Bioethics for clinicians: 25. Teaching bioethics in the clinical setting.

Bioethics is now taught in every Canadian medical school. Canada needs a cadre of teachers who can help clinicians learn bioethics. Our purpose is to encourage clinician teachers to accept this important responsibility and to provide practical advice about teaching bioethics to clinicians as an integral part of good clinical medicine. We use 5 questions to focus the discussion: Why should I teach? What should I teach? How should I teach? How should I evaluate? How should I learn?

An entrustment model of consent for surgical treatment of life-threatening illness: perspective of patients requiring esophagectomy.

OBJECTIVE: Consent to treatment has been extensively discussed and prescribed from the viewpoint of law, ethics, and policy experts; the viewpoint of patients is less well represented. The purpose of this study was to describe the process of decision making and consent to surgical treatment from the patients' perspective, in the context of life-threatening illness. METHODS: Face-to-face interviews with 36 patients who had recovered from esophagectomy for cancer at university hospitals in Toronto, Ontario, were analyzed by means of a qualitative analytic approach. RESULTS: Instead of the accepted model of informed consent and shared decision making, patients identified 6 concepts that describe their experience: (1) cultural belief in surgical cure, (2) enhancement of trust through the referral process, (3) idealization of the specialist surgeon, (4) belief in expertise rather than medical information, (5) resignation to risks of treatment, and (6) acceptance of an expert recommendation as consent to treatment. These concepts were developed into a model of entrustment that unites the narratives of all our patients. CONCLUSIONS: There is a gap between accepted legal and ethical theories concerning consent and the patients' account of their experiences with surgical treatment of esophageal cancer. Although our findings should not be used to circumvent the ethical and legal requirements of the consent process and are limited to survivors of treatment of life-threatening disease, they support a careful reassessment of informed consent that includes the perspective of patients.

Ethical problems in surgery: innovation leading to unforeseen complications.

A hypothetical case that involves a surgical innovation is used to illustrate three ethical issues in surgery: the profound trust that vulnerable patients feel toward their surgeons, even when they innovate; the disequilibrating effect of new procedures on traditional safeguards of surgical competence; and the need for a systematic approach to the evaluation of new surgical procedures.

Bioethics for clinicians: 13. Resource allocation.

Questions of resource allocation can pose practical and ethical dilemmas for clinicians. In the Aristotelian conception of distributive justice, the unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit. Even using these criteria, it can be difficult to reconcile completing claims to determine which patients should be given priority. To what extent the physician's fiduciary duty toward a patient should supersede the interests of other patients and society as a whole is also a matter of controversy. Although the courts have been reluctant to become involved in allocation decisions in health care, they expect physicians to show allegiance to their patients regardless of budgetary concerns. The allocation of resources on the basis of clinically irrelevant factors such as religion or sexual orientation is prohibited. Clear, fair and publicly acceptable institutional and professional policies can help to ensure that resource allocation decisions are transparent and defensible.

Pneumothorax and wound dehiscence related to collagenase deregulation: treatment with diphenylhydantoin.

BACKGROUND: Wound dehiscence is an uncommon complication of operation, usually related to a recognized risk factor. A clinical dilemma arises when dehiscence has no identifiable cause or treatment. METHODS: We describe the case of a previously healthy 45-year-old man in whom recurrent spontaneous pneumothoraces developed followed by multiple dehiscences of thoracotomy, diaphragmatic, and abdominal wounds. Analysis over several years of laboratory investigation of cultured tissue from test incisions was initially unsuccessful. The patient was supported symptomatically until a remarkable laboratory finding enabled us to develop an effective treatment plan. RESULTS: Cultured patient fibroblasts were ultimately found to express abnormally elevated levels of collagenase, which could be inhibited by diphenylhydantoin (phenytoin) in vitro. Treatment of the patient with a course of diphenylhydantoin allowed adequate healing of test incisions and subsequent definitive surgical treatment with successful wound healing. CONCLUSIONS: This report of the rigorous application of the scientific method to the investigation and treatment of an enigmatic case of wound dehiscence might serve as a guide to surgeons faced with similar healing problems.

Pulmonary and thymic carcinoid tumors.

Carcinoid tumors of the lung and bronchi are usually benign lesions with no influence on life expectancy, although occasionally, they are malignant with a poor prognosis. Between these two extremes are atypical carcinoids, which can be slow-growing tumors with an average 5-year survival of 60% and an average 10-year survival of 40%. The myriad names used to describe these lesions complicates the understanding of their behavior, especially as the term carcinoid is used to describe the complete spectrum of disease or exclusively the benign well differentiated lesions with an excellent prognosis. Thymic carcinoids are uncommon lesions. Their prognosis is poor, even in cases that appear favorable in terms of resectability and histology. Pulmonary carcinoids present uncommonly with a paraneoplasic syndrome. Both carcinoid and Cushing syndromes are seen with approximately 2% of these lesions. Cushing syndrome can be present in as many as one-third of patients with thymic carcinoids but an association with the carcinoid syndrome has never been described.

Educating tomorrow's cardiac and thoracic surgeons: a Canadian initiative.

