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Author Archive: Maurice Bernstein, M.D.

About Maurice Bernstein, M.D.

11/12/2017

Medical Advance Directive: An Emphatic "NO!" to Dementia




Norman Cantor, a lawyer and Professor of Law at Rutgers University School of Law wrote a thoughtful article about the medical Advance Directive in the Harvard Law School "Bill of Health" blog


and explaining why he is revising his own medical Advance Directive to instruct his physicians and caretakers to allow him to die if he had developed a dementia "upon reaching a degree of permanent mental dysfunction that I deem to be intolerably demeaning.  For me, this means mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook"


Read his entire presentation at the Harvard Law blog link above and then return to present your views on adding profound mental deterioration to the list of physical illnesses which are irreversible and can be highly distressful to the patient and his family's lives and which he does not want to experience or have his family experience further and if he should face a treatable but serious life threatening condition, he should be allowed to die.


Hopefully, all of my blog readers have their own medical Advance Directive written to designate  a  surrogate to attend to their wishes for treatment of a potentially fatal illness when it occurs. If not, as your physician moderator of this bioethics blog, I would strongly recommend it be created and available for your physicians later to read and observe your directive.


  With Professor Cantor's permission, his Revised Advance Directive is reproduced below. ..Maurice..                                                       
My Revised Advance Directive

     I have witnessed the ravages that Alzheimer's disease and similar progressive dementias produce.  I wish to be allowed to die upon reaching a degree of permanent mental dysfunction that I deem to be intolerably demeaning.  For me, this means mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook.       

     This wish to hasten my post-competence demise is not based on prospective suffering or distress, but rather on my personal vision of intolerable indignity and degradation associated with cognitive dysfunction.  For me, it is critical to shape the post-mortem recollections of my loved ones and to preserve the lifetime image as a vital, critically thinking individual that I have strived to cultivate.  In addition, it is important to me to avoid being an emotional, physical, or financial burden on my family and friends, even if they would willingly assume such burdens. 

    I fully understand that my determination to avoid prolonged, progressive debilitation could prompt my demise even though I might appear content in my debilitated condition.  I am exercising my prerogatives of self-determination and bodily integrity to shape my lifetime narrative, including my dying process, in accord with my strong aversions to mental dysfunction and to dependence on others. 

     My determination not to prolong my life at the described point of debilitation includes rejection of any and all life-sustaining means.  This includes simplistic medical interventions such as antibiotics, blood transfusions, and antiarrythmics, as well as more complex interventions like CPR, mechanical ventilation, dialysis, and artificial nutrition and hydration.  Indeed, if my dementia or any other affliction has produced inability or unwillingness to feed myself – for example, because of swallowing difficulties, or other eating disorders, or just indifference to eating -- I instruct that my caregivers refrain from hand feeding unless I appear receptive to eating and drinking (show signs of enjoyment or positive anticipation).  If I am indifferent or resistant to hand feeding, I do not want to be cajoled, harassed, or in any way impelled to eat or drink.   

     The only limitation on my advance rejection of life-sustaining medical intervention is adherence to humane treatment.  That is, I have no desire to subject my future incompetent persona to a torturous or agonizing dying process.  I presume that palliative steps -- including medication for pain, anxiety, or agitation -- will be taken to ease my dying process. 


     The question may arise as to whether I have had a change of mind and revoked my advance directive.  My wish is that no revocation be found unless I do so while still capable of a considered choice, including appreciation of all the major elements involved.  I urge my decision-making agents to avoid the temptation of manipulating my future, incompetent persona to contradict or alter my advance instructions.  And I direct that my original instructions be honored absent an aware, considered change of mind (as opposed to uncomprehending expressions by my demented persona). 


