Two significant, apparently unrelated, trends have emerged in American society and medicine. First, American medicine is reexamining its approach to dying. The Institute of Medicine, the American Medical Association and private funding organizations have recognized that too many dying people suffer from pain and other distress that clinicians can prevent or relieve. Second, this past decade has marked a sharp increase in the number of physicians prosecuted for criminal negligence based on arguably negligent patient care. The case often cited as (...) a watershed is People u. Einaugfer, which involved a New York nursing home patient whose physician was convicted in 1993 of two criminal misdemeanors after he ordered an elderly dialysis patient to be tube fed through a peritoneal dialysis Catheter.How is the growing awareness of dying patients’ pain and the increasing willingness of prosecutors to charge physicians with crimes connected? Pain at the end of life is frequently treated with narcotics, prescription drugs that are closely regulated by state and federal law. That complex web of laws—and a growing fear of legal sanctions—has deterred physicians from prescribing controlled substances. As those legal sanctions move from disciplinary actions to criminal charges, physicians’ fears may expand. (shrink)

Two significant, apparently unrelated, trends have emerged in American society and medicine. First, American medicine is reexamining its approach to dying. The Institute of Medicine, the American Medical Association and private funding organizations have recognized that too many dying people suffer from pain and other distress that clinicians can prevent or relieve. Second, this past decade has marked a sharp increase in the number of physicians prosecuted for criminal negligence based on arguably negligent patient care. The case often cited as (...) a watershed is People u. Einaugfer, which involved a New York nursing home patient whose physician was convicted in 1993 of two criminal misdemeanors after he ordered an elderly dialysis patient to be tube fed through a peritoneal dialysis Catheter.How is the growing awareness of dying patients’ pain and the increasing willingness of prosecutors to charge physicians with crimes connected? Pain at the end of life is frequently treated with narcotics, prescription drugs that are closely regulated by state and federal law. That complex web of laws—and a growing fear of legal sanctions—has deterred physicians from prescribing controlled substances. As those legal sanctions move from disciplinary actions to criminal charges, physicians’ fears may expand. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:When Doctors Get It WrongKonrad BlairThe BeginningIt was a gloomy winter day as I sat in the back of the car while my father and mother drove me to another appointment in Pittsburgh. It was and wasn’t like so many car trips of my childhood for so many doctors’ appointments. The same deadening silence filled [End Page 89] the car as we drew closer to our destination. My parents (...) never discussed the appointments with me and I just learned to never ask. This appointment was different though; it came about as a result of request by a psychology professor who was conducting a follow–up study on individuals treated by the team of endocrinologists I saw as a child.The professor had reached out to me through my parents, since that was the only contact information available. It had been more than ten years since I had seen any of the doctors who treated me as a child. I was living in another state when I received the call from my mother informing me of the request for my participation in the study. I was really quite shocked; in all the years I was treated in early childhood and adolescence, no one had ever asked me how I felt about the treatment I received. I knew I had a medical condition, but no one ever explained to me why I needed so many appointments, and why I had to take medicine three times a day. No one told me why, when I was two or three years old, I had surgery that left me with memories of gauze and a catheter between my legs, or why medical residents still wanted to examine me, or why I had to be humiliated and ashamed, again and again. I was in my early 30’s by this time. Surely if my condition was so important that someone wanted to talk to me now, so many years later, the conversation would have already happened?!My parents dropped me off at the scheduled location for the interview. The professor introduced himself and his colleague. I didn’t recognize them, which meant they weren’t the doctors who had treated me. I remember feeling somewhat relieved, as I never liked the doctors who treated me as a child. I remembered my last appointment there, and feeling that I was escaping from captivity, that I was free to go on with my life.I wasn’t sure what to expect from this meeting. The professor told me that to date no one had completed any follow–up on the pediatric patients treated by the hospital’s endocrinology team to see how they were faring in life. He said he thought that was quite odd, so had decided to take on the project himself. He began by asking, “so, D_____, [I went by another name then] how are you doing at this point in your life?”I felt a sudden surge of rage, and, to my own surprise, I found myself responding angrily, “Why the hell do you care? It’s been over ten years and nobody, I mean nobody gives a rat’s ass as to how I’m doing and coping with the ramifications of the treatment I received from Dr. X.” Looking back, more than ten years after this meeting, I can see that I had been angry for a long time. I had been compliant and knew to play my role as a good girl. I had a good job, and I was married, but I knew I was far from happy.And so with that first question began what would be the long painful journey to discovering what had been hidden from me for over half my life, the source of my confusion and unparalleled frustration. What I had experienced throughout my childhood would permeate every aspect of my being and perception of myself for years to come. Every day I had to confront the effects of that experience just to live another day.The MiddleI was in shock and disbelief as I read and reread the letter my attorney presented to me from the very group of... (shrink)