Societal, technologic, organizational and educational developments during the past 10 years have brought about increasing promises for change in the graduate medical education of cardiac and thoracic surgeons. These changes effectively lengthened training to 8'years and created a double standard for the education of a thoracic surgeon. A task force mandated by the Royal College of Physicians and Surgeons of Canada nucleus committees in both cardiac and thoracic surgery and with the support of the Canadian Society of Cardiovascular and Thoracic Surgeons studied the problem and made the following recommendation: cardiac surgery and thoracic surgery should each become a primary specialty with its own nucleus committee. Each specialty would require 6'years' training, with the possibility of obtaining certification in both specialties after an additional 18'months training. Each specialty could also be entered after completion of full training in general surgery. The task force also urged the development of a curriculum to guide educational objectives in each specialty. These changes will produce a flexible, shorter, more focused program for cardiac and thoracic surgeons for both university and community settings.

A late defect in wound healing associated with recurrent spontaneous pneumothoraces: a presumptive role for abnormal collagenase activity.

This case report concerns an individual with a defect in wound healing which resulted in recurring, bilateral pneumothoraces during the late postoperative period. This patient had no history of systemic disease or wound healing abnormalities before his recurrent wound disruption. Physical examination and routine biochemical studies failed to identify any causative agent for the multiple wound dehiscences in the patient. Histologic examination of scar tissue showed collagen fiber bundles with a diameter 50% less than that of normal fibrils. Elastic fibers were barely visible, and the scar tissue included a large number of inflammatory cells. A significant finding was an elevated and aberrant expression of collagenase by a fibroblast cell line established from a skin biopsy specimen. This enhanced level of collagenase expression could be inhibited by treatment of the cells with diphenylhydantoin, an inhibitor of collagenase biosynthesis. After initiation of diphenylhydantoin therapy, the patient's scar formation normalized with the recurrent pneumothoraces. These findings support the conclusion that an abnormal expression of collagenase resulted in enhanced degradation of collagen in the patient's wounds, thereby leading to wound dehiscence.

What were the issues of surgical importance in lung cancer treatment in 1977? How did they change over time?

The LCSG tested innovative and standard adjuvant treatments aimed at strengthening the effectiveness of surgical resection. The group addressed issues related to standardizing and improving surgical treatment, and the perioperative use of chemotherapy, radiotherapy, and immunotherapy alone and in combination. The surgical leadership, meticulous methodology, and interdisciplinary cooperation mobilized to address these issues made the group the reference standard for thoracic oncology trials.

The adverse effect of perioperative blood transfusion in lung cancer.

Perioperative blood transfusion appears to increase the risk of recurrence and death in patients with surgically resected lung cancer. This finding is consistent with that in other cancers and several studies in lung cancer report similar risk elevations. We have reanalyzed the Lung Cancer Study Group data relevant to this question, assessing the potential confounding effects of some prognostic factors not examined previously. The results are nearly identical to those reported earlier, suggesting that increased risk is attributable to blood transfusion and not to confounding by known prognostic factors.

Lung tumor resection does not affect debrisoquine metabolism.

Some authors have reported an association of extensive metabolism of debrisoquine with increased lung cancer risk, although others have found no association. Debrisoquine metabolism is controlled by a cytochrome P-450 isozyme encoded at the CYP2D6 locus, which is inducible by antipyrine and rifampicin. Because lung tumors may produce a variety of humoral substances, we wanted to determine whether the tumor induced debrisoquine metabolism. As part of a case-control study of lung cancer, debrisoquine metabolism was measured in patients with histologically confirmed non-small cell lung cancer before and after surgical resection with curative intent. One hundred four incident patients with curative intent. One hundred four incident patients with pathological stage I, II, or IIIA non-small cell lung cancer took debrisoquine (10 mg) orally at 10 p.m. and collected the subsequent 8-h urine both before and after surgery. We compared the values of the metabolic ratio, which is the percentage of the dose excreted as debrisoquine to the percentage of the dose excreted as the principal metabolite. The pre- and postoperative metabolic ratios were highly correlated (Pearson correlation coefficient = 0.96), and did not differ in value significantly (P = 0.88). Using traditional cutpoints (metabolic ratio, 1.0 and 12.6) to categorize the three metabolic phenotypes, the preoperative and postoperative phenotypes were well correlated (kappa = 0.78). These results show that the ability to metabolize debrisoquine is not induced by the presence of a primary lung tumor.

Bronchial and thymic carcinoid tumors: a review.

Bronchial carcinoid tumors are usually indolent, slow-growing tumors with an excellent prognosis. However, even typical carcinoids can metastasize to regional lymph nodes or to distant sites. Atypical carcinoids tend to behave more invasively with more frequent nodal and distant metastases. Despite this, long-term survival can be expected as many tumors grow and spread slowly. At the end of the spectrum are the highly aggressive small cell carcinomas which have a very poor prognosis despite aggressive chemotherapy. Clinically, carcinoid tumors are frequently asymptomatic. Symptoms are most frequently due to obstruction (pneumonia, 'asthma', coughing) or bleeding. Carcinoid syndrome is seen infrequently and usually signifies metastatic disease. Cushing's syndrome is occasionally seen in association with these tumors. The treatment of carcinoid tumors is surgical. Resection should be complete and encompass the regional lymph nodes.