Graphic: Through Google Images. "5th Dementia"PAINTING BY JEFF BOWERING Saatchi Art

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

11/12/2017

Medical Advance Directive: An Emphatic "NO!" to Dementia




Norman Cantor, a lawyer and Professor of Law at Rutgers University School of Law wrote a thoughtful article about the medical Advance Directive in the Harvard Law School "Bill of Health" blog


and explaining why he is revising his own medical Advance Directive to instruct his physicians and caretakers to allow him to die if he had developed a dementia "upon reaching a degree of permanent mental dysfunction that I deem to be intolerably demeaning.  For me, this means mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook"


Read his entire presentation at the Harvard Law blog link above and then return to present your views on adding profound mental deterioration to the list of physical illnesses which are irreversible and can be highly distressful to the patient and his family's lives and which he does not want to experience or have his family experience further and if he should face a treatable but serious life threatening condition, he should be allowed to die.


Hopefully, all of my blog readers have their own medical Advance Directive written to designate  a  surrogate to attend to their wishes for treatment of a potentially fatal illness when it occurs. If not, as your physician moderator of this bioethics blog, I would strongly recommend it be created and available for your physicians later to read and observe your directive.


  With Professor Cantor's permission, his Revised Advance Directive is reproduced below. ..Maurice..                                                       
My Revised Advance Directive

     I have witnessed the ravages that Alzheimer's disease and similar progressive dementias produce.  I wish to be allowed to die upon reaching a degree of permanent mental dysfunction that I deem to be intolerably demeaning.  For me, this means mental deterioration to a point when I can no longer read and understand written material such as a newspaper or financial records such as a checkbook.       

     This wish to hasten my post-competence demise is not based on prospective suffering or distress, but rather on my personal vision of intolerable indignity and degradation associated with cognitive dysfunction.  For me, it is critical to shape the post-mortem recollections of my loved ones and to preserve the lifetime image as a vital, critically thinking individual that I have strived to cultivate.  In addition, it is important to me to avoid being an emotional, physical, or financial burden on my family and friends, even if they would willingly assume such burdens. 

    I fully understand that my determination to avoid prolonged, progressive debilitation could prompt my demise even though I might appear content in my debilitated condition.  I am exercising my prerogatives of self-determination and bodily integrity to shape my lifetime narrative, including my dying process, in accord with my strong aversions to mental dysfunction and to dependence on others. 

     My determination not to prolong my life at the described point of debilitation includes rejection of any and all life-sustaining means.  This includes simplistic medical interventions such as antibiotics, blood transfusions, and antiarrythmics, as well as more complex interventions like CPR, mechanical ventilation, dialysis, and artificial nutrition and hydration.  Indeed, if my dementia or any other affliction has produced inability or unwillingness to feed myself – for example, because of swallowing difficulties, or other eating disorders, or just indifference to eating -- I instruct that my caregivers refrain from hand feeding unless I appear receptive to eating and drinking (show signs of enjoyment or positive anticipation).  If I am indifferent or resistant to hand feeding, I do not want to be cajoled, harassed, or in any way impelled to eat or drink.   

     The only limitation on my advance rejection of life-sustaining medical intervention is adherence to humane treatment.  That is, I have no desire to subject my future incompetent persona to a torturous or agonizing dying process.  I presume that palliative steps -- including medication for pain, anxiety, or agitation -- will be taken to ease my dying process. 


     The question may arise as to whether I have had a change of mind and revoked my advance directive.  My wish is that no revocation be found unless I do so while still capable of a considered choice, including appreciation of all the major elements involved.  I urge my decision-making agents to avoid the temptation of manipulating my future, incompetent persona to contradict or alter my advance instructions.  And I direct that my original instructions be honored absent an aware, considered change of mind (as opposed to uncomprehending expressions by my demented persona). 


Graphic: Through Google Images. "5th Dementia"PAINTING BY JEFF BOWERING Saatchi Art

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

10/20/2017

Patient Modesty: Volume 82







I think that the above image and words sets the tone of the conversation regarding male physical modesty issues which form most of the conversation currently on the Patient Modesty thread.
Thanks  to Alternative Press via Google Images for the graphic for this Volume.