In the United States, clinical interventions such as epidurals, intravenous infusions, oxytocin, and intrauterine pressure catheters are used almost routinely in births in the hospital setting, despite evidence that the overutilization of such interventions likely plays a key role in increasing the need for cesarean section (CS). In 2010, according to the U.S. Centers for Disease Control and Prevention, approximately 32.8 percent of births in the U.S. were by CS. The U.S. National Institutes of Health has reported that CS (...) increases avoidable maternal and neonatal morbidity and mortality. To increase understanding of what might motivate the overuse of CS in the U.S., we investigated the factors that influenced women’s decision making around childbirth, because women’s conscious and unconscious choices about giving birth could influence whether they would choose or allow delivery by CS.In this article, we report findings about women’s decisions related to place of birth—at home or in a hospital. We found that choosing a place of birth was significant in how women in our study attempted to mitigate their perceptions of the risks of childbirth for themselves and their infant. Concern for the safety of the infant was a central, driving factor in the decisions women made about giving birth, and this concern heightened their perceptions of the risks of childbirth. Heightened perceptions of risk about the safety of the fetus during childbirth were found to affect women’s ability to accurately assess the risk of using clinical interventions such as the time of admission, epidural anesthesia, oxytocin, or cesarean birth, which has important implications for clinical practice, prenatal education, perinatal research, medical decision making, and informed consent. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Carmen MirandaJessica LesCarmen Miranda, she called herself today. She suffered from decades of schizoaffective disorder and now more recently, end–stage renal disease from uncontrolled diabetes. I first met Carmen two weeks prior when she had been brought to the hospital on a 72 hour psychiatric hold for self–harm. She failed to go to dialysis for a week, an act that would kill her if allowed to continue. Now she (...) was here again, for the same reason.Everyone of competent mind has the right to refuse medical treatment. Unfortunately, Carmen’s mind was not currently grounded in reality. So against her will, our family medicine team admitted her to the hospital and arranged for dialysis early the next morning. None of us liked doing this. Fortunately, when the time came for the dialysis tech to insert the dialysis catheter into her shunt, Carmen agreed peacefully. After her dialysis, we had no right to keep her in the hospital because her life was no longer in danger, at least until the next week. We discharged her to home. However the question remained, what about next time?To navigate this ethical gray zone, we called an ethics committee meeting. An ethicist, nurses, hospital social workers, the inpatient family medicine resident team, and most importantly, two people who knew her very well—her caseworker and long–term psychiatrist—discussed her case for an [End Page 103] hour. Our medicine team learned that in her last period of clarity two months prior, Carmen made contradictory statements regarding her wishes. Carmen told her caseworker she was tired of dialysis and being sick and stated it was time to let herself go. During the same lucid week she told her psychiatrist that she was grateful she had been forced to complete dialysis against her wishes after a run of non–adherence while suffering psychosis a couple of months prior. Now months later she was in a downward spiral, exacerbated by the deterioration of her mentally ill husband. If she missed a dialysis treatment here and there, it was okay, but when she went on a run missing several treatments, it was slow suicide.The ethics meeting concluded that Carmen needed to complete an advanced directive and select a power of attorney other than her gravely incompetent husband as soon as she was deemed competent. If she did not become lucid again, her psychiatric team should apply for conservatorship, a legally appointed person who serves as guardian for a gravely disabled mentally ill person. However, conservatorship would take months. In the interim, the ethics committee ruled that our medicine team would continue to provide lifesaving treatment for her, against her wishes if necessary.The ethics meeting adjourned but our medicine team remained in a gray area. To what length should we go to treat her? If she continued to refuse dialysis would we hold her in the hospital until she became sufficiently docile by inevitable uremia that we could peacefully dialyze her? Possibly. Would we go so far as to put her under anesthesia to complete her dialysis? Personally, I hoped not.Just three days after the ethics committee meeting, her caseworker found Carmen yelling nonsensical phrases through the front door of her home while her husband held the door shut with his beer belly and good shoulder. After gaining entry later in the day, Carmen’s caseworker found their mutual medication collection strewn in the bathtub and no food in the house. He placed Carmen on a psychiatric hold and transported her to the hospital. The emergency department paged me when Carmen arrived. I braced myself for the possibilities that lay ahead. When I reached Carmen, she was sitting in a room reserved for psychiatric patients and under watch by a friendly police officer accustomed to these situations.“Hi, Carmen,” I said, one step into her room. She sat on the edge of the gurney, wrapped in three blankets.“Cold,” she said.The police officer spoke from behind my shoulder, “She has been requesting cup after cup of ice water, she won’t take anything else.”“Let’s get you more comfortable.” I returned with a warm blanket and draped it over her... