recommendations are advanced to promote a comprehensive evaluation that identifies family strengths and risk factors as they begin the transplant journey.

It's big surgery: preoperative expressions of risk, responsibility, and commitment to treatment after high-risk operations.

OBJECTIVE: To identify the processes, surgeons use to establish patient buy-in to postoperative treatments. BACKGROUND: Surgeons generally believe they confirm the patient's commitment to an operation and all ensuing postoperative care, before surgery. How surgeons get buy-in and whether patients participate in this agreement is unknown. METHODS: We used purposive sampling to identify 3 surgeons from different subspecialties who routinely perform high-risk operations at each of 3 distinct medical centers (Toronto, Ontario; Boston, Massachusetts; Madison, Wisconsin). We recorded preoperative conversations with 3 to 7 patients facing high-risk surgery with each surgeon (n = 48) and used content analysis to analyze each preoperative conversation inductively. RESULTS: Surgeons conveyed the gravity of high-risk operations to patients by emphasizing the operation is "big surgery" and that a decision to proceed invoked a serious commitment for both the surgeon and the patient. Surgeons were frank about the potential for serious complications and the need for intensive care. They rarely discussed the use of prolonged life-supporting treatment, and patients' questions were primarily confined to logistic or technical concerns. Surgeons regularly proceeded through the conversation in a manner that suggested they believed buy-in was achieved, but this agreement was rarely forged explicitly. CONCLUSIONS: Surgeons who perform high-risk operations communicate the risks of surgery and express their commitment to the patient's survival. However, they rarely discuss prolonged life-supporting treatments explicitly and patients do not discuss their preferences. It is not possible to determine patients' desires for prolonged postoperative life support on the basis of these preoperative conversations alone.

[Perioperative care of palliative patients by the anesthetist : medical, psychosocial and ethical challenges]. / Perioperative Betreuung von Palliativpatienten durch den Anästhesisten : Medizinische, psychosoziale und ethische Herausforderungen.

Anesthetists will encounter palliative patients in the daily routine as palliative patients undergo operations and interventions as well, depending on the state of the disease. The first challenge for anesthetists will be to recognize the patient as being palliative. In the course of further treatment it will be necessary to address the specific problems of this patient group. Medical problems are optimized symptom control and the patient's pre-existing medication. In the psychosocial domain, good communication skills are expected of anesthetists, especially during the preoperative interview. Ethical conflicts exist with the decision-making process for surgery and the handling of perioperative do-not-resuscitate orders. This article addresses these areas of conflict and the aim is to enable anesthetists to provide the best possible perioperative care to this vulnerable patient group with the goal to maintain quality of life and keep postoperative recovery as short as possible.

Clinical indication as an ethical appraisal: the example of imaging before middle ear surgery.

PURPOSE OF THE STUDY: Asking whether imaging is indicated before middle ear surgery requires us to examine the question of indication more generally. PROCEDURES: Clinical indication integrates different levels, which are distinguished in this paper. As deciding whether or not an intervention is indicated requires different approaches on each of these levels, these approaches are also explored. RESULTS: Even when sufficient data are available to determine whether an intervention brings some benefit, knowing whether or not this intervention is indicated still requires us to answer 3 additional questions: (1) Is the intervention sufficiently beneficial to be clinically relevant? (2) Is the intervention 'reasonable' in terms of its opportunity costs? (3) How are we to decide which interventions 'make the cut', and which do not? Although we may all have an informed opinion on this topic, the question of the thresholds we ought to apply to very marginal benefits is one where the best answer can only be the one we have all agreed on. This requires a guideline integrating elements of procedural fairness, developed in conditions of protection from the risks of conflicts of interests. CONCLUSION: Although some of these questions integrate considerations of costs, not all do. However, all integrate value judgements, making clinical indication in part a question of ethical appraisal.

Blood transfusion: implications of treating a Jehovah's Witness patient.

Jehovah's Witnesses believe that an individual's life is contained within blood, and that accepting transfusion of blood and blood products is sinful. The administration of blood to a Jehovah's Witness who has refused to accept transfusion may lead to criminal or civil proceedings. From an ethical viewpoint, if a rational adult who has been fully apprised of the consequences of not receiving this treatment persists in a refusal, the decision should be respected. Medical and nursing staff faced with such a problem should explore fully with the patient any transfusion alternatives that the patient might find acceptable, such as cell salvage, volume expanders, antifibrinolytics and pharmaceutical options, such as erythropoietin. This article examines the legal and consent issues around blood transfusion in Jehovah's Witness patients and their implications for medical and surgical management.

[Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management]. / Fundamentos del rechazo a la transfusión sanguínea por los Testigos de Jehová. Aspectos etico-legales y consideraciones anestésicas en su tratamiento.

