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Blog Posts (2407)

September 26, 2015

Implementing Rasouli - CPSO Says Ontario Physicians Must Obtain Consent to Stop Life-Sustaining Treatment

Two weeks ago, the Ontario College of Physicians and Surgeons gave final approval to its Planning for and Providing Quality End-of-Life Care policy.  

Section 5.2 concerns "Potentially Life-Saving and Life-Sustaining Treatment."  Three paragraphs are of note:

"A decision regarding a no-CPR order cannot be made unilaterally by the physician. Where a physician is of the opinion that CPR should not be provided for a patient and that a no-CPR order should be written in the patient’s record, the College requires physicians to discuss this with the patient and/or substitute decision-maker at the earliest and most appropriate opportunity, and to explain why CPR is not being proposed. This discussion must occur before a no-CPR order can be written."

"If the patient or substitute decision-maker disagrees and insists that CPR be provided, physicians must engage in the conflict resolution process as outlined in Section 8 of this policy which may include an application to the Consent and Capacity Board. Physicians must allow the patient or substitute decision-maker a reasonable amount of time to disagree before a no-CPR order can be written."

"While the conflict resolution process is underway, if an event requiring CPR occurs, physicians must provide CPR. In so doing, physicians must act in good faith and use their professional judgment to determine how long to continue providing CPR."

Over at the Healthcare Consent Quality Collaborative, they are "scratching their heads trying to make sense of the actions that are now required of Ontario physicians."  In particular, the final paragraph instructs physicians to "begin CPR (i.e. disregard their clinical judgment about the ineffectiveness of such an action), but then only provide CPR for a period of time considered appropriate by use of the same professional judgment."

September 26, 2015

"Peter and Anne Snell" [EOL in Art 138]

This is "Peter and Anne Snell" by Antonia Rolls. "Peter asked to be included in the exhibition but did not live to see this painting.  His wife Anne loved him to the end."
September 25, 2015

Beyond the Rant: Negotiating the (Ethical) Costs of Care for Patients, Payers and Hospitals

Beyond the Rant: Negotiating the (Ethical) Costs of Care for Patients, Payers and Hospitals 

October 5, 2015
1:00 – 4:00 pm

Wilf Auditorium
University of Minnesota Masonic Children’s Hospital
2450 Riverside Ave
Minneapolis, MN, 55454 

3 Contact Hours
No registration required

September 25, 2015

Want to Pay Higher Prices? Try a For-Profit Hospital!

If she had been eligible for Medicare, the hospital would have charged the government $10,000 for the services it provided to her, with Medicare picking up most of the tab. But lacking insurance, she was billed directly from the hospital, … Continue reading

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September 25, 2015

Near the End, It’s Best to Be ‘Friended’

Elizabeth Evans, 88, needs to decide who will be her health care proxy if she becomes ill. Check out Paula Span's cleverly titled article in today's New York Times. It covers the growing yet under-addressed problem of incapacitated patien...
September 25, 2015

"Dancing Steve Out Of Life" [EOL in Art 137]

This is "Dancing Steve Out Of Life" by Antonia Rolls.   "An image I painted of what was happening to us, when Steve was so ill.  He loved this image and kept it by his bed."
September 25, 2015

Goals of Care: Driver of Shared Decision Making

When the Harvard Business Review (HBR) and the Journal of the American Medical Association (JAMA) both publish articles in the same week on virtually the same topic by two distinctive and veteran experts in the country, it becomes a must-read opportunity – for those within and outside healthcare. 

Missing Metrics

The importance of focusing on the PATIENT’s goals of care directs provider attention to one of the most critical but overlooked challenges faced by families dealing with advanced illness. Both authors speak to our need to integrate personal “Goals of Care” as defined, experienced and articulated by the patient and family into the care planning process – not just as a component of shared decision making – but the driver of it. For those dealing with advanced chronic and progressive disease, patients’ values and preferences regarding independence, functional status and quality of life should be PRIMARY considerations in establishing the care plan. Sadly though, both experts shared how sorely lacking adequate resources, tools and metrics are to professionals in helping measure outcomes for this oft-over-medicalized legion of vulnerable patients.

Diane Meier, MD, director of the Center for the Advancement of Palliative Care, writing in HBR put it this way: that we should “start by asking patients and their families what matters to them, not focusing on the disease alone. We recognize that for patients with serious, progressive (usually chronic) conditions, as their illness evolves, what matters to them and their families also changes.”