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Feminist Studies 46, no. 1. © 2020 by Abby Minor 103 JUMP ROPE CHANT: A CURE FOR ALL KINDS OF STOMACH ACHES, ca. 2000 BCE–ca. 2000 CE Abby Minor Happy are those who stand in a field at night and hear the double rainbows land, or clap the gaps that RHYTHM makes, or shout to the beat of grasses; They are like trees planted by streams of water, which (...) yield their fruit in its season, & their leaps & their leaves & their feet do not wither, they leap up in the morning singing, in all that they do they chant, and jump, and are singing: “Blood root, hair pin, lupine, clover, watermints and cinnamon, a pencil, myrrh, poplar, juniper, copper water, whiskey, cotton root, snake root, savin, wire,  Clap your hands, all you peoples. —Psalm 47.1 104 Abby Minor wallflower, gunpowder, emeralds, myrtle, tonic of geranium, lace seeds, soap, bone stay, coltsfoot, catheters, quinine, a hoop bound with oil-silk, a hat pin, oak—” I chant a long time I chant from within a hollow place I chant all colors of cohosh Instantly as dawn clips green & white, I chant to dissolve separate parts I jump backwards and I chant So that you may bathe your feet in blood, it was in the Psalms, it’s what God does it might be a rain dance it will come to you like a beautiful cigar filled with fine leaves like the fine feet of a deer cleft in gold leaves Like rhythm a hair pin, rhythm a hat pin, rhythm a knitting hook, rhythm a nail RHYTHM makes my feet like the feet of a deer. I chant rosemary so assiduous I chant pennyroyal forever most poisonous I chant intransigence and double rainbows pop on the sidewalks of the cosmos, double Abby Minor 105 Dutch ropes spin like twin rivers, there I am planted like a tree by the water, like an outrider dropping fire into the ropes: I will kick up my heels seven times there will be a noise and the seed will fall out on the ground shouting, “Date palms, dancing, anise, trillium, turpentine, scissors, silphium, rum, cundums, pomegranate, pearlash, iron, foot baths, borax, birthwort, rue, wormwood, fern root, fig leaf, sneezing, a small ball of sheep’s wool, smart weed, brass, blackberries, goldbeaters, button hooks, hawthorn, womb veil, vinegar, saffron, glass—” If you try our hearts, RHYTHM, if you visit us by night; if I forget which is my left hand and which is your right— just let it be me; psalmist, you, a trace of blood. Me, muscle, 106 Abby Minor you, myrrh. Or you jumping, me rope. Me mirrorstep, you leave your dark prints on the light. Me ambush, you flood. Me bloodthirsty, you a smaller blood. You bloodthirsty, me myrrh. Me fortress, you a tent for the sun. Me splendor, you go on and on. Me hat pin, me flood. You poetry, me a clapping tree, or me poetry and you nothing at all. I say to RHYTHM, “You are my Rhythm, I have no song apart from you and I could never tell just where the sole leaves the sidewalk and turns into the smallest lit pause popped, suspended above shoe shadow; I could never say whether I’m the jumper picking up her knees or the turner planted so still save for her hands— and what pilots her hands, pilot, if not you, if not her hands? If not the offbeat, the bows of light we pattern, Rhythm which is both the rivet and what’s held: like rhythm a hair pin, rhythm a hat pin, rhythm a knitting hook, rhythm a nail Abby Minor 107 RHYTHM makes my feet like the feet of a deer. Now I chant the bitter melon fruit who lights up darkness and my feet do not grow weary writing RHYTHM on the sidewalk lighting incense in the bathtub filled with gin in which I lay chanting like the singers in front, like the musicians last, like the girls between them playing tambourines: Rhythm make a riot Rhythm eat a bee Rhythm use a chicken feather & make a joyful noise Praise Rhythm with mint & astringents with spearmints & syringes with pipes, pen handles, mercury... (shrink)

Objectives: To examine the willingness of patients to participate in a resuscitation study that requires exception from informed consent and to determine if willingness to participate is associated with demographic and other characteristics.Methods: Adult patients in an emergency department and in a geriatric outpatient clinic were surveyed. Patients were asked to imagine that they presented to an emergency department with cardiac arrest and asked about their willingness to receive a new drug outside of a study, receive a new drug as (...) part of a study and participate in a randomised controlled trial for a new drug. Patients were also asked about participation in studies of invasive procedures.Results: 213 patients from a geriatric clinic and 207 from an emergency department were surveyed. Two thirds of patients from the geriatric clinic and 83% from the emergency department were willing to receive an experimental drug outside of a study. Patients were less willing to participate in a study of the new drug and even less likely to participate in an RCT for the new drug . Patients were less likely to participate in a study of thoracotomy than in a study that required placement of a femoral catheter . Willingness to participate was not associated with trust in the doctors.Conclusions: Study design and invasiveness of the intervention were associated with the willingness of patients to participate in resuscitation studies that require exception from informed consent. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Retention, Reliability, and DedicationRenee J. TillmanI love what I do. I am a Hospice and Palliative Nurse Assistant. I have been for 16 years. I have worked in this field for 37 years—in long term care, private duty and home health. I still like getting up and going to work. I have a great work ethic. I think it came about when I started working for Leader Nursing and (...) Rehabilitation Center. My plans were to become a nurse, just like my mother. This employer believes that if he contributed to his employees by way of educating them he would accomplish two things. Loyal employees and highly skilled nurse aides. He knew we were the backbone of his center and believed in his strategy to give the very best care his employee's could provide.I was one of the first nursing assistants in the building. I started on the 11-7 shift, myself and a licensed vocational nurse (LVN). She was a gem. In a four story building. They had security for us. They started from the top and filled the building up. I was never so proud to be a nurse aide. Pretty soon we were filled. I worked the night shift for three years and decided to go to the day shift, 7 to 3. [End Page 154]It was then that I decided this