Where the World Finds Bioethics Wed, 01 Jul 2015 01:13:23 +0000 en-US hourly 1 Professionalism in Medicine: I Know it When I See it Tue, 30 Jun 2015 22:56:20 +0000 by Jennifer Chevinsky, BS

A medical student comes into the hospital wearing his favorite pair of old, ripped, dirty jeans.

A physician ‘pimps’ a medical student and publicly shames her when she doesn’t know the answer.

A nurse tells the patient that he really does not like working with the case manager on the medical service.

A resident presents her patient to the attending, including a complete physical exam that she did not perform.

In recent years, increased focus has been placed on the concept of professionalism in medicine by the Association of American Medical Colleges (AAMC), Liaison Committee for Medical Education (LCME), Accreditation Council of Graduate Medical Education (ACGME), and Accreditation Council of Continuing Medical Education (ACCME).…

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Vanitas [EOL in Art 51] Tue, 30 Jun 2015 10:00:00 +0000 0 Estate Planning In the 21st Century: Seismic Shifts and Predictions for the Future – CFP Tue, 30 Jun 2015 10:00:00 +0000 0 Ethical Issues at the End of Life – CFP Tue, 30 Jun 2015 09:00:00 +0000 0 Jahi McMath – Children’s Hospital Demurrer Tue, 30 Jun 2015 01:28:00 +0000 0 Judge Strikes California Law that Allowed Nursing Homes to Make Medical Decisions for Unbefriended Residents Mon, 29 Jun 2015 13:21:00 +0000 I just updated my prior articles on decision making for adult orphans, unbefriended, unrepresented patients without surrogates (forthcoming 26(2) J Clinical Ethics).  And then this.

A California law allowing nursing homes to make medical decisions on behalf of certain mentally incompetent residents is unconstitutional, a state court ruled this week.

The law, which has been in effect more than 20 years, gave nursing homes authority to decide residents’ medical treatment if a doctor determined they were unable to do so and they had no one to represent them.

Alameda County Superior Court Judge Evelio M. Grillo wrote in the June 24 decision that the law violates patients’ due process rights because it doesn’t require nursing homes to notify patients they have been deemed incapacitated or to give them the chance to object.

Grillo acknowledged the decision is likely to “create problems” in how nursing home operate but wrote that patients’ rights are more compelling.

“The stakes are simply too high to hold otherwise,” the judge wrote. Any error could deprive patients of their rights to make medical decisions that “may result in significant consequences, including death.”

The medical decisions on incapacitated residents without representatives are made by a team that includes a physician and a nurse.

The fact that nursing homes are making end-of-life decisions without patient input is a big concern, according to the ruling. The decision cited one nursing home resident who was found to be mentally incapacitated and who had no representative. The facility staff made a decision to take him off life-sustaining treatment and he passed away in 2013.

The ruling came after the California Advocates for Nursing Home Reform, an advocacy group, filed a lawsuit in 2013 against the state Department of Public Health. The suit alleged that nursing homes used the law to administer anti-psychotic drugs, place residents in physical restraints and deny patients life-sustaining treatment.

Tony Chicotel, a staff attorney for the group, said the ruling will dramatically impact the lives of the most vulnerable nursing home residents.

“What [nursing homes] used to do was routinely make decisions big and small for their residents without really any regard to due process,” Chicotel said. “Now the residents are finally going to have their rights acknowledged and honored.”

Even patients who are compromised should still have a say in their medical care, he added.

“They have been ignored,” he said. “Unrepresented residents and the way they are treated in nursing homes has never been a priority of the Department of Public Health.”

The department is reviewing the decision, a spokesman said. Department officials declined to comment further or say whether they planned to appeal.

The law was enacted in 1992 because nursing facilities needed a way to give medical treatment to their incapacitated residents without having to wait up to six months for state approval, according to the ruling.

But the decision could make it challenging for nursing homes to provide routine medical care or to offer hospice care to residents who lack the mental capacity to make their own decisions and have no designated representatives, said Mark Reagan, an attorney representing the trade group, California Association of Health Facilities, which is not part of the lawsuit.

“If the person objects, then what?” Reagan said. “That can put patients and facilities in a difficult place.”

And seeking court approval to provide anti-psychotic medication to residents who truly need it would be costly and time-consuming for nursing facilities, he said. “How do you keep that person safe and how do you keep the other residents of the skilled nursing facility safe?” he said.

Reagan believes the ruling could have an unanticipated outcome: Patients without decision-makers could have a hard time finding a nursing facility willing to take them.

“If this decision makes it more difficult to supply necessary care at the bedside, this population is going to be less served,” he said.