Continuing on with the Comments, here is the last one as of the time of creating this new Volume and it is by AB who professionally appears to know much of the ins and outs of the medical system. ..Maurice.


At Friday, October 20, 2017 2:41:00 PMAnonymous Anonymous said...
I cannot speak knowledgeably on the distribution of genders in hired medical scribes. It is my impression both male & females are hired to be scribes. At my old medical center, in the emergency department we hired scribes to assist the ED physicians but there was no requirement they only be female. This was the only location where we allowed scribes. Nationwide I don’t know if there is a trend toward one sex or another for scribes, I don’t think there is.

Medical assistants in private practices and clinics is more sinister matter. MAs assisting as a chaperone, for example, always mean the physicians/NP/PA is also present with the chaperone/MA when the patient is naked. As such there should be ZERO reluctance to hire males to perform this duty, if medicine is gender neutral and patients have no preferences (which of course we know is not true for BOTH sexes). The “risk management” issues of a male being alone with an unclothed female are removed in the chaperone situation. Most of the other MA duties in clinics, say a Dermatology clinic, never involve the MA being alone with a naked patient (the physician is always present, at least). (Urology is a special situation which I’m omitting admittedly). So again, no “risk” barrier to hiring male medical assistants in such clinics. But unless others can provide evidence to the contrary it is my personal experience and impression physicians and clinics almost always hire female medical assistants if they will be in attendance with naked patients. Its way more than just happenstance - it is a preference for most physicians. So the question is why is there this preference?

Reasons include 1) the belief men are NOT entitled to the same or any bodily privacy respect as are women (see recent articles above on how its okay for the whole department to view male genitalia), 2) the belief female MAs will not be as great a “risk” as male MAs, 3) physicians can and DO pay females less than they would males, so they can save $ by not hiring males. I think all of these are contributing factors, but they all hinge on #1 being valid and enforceable.

Finally, a comment on the naked Dermatology exam. Standing naked for 10 minutes while the Dermatologist examines every square inch, possibly with a “scribe”/“chaperone” present is a really poor medical practice. There is NO medical reason a patient should be made to remain naked for the entire exam. If that were true every physical exam one got would require being totally naked the whole time. Its absurd. Dermatology needs to modernize and stop their archaic practice that violates basic bodily privacy considerations. All patients need to speak up about practices that make them uncomfortable. And you do NOT have to agree to the presence of an observer/scribe/chaperone. That is your decision. The physician will tell you if she/he feels comfortable performing the exam without their chaperone present. You are paying for this service. —AB

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

10/20/2017

Patient Modesty: Volume 82







I think that the above image and words sets the tone of the conversation regarding male physical modesty issues which form most of the conversation currently on the Patient Modesty thread.
Thanks  to Alternative Press via Google Images for the graphic for this Volume.





Continuing on with the Comments, here is the last one as of the time of creating this new Volume and it is by AB who professionally appears to know much of the ins and outs of the medical system. ..Maurice.


At Friday, October 20, 2017 2:41:00 PMAnonymous Anonymous said...
I cannot speak knowledgeably on the distribution of genders in hired medical scribes. It is my impression both male & females are hired to be scribes. At my old medical center, in the emergency department we hired scribes to assist the ED physicians but there was no requirement they only be female. This was the only location where we allowed scribes. Nationwide I don’t know if there is a trend toward one sex or another for scribes, I don’t think there is.

Medical assistants in private practices and clinics is more sinister matter. MAs assisting as a chaperone, for example, always mean the physicians/NP/PA is also present with the chaperone/MA when the patient is naked. As such there should be ZERO reluctance to hire males to perform this duty, if medicine is gender neutral and patients have no preferences (which of course we know is not true for BOTH sexes). The “risk management” issues of a male being alone with an unclothed female are removed in the chaperone situation. Most of the other MA duties in clinics, say a Dermatology clinic, never involve the MA being alone with a naked patient (the physician is always present, at least). (Urology is a special situation which I’m omitting admittedly). So again, no “risk” barrier to hiring male medical assistants in such clinics. But unless others can provide evidence to the contrary it is my personal experience and impression physicians and clinics almost always hire female medical assistants if they will be in attendance with naked patients. Its way more than just happenstance - it is a preference for most physicians. So the question is why is there this preference?