profession was for me, and I was going to be the best. Everything we did was a learning experience. We received report at the beginning of our shift. We were asked to be on the job 15 minutes before shift, and we did so without pay. We felt it was important to get information to care for the residents. The incentives were what they called the Leader Ladder. This Ladder was there for you to climb to the highest occupation in the nursing field you wanted to go, with the help from the scholarship program in place. The goals of the employer were retention, reliability, support, and dedication from the employees.That is not in place today, especially in the long-term care settings. There is a revolving door in most places. In most places employees don't even have nametags. If they do have them, they're in the pockets just to swipe the clock. Uniforms are not decent, I mean wrinkle-free and clean. Even hair and faces are not groomed. Yes I see this today. We are the forgotten, the invisible. Shame on those watch dogs. When I was with Leader, I would watch my nurse do everything—catheters, suctioning, wound care—everything. We used to do wound care and finger sticks. In some places, they don't even let the aides do vital signs.One of the cases I will never forget, this was at a rehabilitation center with a floor that was skilled. This lady was admitted. She was only 60. She had the biggest tumor I had ever seen on the side of her neck; it was cancerous. The tumor was growing outside her neck. I was just 25. When we received report that morning, we were told of physical and history, where she was with her disease, and that she had come there to die. She had no family. We quickly became her family. She was tall and skinny with dark hair. We were also told how she would die and to be prepared so it would not be scary for her or for us. She was going to bleed to death from the tumor. But, our biggest challenge, you see, was not to show that there was an odor when in her room or where ever she was. The cancer was very foul-smelling. I think that is why she loved us; we acted like there was no smell. The day she died, her tumor started a steady flow of blood. She knew it was the end. We had dark towels for her, she lay in her bed, she was never left alone. We had our work to do, but she was never left alone. What I remember the most is her eyes; you see, she could not speak that day. She... (shrink)

IntroductionIn the context of giving risk information for obtaining informed consent, it is not easy to comply with the ethical principle of “primum nihil nocere.” Carelessness, ignorance of nocebo effects and a misunderstood striving for legal certainty can lead doctors to comprehensive and brutal risk information. It is known that talking about risks and side effects can even trigger those and result in distress and nonadherence to medication or therapy.MethodsRecently, we have reported on significant clinically relevant effects of verbal and (...) non-verbal suggestions on maximal muscular arm strength in healthy volunteers and in patients at two time points before surgery. Maximal strength during arm abduction was measured by dynamometry of the deltoid muscle group. Suggestions from clinical everyday life were formulated as presumed negative and neutral versions.ResultsHere, we report on the effects of two versions of risk information in 45 patients. After sole mentioning risks of a puncture for the placement of a pain catheter, the maximal arm muscle strength was significantly reduced to 83% of baseline several days, and to 84% the evening before surgery. Strength was not significantly decreased and close to baseline at T1 and T2 when risks and benefits of a pain catheter were combined in one sentence. The difference between both versions was significant. With persistent normal distribution of values, the effect was due to uniform reactions of many patients, not to strong reactions of a few. High suggestibility and increase of anxiety with approaching surgery were identified as influencing factors for the neutralizing effect of modified wording.ConclusionWe not only suggest an alternative formulation for risk information to avoid nocebo effects but present an objective method to quantify and compare effects of different wordings. Thereby, we provide evidence that concurrently given positive aspects can neutralize negative effects during medical interview. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Vagaries and Vicissitudes of WarRichard W Sams III remember standing in the kitchen of our home on Camp Pendleton—a United States Marine Corps base in Southern California—listening to National Public Radio (NPR) and doing dishes in the fall of 2002. President Bush announced to the world that he was considering a pre-emptive invasion of Iraq on the pretext of Saddam Hussein harboring weapons of mass destruction (WMD). Three (...) months later, as a Navy Family Physician, I deployed with a surgical company in support of Operation Iraqi Freedom. Reflecting on the situation with a like-minded close friend, I was not sure— would this be a just war? A necessary war? In my mind, it did not rise to the level of conscientious objection, yet the rightness of invading another country with all the anticipated death and destruction was not clear.En route to Kuwait, we laid over in Spain. While fixed to a TV in a holding area, I watched the Secretary of State make a case to the United Nations (UN) and the world that removing Hussein from power would protect us from mobile anthrax labs that could kill tens of thousands. I thought to myself, Either he is absolutely right, and we are protecting our country and the rest of the free world, or he is terribly mistaken and we are embarking on a disaster.As we trained, prepared, and waited in our tents to invade, we listened to the news on “Voice of America” with a hand crank radio. Thousands of citizens from nations around the world protested. Pope John Paul II, a man well acquainted with the tragedy of war, even spoke out about the planned invasion. “War is not inevitable. It is always a defeat for humanity.” He admonished our leaders that war needed to be the very last option. As a man of faith, I was troubled by his resolute, thoughtful opposition to the crusade I was embarking on. As the