The refusal of Jehovah's Witnesses to agree to blood or blood product transfusion based on religious beliefs is one of the most challenging conflictive issues health care givers have to face today. Such conflict is a by product of the ideological and religious diversity in society today. The perioperative care of such patients constitutes a genuine challenge for anesthesiologists and surgeons from technical, scientific, ethical, and legal perspectives. We review the reasons why Jehovah's Witnesses refuse transfusion and discuss the ethical, legal, and anesthetic aspects of their care. The literature up to August 2005 was reviewed by MEDLINE search. The following search terms were used: Jehovah's Witnesses, anesthesia (and anaesthesia), legislation and jurisprudence, ethics, blood transfusion, alternatives, anemia (and anaemia), erythropoietin, trigger, and critical care. To further cover ethical and legal aspects, we reviewed current laws in Spain and similar practice settings.

Fundamentos del rechazo a la transfusión sanguínea por los Testigos de Jehová. Aspectos ético-legales y consideraciones anestésicas en su tratamiento / Jehovah's Witnesses refusal of blood: religious, legal and ethical aspects and considerations for anesthetic management

Uno de los conflictos asistenciales que la medicinaactual afronta, consecuencia de la pluralidad ideológicay religiosa de nuestra sociedad, es el rechazo a la transfusiónde sangre y derivados sanguíneos por los Testigosde Jehová a causa de sus creencias religiosas. El tratamientoperioperatorio de estos pacientes supone un retopara anestesiólogos y cirujanos, tanto desde el punto devista técnico y científico, como ético y legal. Revisamoslos fundamentos del rechazo a la transfusión sanguíneapor los Testigos de Jehová, así como los aspectos éticos,legales y consideraciones anestésicas en su tratamientoPara ello hemos revisado la literatura médica existentehasta agosto de 2005 mediante búsqueda en MEDLINE,utilizando los términos de búsqueda "Jehovah’s Witnesses,anaesthesia, legislation and jurisprudence, ethics,blood transfusion, alternatives, anaemia, erythropoietin,trigger, critical care". Para cubrir los aspectos éticos ylegales se ha revisado la legislación vigente en España yen otros países de nuestro entorno

The refusal of Jehovah's Witnesses to agree to bloodor blood product transfusion based on religious beliefs isone of the most challenging conflictive issues health caregivers have to face today. Such conflict is a by product ofthe ideological and religious diversity in society today.The perioperative care of such patients constitutes agenuine challenge for anesthesiologists and surgeonsfrom technical, scientific, ethical, and legal perspectives.We review the reasons why Jehovah's Witnesses refusetransfusion and discuss the ethical, legal, and anestheticaspects of their care. The literature up to August 2005was reviewed by MEDLINE search. The followingsearch terms were used: Jehovah's Witnesses, anesthesia(and anaesthesia), legislation and jurisprudence, ethics,blood transfusion, alternatives, anemia (and anaemia),erythropoietin, trigger, and critical care. To furthercover ethical and legal aspects, we reviewed current lawsin Spain and similar practice settings

Withdrawal of ventricular assist device support.

OBJECTIVE: Ventricular assist devices (VAD) are mechanical pumps implanted into patients with advanced heart failure who are at risk of imminent death. VADs are a treatment and not a cure, and mortality on device support remains high. Recognizing the dire nature of the decisions for patients and families and the associated high mortality rates, we actively included processes for device withdrawal as part of our program mandate. METHODS: At Toronto General Hospital, from October 2001 to December 2004, 22 patients underwent implantation of a VAD. Seven patients died following device withdrawal. RESULTS: The average time spent on support prior to device withdrawal was seven days. In four of the seven cases, family members initiated discussions regarding device withdrawal. Family-initiated discussions were more likely to occur if patients were implanted electively, as a bridge to transplantation. Disagreements occurred between the ICU and the transplant teams regarding the timing of device withdrawal and responsibility for stopping the pump. DISCUSSION: Establishing a process for device withdrawal has been a key factor in the success of our VAD program. This process relies heavily on pre-implantation preparation, a strategy for resolving disagreements, and a process for withdrawing device support.

Until they have faces: the ethics of facial allograft transplantation.

The ethical discussion of facial allograft transplantation (FAT) for severe facial deformity, popularly known as facial transplantation, has been one sided and sensationalistic. It is based on film and fiction rather than science and clinical experience. Based on our experience in developing the first IRB approved protocol for FAT, we critically discuss the problems with this discussion, which overlooks the plight of individuals with severe facial deformities. We discuss why FAT for facial deformity is ethically and surgically justified despite its negative portrayal in the media.

Ethical issues in the perioperative management of neurologic patients.

The perioperative care of patients who have diseases of the nervous system provides the setting for challenging ethical issues. In the preoperative period, these issues include obtaining informed consent for surgery and its complications, surrogate decision making for the neurologically incapacitated patient, the use of advance directives for medical care, and the temporary suspension of do-not-resuscitate orders during the perioperative period. During postoperative care, ethical issues include establishing and communicating prognosis in patients who are brain damaged, a trial of therapy when prognosis remains uncertain, surrogate consent and refusal of life-sustaining therapy in the neurologically impaired patient, and the management of brain death.

What are the benefits and the pitfalls of preoperative fasting?

Preoperative fasting has been a traditional practice for many years to reduce the risk of aspiration while the patient is under general anaesthetic and to eliminate the risk of postoperative nausea and vomiting. Although it is generally accepted that fasting is beneficial, the fasting regimens that patients undergo are not dependent on the individual patient or the timing of their operation.