Reasons include 1) the belief men are NOT entitled to the same or any bodily privacy respect as are women (see recent articles above on how its okay for the whole department to view male genitalia), 2) the belief female MAs will not be as great a “risk” as male MAs, 3) physicians can and DO pay females less than they would males, so they can save $ by not hiring males. I think all of these are contributing factors, but they all hinge on #1 being valid and enforceable.

Finally, a comment on the naked Dermatology exam. Standing naked for 10 minutes while the Dermatologist examines every square inch, possibly with a “scribe”/“chaperone” present is a really poor medical practice. There is NO medical reason a patient should be made to remain naked for the entire exam. If that were true every physical exam one got would require being totally naked the whole time. Its absurd. Dermatology needs to modernize and stop their archaic practice that violates basic bodily privacy considerations. All patients need to speak up about practices that make them uncomfortable. And you do NOT have to agree to the presence of an observer/scribe/chaperone. That is your decision. The physician will tell you if she/he feels comfortable performing the exam without their chaperone present. You are paying for this service. —AB

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

08/26/2017

Patient Modesty: Volume 81

To make the necessary changes in the medical system's duty to provide gender equality to the personal and intimate concerns of all patients, perhaps what is needed is that both genders stand together to achieve that goal. ..Maurice.Graphic: Google Imag...

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

08/26/2017

Patient Modesty: Volume 81

To make the necessary changes in the medical system's duty to provide gender equality to the personal and intimate concerns of all patients, perhaps what is needed is that both genders stand together to achieve that goal. ..Maurice.Graphic: Google Imag...

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

07/02/2017

Patient Modesty: Volume 80

This Volume's graphic is another example of an attempt to "speak up" when informing the  medical profession of the patient's desires for attention of the system to the patient's modesty and dignity issues. (Thanks to Readers Digest. u.k. via Googl...

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

07/02/2017

Patient Modesty: Volume 80

This Volume's graphic is another example of an attempt to "speak up" when informing the  medical profession of the patient's desires for attention of the system to the patient's modesty and dignity issues. (Thanks to Readers Digest. u.k. via Googl...

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

05/31/2017

Who is the Father?: Sperm Donor Identification


  




The issue is whether the donor of sperm obtained via a sperm bank should be identified even though the donor provided the specimen with the understanding of anonymity?
The following are stories of how through current public accessibility to  DNA identification resources anonymity of the "father" is no longer guaranteed. There is an example of this accessibility in a 2010 issue of Slate and a more current example as presented in the Netherland's Dutch News.

Providing sperm to a sperm bank is of monetary significance to both the donor and finally for the bank itself and the "donation" is still considered a needed action by society. Despite the potential with public-accessible technology and investigations as noted in the two above articles,  should the utilization of the sperm for fertilization continue to permit anonymity of the source?  Well, if the goal is to encourage further donations then a recent study in the journal "Law and the Biosciences" regarding loss of anonymity suggest a problem in procurement as outlined in the Abstract of the article.