day of the invasion approached, scud missiles flew over our camp and we scurried into bunkers, day and night, with our gas masks donned to protect us from possible WMD attacks. In March, with the announcement of a “shock and awe” missile attack on Hussein’s palace, the invasion commenced.Within a day of flying by helicopter into enemy territory to set up a surgical company, the fog of war set in. A series of mass casualties streamed in from nearby Nasiriya. We received dozens of injured enemy combatants and American soldiers. Most troubling were the civilians. An entire extended family fleeing for their lives stumbled into an Iraqi minefield meant for us: a mother dead, the men with shrapnel wounds, and an aunt lost both of her legs. Then there was the little boy. By doctrine, our leaders reassured us we would not care for children. Yet, out of instinct, the field corpsmen scooped up all injured, including children, and [End Page 170] brought them to us. The five-year-old’s legs were blown to bits. We had no pediatric supplies. The anesthesiologist heroically intubated the child’s tiny airway with a urinary catheter and placed an adult IV. The surgeons corrected the wounds the best they could. Hours later, in futility, we performed chest compressions on his tiny mangled body.A day later, the worst sandstorm in a decade struck the area. We struggled to keep the patient-filled tents erect. A Marine appeared on the scene out of the darkness (you could not see beyond your nose in the storm) exclaiming we were going to condition one—lock and load our weapons due to an imminent threat. As healthcare professionals, Geneva Conventions dictated we were to use weapons only in self-defense. We chambered our 9-millimeter pistols to defend our patients and ourselves while Marines formed a defensive perimeter. I thought to myself, Great I’m gonna be shot up and die during a freaking sandstorm in Iraq. Hours later, we were told to stand down. The threat was not from approaching enemy combatants but from shepherds running from the crossfire. I had a small nervous breakdown, sleep deprived and under duress... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Consenting for Novel and Dangerous Surgical Procedures with Minimal Supporting EvidenceMichelle J. ClarkeFrank1 was a 19–year–old man referred to me after a workup for back pain led to the discovery of a large, aggressive tumor in his sacrum. The tumor wrapped around the nerves controlling bowel, bladder, and leg function. We performed a needle biopsy and learned that the tumor was an angiosarcoma, an extremely aggressive and usually deadly (...) form of cancer. However, the tumor was unique in that it theoretically could be cured if removed in one piece. But, to do so would necessitate sacrificing the nerves, leaving the patient irreversibly incontinent, lacking sexual function, and confined to a wheelchair.Once we knew the diagnosis, Frank came to the office with his family to discuss treatment options. He appeared terrified and was almost silent through the appointment, deferring most questions to his parents. Due to the speed of tumor growth, we discussed palliative therapy, conventional treatment, and the one–piece or “en bloc” surgery, which was new and unproven for his disease. Based on the remarkable tumor growth we noted during the work–up, with palliative treatment the patient would likely survive for less than six months. Conventional treatment, in which surgery is done to remove part of the tumor while sparing the nerves to bowel and bladder function, was known to have a high rate of recurrence and death. Further, this tumor didn’t respond well to radiation and chemotherapy, so chance of survival was limited, although his life might have been extended for a short period. Thus our conversation turned to the novel “en bloc” procedure.The en bloc procedure offered a hope of long–term survival unlike the other options. However, this came with an enormous cost. The surgery itself would be planned to occur over three days with five separate surgical teams and a very real chance of major complications or death. Nerves to bowel and bladder would be cut, irreversibly leaving the patient without sexual function, and completely incontinent with a urinary catheter and colostomy. Walking was expected to be disrupted or potentially impossible due to the nerve resection. We went to great lengths over the course of many visits to describe the impact of the surgery on the patient’s function, and the impact on his quality of life. To make matters more challenging, as this procedure was so new and the tumor so rare, research did not yet exist to quantify his likelihood of long–term survival.Personally I was very uncomfortable with the situation. From a medical standpoint, the surgery offered was the best distillation of research and professional experience. En bloc surgery offered the best—if not the only—chance for survival in [End Page 5] this young man. Additionally, having treated many spine–injured patients I was aware that many patients with similar deficits led happy and productive lives following an emotional and physical adjustment period. However the surgery was also extreme. I worried that we would not be able to accomplish the goal of a one–piece resection and would accidentally spill some of the tumor, creating all of the deficits but no survival benefit. Frankly, I thought there was a 25% chance that would happen, which was explained to the family preoperatively. Were we overreaching our abilities and making a dying patient’s life worse by proceeding?Second, I was uneasy about the social situation. The patient’s family was very supportive, traveling with him to all appointments and assisting with his care. The patient himself usually deferred all scheduling to his mother, which wasn’t entirely unusual for such a young man. However it was difficult to grasp how much the patient understood of his disease or supported the plan. We attempted to delve more deeply into his thoughts, including without his parents present, but got only short answers, which revealed little. While the family appeared to have accepted the diagnosis and wanted to get to the business of treatment, the patient seemed to me to still carry the shock of his recent cancer diagnosis. Pushed by the rapid tumor growth, we were limited in how long we could wait for... (shrink)