In her HBR piece, entitled “Measuring Quality Care for the Sickest Patients,” she laments that we are not invested in the “the science of quality measurement...enough to measure what matters most to these patients,…because we don’t yet know how to allocate resources to achieve patients’ care-related goals.” Mind you now, the U.S. spends multiple times over what other developed counties do on health care, but it seems our investments are directed at highly technical and invasive therapies rather than those that are more palliative in nature and socially responsive – for a group of folks who can gain little from attempts at rescue medicine and aggressive measures.

Dr. Joanne Lynn’s Viewpoint piece in JAMA, entitled “Value-based Payments Require Valuing What Matters Most to Patients” describes her position as follows: Paying for value “requires measuring what actually matters to patients.” She continued, stating that almost all current quality metrics reflect professional standards, which is a good thing, but called out the shortcomings of professional standards for those living with “serious, life-altering, and ultimately life-ending chronic conditions because traditional professional standards may not effectively address what an individual most wants.”

Call to Action for Consumers and Families

Both Lynn and Meier propose a series of “shoulds” that clinicians, researchers, systems and payers ought to be considering to address the structural deficiencies and quality measures our most fragile patients need. I applaud them both for their insightful prescriptions and tactical  recommendations. Professionals of all disciplines should heed their wise counsel. 

My focus, however, remains a bit more patient directed. It is time for us as consumers and family members to take our “shared decision making” obligations more seriously and begin engaging in the kinds of conversations that will assist those clinicians in clearly understanding what kinds of goals they should be matching with those “patient preferences.” 

Get hold of a Caring Conversations® workbook, flip through our Conversations starter booklet®. We, as patients and families, have to do our part in reducing the burden of providers in feeling their way about what we want most. This is our job as much as it is theirs, and we owe it our loved ones to clearly articulate the values that point to the right set of goals that should be adopted, measured and achieved.

John G. Carney is the president and CEO of the Center for Practical Bioethics. In 2008 he served as one of the co-authors in a Report to Congress on Advance Care Planning.
September 25, 2015

A Modest Proposal to Solve the Physician-Assisted Suicide Debate

Yesterday’s Chicago Tribune carries an editorial by Steve Chapman entitled “The Case for the ‘right to die.’” Aside from missing the central point of the whole question, Chapman does a creditable job of marshalling arguments and bioethicists to support his support for physician-assisted suicide. However, he does neglect the central point, which, of course, is that doctors do not and should not kill — including not giving... // Read More »
September 25, 2015

Publishing Research Ideas

<p><span style="font-size: 11.2px; line-height: 19.04px;">The newest science journal on the block with several unique twists is <a href="">Research Ideas and Outcomes</a> (RIO). RIO aims to publish a variety of outputs in the research cycle, not only the results of research. The journal will publish papers on ideas, proposals, methods, research results, and software. They also publish review articles, opinion pieces, data papers, software descriptions, workflows, data management plans, conference abstracts, single figure publications, project reports and much more. Their aim is to better use the efforts scientists spend on writing and evaluating research proposals and other products within the research cycle. RIO does have limits; they will not accept teaching lectures or materials, clinical trials, patient or other data that may be considered unethical, homeopathy, nuclear or bioweapons research, creationist or religiously motivated research, cryptozoology, and pseudoscience. The journal also has many other interesting aspects. While they are an open access journal, unlike others, they do not charge the typical high costs of thousands of dollars. The journal charges between 50 to a few hundred euros for most types of publications. Peer review is also optional and RIO relies on public scrutiny to promote transparent and public peer review. Expert driven peer review, typically done in most medical and science journals, however, can be done upon the author’s request. The typical review process for papers submitted to RIO includes several technical checks and an external pre-submission review from a colleague.</span></p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.04px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong></p>
September 25, 2015

A bit more about “3-parent babies”

It is reported that the UK’s Human Fertilisation and Embryology Authority (HFEA) issued guidelines last week to govern the practice of mitochondrial transfer, which the UK government approved in February.  In this case, the term “mitochondrial transfer” refers to any of several possible techniques that could be used to allow women with certain rare but debilitating diseases of the mitochondria—the “energy factories” of the cell—to... // Read More »