The judge, however, wrote that informing patients and allowing them to object is not likely to result in any significant burdens on nursing homes.

Golden Gate University Law School Professor Mort Cohen, who filed the case, said the next step is for the judge to issue an order directing the state Department of Public Health, which oversees nursing homes statewide. The state could ask the court for a stay or could appeal the decision, but Cohen said he expects the decision to stick.

[From Kaiser Health News (KHN), a nonprofit national health policy news service.]]]> 0
iPhone App Will Track Sexual Activity and Reproduction Mon, 29 Jun 2015 10:06:00 +0000 0 Relics – Film on Assisted Death [EOL in Art 50] Mon, 29 Jun 2015 09:00:00 +0000 0 Support Informing Bioethics Policy Mon, 29 Jun 2015 08:30:00 +0000 0 Heartfelt – Photography of Troubled Births [EOL in Art 49] Sun, 28 Jun 2015 09:30:00 +0000 0 Art of Hospice [EOL in Art 48] Sat, 27 Jun 2015 08:00:00 +0000 0 PATIENT-CENTERED RESEARCH CAN IMPROVE CHRONIC PAIN CARE AND ADDRESS OPIOID ABUSE Fri, 26 Jun 2015 19:27:00 +0000 Going for the Brass RingLast year, Joe Selby, MD, executive director of the Patient-Centered Outcomes Research Institute (PCORI), spoke to members of the NIH Interagency Pain Research Coordinating Committee (PCORI) to inform those of us on the committee about PCORI’s intentions to do more funding focused on chronic pain research. Dr. Selby said their interests were possibly in low back pain, migraine, musculoskeletal pain, and/or opioid abuse. I was elated. Then about a month ago (May 14, 2015), Dr. Selby posted a blog on the PCORI website titled, “Patient-Centered Research Can Improve Chronic Pain Care and Address Opioid Abuse.” 

I hope with all my heart that he is right; research or policy that can do both of these things is like grabbing the brass ring while on a merry-go-round. It is certainly a worthy goal but, to many, seems all but impossible. If anybody can do this, however, PCORI may have the best chance. Established by the Patient Protection/Affordable Care Act in 2010, PCORI’s mission is to “examine the relative health outcomes, clinical effectiveness, and appropriateness of different medical treatments” – particularly complex problems that threaten the health and well-being of all Americans. Chronic pain certainly meets that criterion.

In Dr. Selby’s blog, he said, “Since 2012, PCORI has built a sizeable portfolio of studies on chronic pain, two of which specifically address opioid treatment.” He went on to list some of the questions these studies have focused on:

  • How can we improve patients’ ability to communicate confidently with doctors about pain and pain medication?
  • What approaches to care delivery can minimize health and safety risks when long-term opioid use is considered?
  • What collaborative-care approaches to pain can improve quality of life, patient satisfaction, and adherence to other treatments?
  • How can we encourage patients to join and stay enrolled in integrative treatment plans that show promise of reducing chronic pain while lowering risk for opioid abuse?

He also informed readers that, in June, PCORI would be hosting “multi-stakeholder workshops” to discuss whether comparative effectiveness research (CER) can be helpful in addressing these issues. 

The week before Dr. Selby posted his blog, I was pleased to receive a letter from him inviting the Pain Action Alliance to Implement a National Strategy (PAINS) to send four representatives to two workshops in Washington, DC – one focused on low back pain and the other on long-term use of opioids in the treatment of pain. We quickly accepted, and on the morning of June 8, two members of the PAINS team and two of our Citizen/Leaders (people living with chronic pain and/or family members caring for chronic pain sufferers) went to the airport excited about traveling to our nation’s Capitol and participating in these important discussions. After six hours at the airport and our second plane cancellation due to mechanical problems in Kansas City and bad weather in DC, I emailed our PCORI contact to tell him that we would not be coming to DC, and we headed home with heavy hearts. 

The next day, I tried to participate in the opioid workshop remotely, but technical difficulties that even their “help desk” didn’t seem to be able to overcome, made it all but impossible for me to do so. I must say, however, that I am grateful to one of the meeting participants and the facilitator of the “opioid workshop” for their extraordinary efforts to include me. I am also grateful that the next day the PCORI facilitator sent me the rank-ordered questions that emerged from the workshop and gave me permission to share them. They are very interesting, and can be seen at:

That afternoon I wrote to Dr. Selby to express our gratitude for PCORI’s interest in chronic pain and to explain to him why PAINS representatives were not at the workshops the day before. I said that it is our view that, “PCORI is essential to the ‘cultural transformation in the way pain is perceived, judged and treated’ called for in the IOM report, Relieving Pain in America, and echoed in the forthcoming National Pain Strategy Report.” I also invited him and/or others at PCORI who he would deem appropriate to visit Kansas City to meet with our team and PAINS’ Citizen/Leaders. I told him that our Citizen/Leader Group has met with and advised us for more than two years and that they have been enormously helpful. I encouraged him to activate the following link (and click the link there to the video, “The Faces of Pain”), so that he could meet some of these outstanding individuals:

I also suggested that these remarkable people and others like them could be very helpful to PCORI, in fact, I believe, essential, as they build out their pain portfolio. I also offered to arrange for us to come to DC if it was not possible for them to come to Kansas City.

The ambitious goal PCORI has set -- comparative effectiveness research that will improve chronic pain care and address opioid abuse -- will require the involvement of many stakeholders. The most important among those may well be people who struggle to live with chronic pain and family members who care for them day-after-day. PCORI’s very name implies that they understand that. I look forward to hearing from Dr. Selby and welcoming him and others to Kansas City. In the meantime, I can almost hear the calliope music on the merry-go-round.

By Myra J. Christopher

Myra J. Christopher is the Kathleen M. Foley Chair in Pain and Palliative Care at the Center for Practical Bioethics and Director of PAINS.

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Supreme Court Decision in King v Burwell: Backstory and Next Steps Fri, 26 Jun 2015 14:54:00 +0000 0 Hospice [EOL in Art 47] Fri, 26 Jun 2015 09:00:00 +0000 0 No Immunity for Providers Who Treated Patient Contrary to Her Advance Directive Fri, 26 Jun 2015 08:30:00 +0000 0 Pluralism, Futility, and Thresholds for Treatment in Intensive Care Fri, 26 Jun 2015 07:00:00 +0000 0 SCOTUS Has Ruled on Obamacare. So What’s Next? Thu, 25 Jun 2015 19:11:22 +0000 In a 6-3 decision, the Supreme Court Thursday spared the Affordable Care Act from what would have been a death blow. The Court’s action upholds the right of the federal government to subsidize low-income Americans who purchase health insurance through … Continue reading

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Mandatory Vaccinations??? Thu, 25 Jun 2015 18:36:51 +0000 ]]> 0 What Physicians Can Learn from Veterinarians Thu, 25 Jun 2015 15:03:13 +0000 A while back, I linked to a story by Rebecca Plevin, out of California Public Radio, on the challenge of discussing health care costs.  Well, she has tuned up that piece and placed it on Marketplace. Here is a print … Continue reading

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Hospice Stamp [EOL in Art 46] Thu, 25 Jun 2015 09:00:00 +0000 In 1999, the U.S. Postal Service issued the Hospice Care Commerative Stamp to help raise awareness about hospice.

The stamp was designed by veteran stamp designer Phil Jordan to symbolize life’s journey to its final stage, the stage where Hospice lends its vision for end-of-life care.  The Hospice stamp features a large green field in front and a tree beside a while house, with a large yellow and red butterfly flying above. 

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SNF Fined $400,000 for Blindly Following the Surrogate Thu, 25 Jun 2015 08:00:00 +0000 Earlier this week, I wrote about a recent CMS investigation in which a hospital wrongly looked to a surrogate even though the patient still had capacity to make her own healthcare decisions.  Today, I summarize a similar case from the DHHS Departmental Appeals Board in which the facility was fine nearly $400,000.

NMS Healthcare of Hagerstown is a skilled nursing facility.  It confined one of its residents and restricted her access to members of her family and others.  NMS did this at the request of the resident's daughter even though there was no medical or other basis for doing so.

The ALJ observed:  "A skilled nursing facility is not excused of its obligations to provide care by the fact that a resident or someone on the resident’s behalf demands that the facility provide a certain type or level of care. The regulations governing skilled nursing facilities do not allow facilities to abdicate their responsibilities to residents in order to cater to the whims of residents’ family members, whether or not they have POAs."

"Moreover, a facility is not inherently a neutral arbiter. There can be a conflict of interest between a facility and its resident. . . . Resident # 4 generated a steady stream of revenue to Petitioner . . . .  Given that potential conflict of interest it was incumbent on Petitioner to be scrupulously neutral in dealing with the resident. Simply going along with JF’s wishes in this case – without independently assessing the resident to determine whether confining her and restricting her access to visitors was appropriate – was anything but neutral."