On December 20, 2002, the Ohio Supreme Court issued an opinion in Dardinger v. Anthem Blue Cross & Blue Shield granting a landmark punitive damages award against the defendant-insurer for breach of contract and bad faith in its coverage of a cancer patient. The court directed that the punitive damages award of $30 million, should it be accepted by the plaintiff, be apportioned between the plaintiff and a cancer research fund to be established in the name of the plaintiff's deceased (...) wife, Esther Dardinger. In so doing, the court broke new ground in the scope and social purpose of punitive damages in health care litigation, as well as the courts’ role in distributing those damages.After being diagnosed with metastatic brain tumors in October 1996, Esther began intra-arterial chemotherapy treatments at the recommendation of her physician, Dr. Newton. IAC is a targeted form of chemotherapy in which an arterial catheter is threaded through a cranial artery near the tumor and into the brain. (shrink)

On December 20, 2002, the Ohio Supreme Court issued an opinion in Dardinger v. Anthem Blue Cross & Blue Shield granting a landmark punitive damages award against the defendant-insurer for breach of contract and bad faith in its coverage of a cancer patient. The court directed that the punitive damages award of $30 million, should it be accepted by the plaintiff, be apportioned between the plaintiff and a cancer research fund to be established in the name of the plaintiff's deceased (...) wife, Esther Dardinger. In so doing, the court broke new ground in the scope and social purpose of punitive damages in health care litigation, as well as the courts’ role in distributing those damages.After being diagnosed with metastatic brain tumors in October 1996, Esther began intra-arterial chemotherapy treatments at the recommendation of her physician, Dr. Newton. IAC is a targeted form of chemotherapy in which an arterial catheter is threaded through a cranial artery near the tumor and into the brain. (shrink)

Vijay is a forty-eight-year-old man with profound mental retardation and cerebral palsy. He uses a wheelchair, cannot speak or eat by mouth, and requires constant care. He lived in a group home for twenty-eight years. During the last year, Vijay has required two visits to the emergency room on average per month and has been hospitalized for two hundred days in total. These hospitalizations are the result of a number of painful and dangerous complications related to the gastrostomy tube that (...) provides his nutrition. The last time he was in the hospital, doctors had to give him a peripherally inserted central catheter, or PICC line, to provide nutrition because the gastrostomy tube was no longer effective .. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:To Nurse BetterJaime HenselWhen things were quiet again I asked him what training he’d had to become the director of hospital security. “I worked for 20 years in corrections,” he answered proudly, and I was saddened but not surprised.In September 2010 I started an accelerated graduate entry nurse practitioner program to become a family nurse practitioner. Accelerated programs leave little time for preamble, since the idea is to take (...) a total novice and turn her first into a nurse and then into a nurse practitioner in just three years. While the classroom information was vital, it was our clinical experiences that really initiated us into the profession. In just the second week of school, we were divided into small groups and assigned to clinical preceptors—hands–on teachers who introduced us to our first patients, curbed our mistakes, quelled our fears, and pushed and pulled and cajoled us into being nascent healthcare providers. In showing us how to give bed baths, suction secretions, insert Foley catheters, and hang IV bags, our preceptors really began showing us how to use our hands as healers.In that first semester my patients also proved to be invaluable instructors. Talking to them, administering their medication, washing their bodies made me keenly aware of the delicate balance of vulnerability and power and trust and respect and intimacy that underlies all healthcare relationships. I hope, wherever those patients are now, they know how deeply I appreciate their patience and good humor and their collusion in my education.In December, the first semester and the first clinical rotations ended. Four months into nursing school I had a basic understanding of what it means to be a nurse. Frankly, most days I still felt like an impostor in blue pajamas sporting a stethoscope I didn’t really know how to use and new Dansko clogs that squeaked with every step. But in an accelerated program, fast and furious is the name of the game. We went away for winter break—a much needed breather—and came back to something completely different: psychiatric nursing.In preparation for these new clinicals, we were taught in class that we should not wear dangly jewelry or stethoscopes. That we should never let the patient get between us and the door. That psychiatric (psych) patients could escalate quickly; psych patients could have surprising triggers; psych patients could be very unpredictable. And psych patients could be violent. We were taught about physical and chemical restraints, and about show of force. We were cautioned, as students, to stay out of the way if things got tense on the floor. In stark contrast to medical patients, psych patients were made to sound less like people who had diseases and more like adversaries. I drove to my first day on the floor with trepidation.My new preceptor had spent her entire career in psych. She loved her job, loved the care of psychiatric patients. She set up a rotation because she wanted our entire clinical group to get full exposure to the breadth of psychiatric services offered by this medium–sized community hospital. We would each get to spend shifts on the locked psych floor, observing outpatient group therapy sessions, and in the psych emergency department (ED).I rotated to the psych ED for the first time on a Friday night. The first couple hours of the shift were very slow. I started talking to the mustachioed guard on duty, who looked as bored as I felt. He told me about his kids, I told him about nursing school. He seemed nice.When our conversation flagged, I explored the psych ED. It didn’t take long—just a short hallway with a bathroom, the social workers’ office, and two patient rooms without doors. The majority of the designated psych beds were actually around the corner in the main room of the medical ED—stretchers lined against the wall, without curtains or any [End Page 98] other attempt at privacy. I noticed that from where the guard stood at the corner of the psych hall he had a pretty good view of all the beds. Then again, so did most of the other patients... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My Gratifying Testimonial of My Extended Warranties of LifeDanette RaginMy name is Danette Ragin. I am a 2-time kidney recipient who has been diagnosed with ESRD (End Stage Renal Disease). Both transplants were performed in Baltimore, Maryland. I am also a 3-time Donor Family Member and the proud Mom of a living donor.I received the first kidney from a deceased donor on June 22, 2008. The donor was traveling (...) thru Maryland with her family on vacation and experienced heart complications. My second kidney was donated to me by my youngest daughter Angel on December 20. 2016. I am thankful to God for both of my extended warranties. I’d like to share a little about my journey with you.Around the year 2002, I started seeing my PCP (Primary Care Physician) for terrible migraine headaches, which on occasions lasted for weeks. After several tests, she expressed her concerns. I had been spilling protein in my urine and my kidney function was showing some abnormalities. My PCP sent me to see a neurologist after several failed attempts to gain some type of reprieve from the nerve-racking headaches. My nephrologist confirmed my PCP’s diagnosis, and I had visits with the nephrologist every 6 months until they noticed a substantial change.“Ah, Mrs. Ragin, you’re in the beginning stage of End Stage Renal Disease”. Boom! (That hit me like a ton of bricks.) “Umm, you mean I have kidney failure! No! Not me. I’ve worked in dialysis. That can’t happen to me!”Of course, I was in complete denial. Both my PCP and nephrologist were very supportive mentally, physically, emotionally, and even spiritually. This information was so devastatingly painful that I started working harder and longer. I turned into a Superwoman with my family, work, and church. I was trying to drown out the fact that my health was being compromised, refusing to believe this could happen to me. I started to slow down in my daily functions, my appetite decreased, and I lost weight as a result. I thought that my weight loss was bringing my “Sexy Back,” only to realize that I am not exempt from sickness. My nephrologist assured me of a possible solution. He advised me to have my name placed on the waitlist of one of the transplant centers in Maryland.In October 2006, I had surgery to have an A/V fistula placed in my left arm to prepare for possible dialysis treatments in the future. In January 2007, I went to be evaluated for a kidney transplant. I was given 6 weeks to complete all required tests to secure a place on the transplant waiting list. Determination allowed me to complete all tests within 2 weeks.In April 2007, I was approved to be placed on the transplant list. In October, I had a PDC (Peritoneal Dialysis Catheter) placed in my abdomen so that I could dialyze myself at home. I loved it but it didn’t love me. It was removed in January 2008. Right afterward, I received my first unsuccessful call to be transplanted. (The kidneys were cystic and could not be used.) “Bummer.” I also received another call in April 2008 (Easter Sunday). Those kidneys were [End Page 134] at another hospital in Maryland, so if the waiting patient at their facility refused the kidney, I would be next in line. The patient accepted the donation. It wasn’t my turn yet.In the meantime, I had already started hemo-dialysis in mid-March 2008. On Saturday, June 21, 2008, while enjoying the weekend with my family, I received a call around 2:30 p.m. My youngest daughter and I were out shopping. We were in a crowded store that was going out of business, and I felt my phone vibrate. I noticed a slightly familiar number. I stepped out of the store to retrieve the call.“Mrs Ragin...Me: Yes.“Danette Ragin...Me: Yes.“We are calling from the University with an organ offer for you!”I told them they had me at the sight of the first few digits of the phone number they were calling from!In June... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Right Thing to DoJane RogersIn stark contrast to getting my graduate degree in bioethics in which I discovered that I am inclined to favor an ethics based on my religious beliefs, in nursing school I learned that I had to take my religion out of nursing care. As a bioethics student, I read in my textbook, Bioethics: A Systematic Approach, that “… just because an action is rationally (...) allowed does not mean that everyone agrees one ought to act in that way.” Yet often in nursing I found that we nurses knew what was best for our patients, even if they did not. At least, we believed that we did. This general paternalistic belief spread into every area of the care we gave except for one, and that was religion. [End Page 208]As student nurses, we learned to separate our religion from our care to focus on the patient’s religion or spiritual needs. Our patients should never know of our religious beliefs or even if we had a lack of them. We needed to be completely neutral on all religious issues and focus solely on the patient’s preference. If our patients needed spiritual care, we would find someone to provide it and we would incorporate it into the nursing plan of care. Providing care of the whole patient including their religious needs was the definition of a good nurse. Certainly I wanted to be a good nurse, so I swore I would always include the spiritual needs of my patients as part of my care, while never expressing my own.As fate would have it, as a new nurse I found myself overwhelmed running around just trying to give medications, admit and discharge patients, start IV’s, insert catheters, note doctor’s orders and get my charting done. My time was engaged in trying to calm confused