Most sperm donation that occurs in the USA proceeds through anonymous donation. While some clinics make the identity of the sperm donor available to a donor-conceived child at age 18 as part of ‘open identification’ or ‘identity release programs,’ no US law requires clinics to do so, and the majority of individuals do not use these programs. By contrast, in many parts of the world, there have been significant legislative initiatives requiring that sperm donor identities be made available to children after a certain age (typically when the child turns 18). One major concern with prohibiting anonymous sperm donation has been that the number of willing sperm donors will decrease leading to shortages, as have been experienced in some of the countries that have prohibited sperm donor anonymity. One possible solution, suggested by prior work, would be to pay current anonymous sperm donors more per donation to continue to donate when their anonymity is removed. Using a unique sample of current anonymous and open identity sperm donors from a large sperm bank in the USA, we test that approach. As far as we know, this is the first attempt to examine what would happen if the USA adopted a prohibition on anonymous sperm donation that used the most ecologically valid population, current sperm donors. We find that 29% of current anonymous sperm donors in the sample would refuse to donate if the law changed such that they were required to put their names in a registry available to donor-conceived children at age 18. When we look at the remaining sperm donors who would be willing to participate, we find that they would demand an additional $60 per donation (using our preferred specification). We also discuss the ramifications for the industry.

    So the question to my visitors is whether the sperm donor should be identified by the sperm bank or attempted, if undisclosed, with current available resources to the public? What is the implication of that decision on the future of the created child, the family, the donor and the whole banking system itself? Is identification what society wants and needs? If lawful will it be ethical? And what role might religion and sociology and medicine play in any decision?  It would be interesting to read what my visitors think.  ..Maurice.

Graphic: From Google Images.

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.

05/31/2017

Who is the Father?: Sperm Donor Identification


  




The issue is whether the donor of sperm obtained via a sperm bank should be identified even though the donor provided the specimen with the understanding of anonymity?
The following are stories of how through current public accessibility to  DNA identification resources anonymity of the "father" is no longer guaranteed. There is an example of this accessibility in a 2010 issue of Slate and a more current example as presented in the Netherland's Dutch News.

Providing sperm to a sperm bank is of monetary significance to both the donor and finally for the bank itself and the "donation" is still considered a needed action by society. Despite the potential with public-accessible technology and investigations as noted in the two above articles,  should the utilization of the sperm for fertilization continue to permit anonymity of the source?  Well, if the goal is to encourage further donations then a recent study in the journal "Law and the Biosciences" regarding loss of anonymity suggest a problem in procurement as outlined in the Abstract of the article.

Most sperm donation that occurs in the USA proceeds through anonymous donation. While some clinics make the identity of the sperm donor available to a donor-conceived child at age 18 as part of ‘open identification’ or ‘identity release programs,’ no US law requires clinics to do so, and the majority of individuals do not use these programs. By contrast, in many parts of the world, there have been significant legislative initiatives requiring that sperm donor identities be made available to children after a certain age (typically when the child turns 18). One major concern with prohibiting anonymous sperm donation has been that the number of willing sperm donors will decrease leading to shortages, as have been experienced in some of the countries that have prohibited sperm donor anonymity. One possible solution, suggested by prior work, would be to pay current anonymous sperm donors more per donation to continue to donate when their anonymity is removed. Using a unique sample of current anonymous and open identity sperm donors from a large sperm bank in the USA, we test that approach. As far as we know, this is the first attempt to examine what would happen if the USA adopted a prohibition on anonymous sperm donation that used the most ecologically valid population, current sperm donors. We find that 29% of current anonymous sperm donors in the sample would refuse to donate if the law changed such that they were required to put their names in a registry available to donor-conceived children at age 18. When we look at the remaining sperm donors who would be willing to participate, we find that they would demand an additional $60 per donation (using our preferred specification). We also discuss the ramifications for the industry.

    So the question to my visitors is whether the sperm donor should be identified by the sperm bank or attempted, if undisclosed, with current available resources to the public? What is the implication of that decision on the future of the created child, the family, the donor and the whole banking system itself? Is identification what society wants and needs? If lawful will it be ethical? And what role might religion and sociology and medicine play in any decision?  It would be interesting to read what my visitors think.  ..Maurice.

Graphic: From Google Images.

Full Article

This entry was posted in Health Care and tagged . Posted by Maurice Bernstein, M.D.. Bookmark the permalink.