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Aid in Dying – Minnesota Wed, 24 Jun 2015 20:54:00 +0000 0 Your New Liver Is Only A Learjet Away: First Of Three Parts Wed, 24 Jun 2015 17:33:38 +0000 The forty million dollar Gulfstream jet landed at Memphis International airport in the early morning hours, its schedule hastily arranged earlier that day from Northern California, where the flight originated. Waiting on the tarmac was Dr. James Eason, head of … Continue reading

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New Primer for Researchers on Neuroscience and Consent Capacity Now Available Wed, 24 Jun 2015 16:20:35 +0000 0 Bioethics and Gnosticism Wed, 24 Jun 2015 15:23:30 +0000 Read More »]]> 0 Rats Have Empathy, But What About the Scientists Who Experiment on Them? Wed, 24 Jun 2015 14:54:00 +0000 Alka Chandna]]> 0 Process of Dying in 6 Paintings [EOL in Art 45] Wed, 24 Jun 2015 09:00:00 +0000 0 Considering best care for extremely premature babies Wed, 24 Jun 2015 00:05:24 +0000 Read More »]]> 0 Jahi McMath Malpractice Lawsuit – June 2015 Update Tue, 23 Jun 2015 19:13:00 +0000 0 Time and Death [EOL in Art 44] Tue, 23 Jun 2015 10:00:00 +0000 0 NIH Emeritus Grant: Letting in the New Crop and Kicking the Old Out Tue, 23 Jun 2015 09:06:01 +0000 0 The Issue of Physician Motive in Physician-Assisted Suicide Tue, 23 Jun 2015 01:45:50 +0000 Read More »]]> 0 Aid in Dying – Minnesota Public Radio Mon, 22 Jun 2015 22:25:00 +0000 0 At Long Last: FDA Changes the Law for Hemochromatosis Mon, 22 Jun 2015 21:19:19 +0000 by Arthur Caplan, Ph.D.

Summer in the U.S. is known for many things—time at the beach, picnics, baseball, thunderstorms, vacations and ice cream. Sadly, it is also known by hospitals as the season when blood is in short supply. Schools and businesses close making blood drives harder. Frequent donors go away leaving blood and blood products in their communities in short supply. That is why a recent hard-fought breakthrough as to who can donate blood deserves much more attention and recognition than it has received which, if Google is to be believed, to date has been exactly nothing.…

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Death Listens [EOL in Art 43] Mon, 22 Jun 2015 09:30:00 +0000 0 Atul Gawande in Minnesota (Sept. 18, 2015) Mon, 22 Jun 2015 09:00:00 +0000 0 Do Not Look to the Surrogate If the Patient Still Has Capacity Mon, 22 Jun 2015 09:00:00 +0000 0 Reflections on Father’s Day from a “Single” Mother Mon, 22 Jun 2015 05:02:29 +0000 by Nanette Elster, JD, MPH

Today on Father’s Day, as I miss my own father who has been gone for 17 years now, I am reflecting on my decision to intentionally become a single mother. I think about all of the ways my father shaped the woman I am today and how he is the one who gave me the courage to become a mother with or without a husband or partner. He is the one who gave me career advice, dating advice, took me to get my first prom dress (and even my first bra).…

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Letter Remained Unfinished [EOL in Art 42] Sun, 21 Jun 2015 09:00:00 +0000 0 Ontario Medical Board Cautions Physicians for Writing Unilateral DNR Order (Wawrzyniak v. Chapman & Livingstone) Sun, 21 Jun 2015 08:30:00 +0000 0 ASBH Annual Meeting (October 2015) Sat, 20 Jun 2015 21:24:00 +0000 0 Hospital Sanctioned for Patients Lacking POLST Sat, 20 Jun 2015 10:00:00 +0000 0 Fin – by Kotarbinski [EOL in Art 41] Sat, 20 Jun 2015 08:30:00 +0000 0 Ethics of Artificial Intelligence Fri, 19 Jun 2015 23:06:40 +0000 Read More »]]> 0 Savulescu on Rationing in the NICU Fri, 19 Jun 2015 09:00:00 +0000 0 Cleaning Corpses during an Epidemic [EOL in Art 40] Fri, 19 Jun 2015 08:30:00 +0000 0 Bioethics Commission Urges Neuroscientists to Participate in Legal Processes, and Cautions Against Hype Thu, 18 Jun 2015 15:59:33 +0000 0 Critically Impaired Infants and End of Life Decision Making: Resource Allocation and Difficult Decisions Thu, 18 Jun 2015 09:00:00 +0000 0 Death is a Woman [EOL in Art 39] Thu, 18 Jun 2015 08:30:00 +0000 0 Does Clinical Ethics Consultation Lend Itself to Professionalization? Thu, 18 Jun 2015 02:06:02 +0000 0