and combative patients, running to grab an emesis basin for a patient to throw up in or answering the phone, so thinking about religion or spiritual care for my patients most of the time amounted to “God help me and my patients get through this shift.” My goal of being a good nurse was starting to look dismal as I realized I had no idea if I could find the time or means and ways to incorporate religion into the care I gave, or if it even mattered if I did.Fortuitously for me, most of my patients never mentioned religion, although at times they did leave some nonverbal clues. I could see a rosary laying on a bedside table or a bible or prayer book next to them in bed. While I would make sure their religious item was always within reach, I remained respectful yet distant in religious matters, never offering any spiritual care or assistance. I was quite accepting of my first Mormon patient wearing the garment under the traditional hospital gown. I was appalled when an unconscious Jehovah Witness patient was nearly given blood. When a minister or priest came to visit, I’d excuse myself quickly so that the work of their God could do what I could not or should not do. Occasionally I was asked by family members to call in a minister or a priest or chaplain and I did that with a great feeling of satisfaction as I was surely providing the spiritual care they requested.Eventually however I did start to indulge in highly spontaneous and random acts of religion. These were always done secretly. The patient or family must never know. Thinking it would help I once covertly gave a patient a special rosary I had with Lourdes water in it thinking it might heal him. I waited to see a miracle. It never came. Despite the absence of that miracle I was still hopeful that perhaps my prayers or another rosary could heal or at least help some of my patients. After all, as a nurse I witnessed lots of healings that astounded me. People I never thought would get better sometimes did anyway.Although I was cognizant that some healing was the direct result of superb medical intervention and excellent nursing care, there were always... (shrink)

Intravenous drug abusers may incur bloodstream infections, in particular those involving the heart valves, that often require extended courses of antibiotics, commonly on the order of six weeks.Conventional wisdom has dictated that even when patients are sufficiently well to not need ongoing hospitalization, it is unsafe to complete their antibiotic course in any setting other than in a closely supervised facility, even if this is contrary to their wishes. The assumption has been that such patients would be at risk of (...) using their indwelling intravenous catheter for illicit purposes. Recent advances in the care of patients who suffer from addiction disorders suggest that when patients receive state-of-the-art addiction treatment, many may be able to continue their intravenous antibiotic course unsupervised, at home. This represents a departure from the parentalistic model of care of impaired patients who are prone to self-harm, moving towards a model that respects autonomy and trusts patients who are in recovery to continue their care in a manner that is self-beneficial. (shrink)

An elderly patient in his early eighties is hospitalized in a long-term facility, with advanced Alzheimer disease. He is otherwise relatively strong and free from other life-threatening conditions, except for the fact that he has difficulties swallowing. After several episodes of acute aspiration pneumonia doctors prescribe “strict fast”: only hydration through an IV catheter should be administered during the night, in order to relieve the feeling of hunger, provide comfort, and stave off death. The patient is surrounded by a warm (...) and extremely close-knit Mediterranean family. His wife and six adult children take turns feeding him properly mixed food twice a day and prefer to take the risk of causing another... (shrink)

A number of recent articles attribute the origin of the use of cervical balloon dilation in the induction of labor to either Barnes in the 1860s or Embrey and Mollison in the 1960s. This review examines the historical record and reveals that, based on current practice attribution should rather be made to two contemporaries of Barnes: the Storer and Mattei. More importantly, Storer’s warning about the rubber used in dilators was ignored, leading to decades of possibly unnecessary deaths following childbirth. (...) To conduct this study key search terms for PubMed, Google Scholar and the website of the University of Ryerson were utilized as “Barnes”, “Woodman”, “balloon dilation”, “balloon catheter”, “foley”, “colpeurynter”, “cervix uteri” and “induction.” Subsequent analysis was done on downloaded articles using BibDesk. (shrink)

Bear bile has long been used in the Asian traditional pharmacopoeia. Bear farming first started in China ~30 years ago in terms of reducing the number of poached bears and ensuring the supply of bear bile. Approximately 13,000 bears are today captivated on Asia’s bear farms: their teeth are broken and the claws are also pulled out for the sake of human safety; the bears are imprisoned in squeeze cages for years; and a catheter is daily inserted into a bear’s (...) gall bladder or a tube is implanted inside its body in order to collect the dripped bile—captive bears moan in severe pain whenever the bile is extracted. When the bears cannot produce sufficient bile, they are often left to die of starvation. It must be impossible to justify the bile extraction from living bears because (1) medicinal/herbal alternatives are similar to bear bile; (2) there is no evidence to suggest that bear farming has any beneficial effects on wild bear populations; and (3) ethical problems lie not only in the painful bile extraction but also the whole lifecycle of captive bears. In conclusion, human welfare (health care) based on traditional medicine is upheld by sacrificing bear welfare. Since a trial calculation suggests that it is economically unfeasible to keep a proper balance between bear welfare and the traditional pharmacopeia, the cultivation of herbal alternatives seems to be a possible solution to phase out bear faming and maintain the practice of traditional medicine in Asia. (shrink)