Search PubMed⌕ Search

Biomedical subjects

C A Marco

Publications and source records attributed to C A Marco.

At least 19 recordsLinked to original sources
PubMed2005

Ethical issues of resuscitation: an American perspective.

Challenging issues confront emergency physicians routinely when performing cardiopulmonary resuscitation. Ethical issues surrounding resuscitation may include issues of futility, withholding or withdrawing interventions, advance directives, family presence, practising procedures on the newly dead, palliative care, and communication. Principles of bioethics can be valuable in assessing and debating ethical dilemmas. In many cases where curative care is not possible or is not desired, the goal of medical care at the end of life is to provide comfort to the patient and family, rather than initiating technological interventions that are unlikely to benefit the patient.

Advance Directives↗
PubMed2001

Resuscitation research: future directions and ethical issues.

Cardiopulmonary resuscitation research is a vital area of research that has made significant contributions to medical care over the last several decades. Abundant information currently exists in the medical literature, as a result of research in the areas of cardiac arrest and outcomes, physiology of cardiac arrest, pharmacologic treatments, mechanical interventions, and societal and ethical issues. Despite numerous clinical trials demonstrating physiologic benefit of various interventions, few interventions have had as much impact on outcomes of cardiac arrest as have improvements in out-of-hospital response times and rapid availability of medical treatment. Although abundant information exists regarding physiologic aspects of resuscitation, relatively little information exists about ethical, psychological, and social aspects of resuscitation. In addition to attempts to improve outcomes of cardiac arrest, researchers should also strive to improve the experiences of patients and families involved. These realities provide future strategies and directions for the best use of resuscitation research resources; although physiologic and pharmacologic research will always have significant roles in the improvement of medical care, the rapid delivery of out-of-hospital care and ethical issues will be indispensable areas of research focus in the future.

Biomedical Research↗
PubMed2001

Ethics seminars: beyond authorship requirements-ethical considerations in writing letters of recommendation.

Letters of recommendation may serve a number of vital functions related to the evaluation, selection, and promotion of candidates. The lure of academic celebrity or the desire of an individual candidate for a flattering letter must not threaten the veracity of the content. Letters of recommendation should be appropriately authored to meet the needs of the institution or individual requesting the letter, while keeping authenticity paramount. Length and content should be complete but not overly verbose. Relevant elements suggested by standardized formats should typically be included, such as nature of contact with the applicant, commitment to emergency medicine, work ethic, ability to develop a differential and treatment plan, personality, interpersonal interactions, and an overall comparative ranking. The seven cardinal elements of an exemplary letter of recommendation are that it should be: 1) authentic (based on adequate first-hand knowledge of the candidate's skills); 2) honest (accurate; avoiding exaggeration or hyperbole); 3) explicit (avoidance of veiled omissions); 4) balanced (taking care to incorporate both strengths and weaknesses); 5) confidential (avoiding unnecessary or unanticipated disclosure); 6) of appropriate detail and length (content relevant to the institutional or individual requests); and 7) technically clear (avoidance of unnecessary abbreviations and jargon). The implied duty to future students, colleagues, researchers, and patients who might come in contact with the applicant should motivate authors to write honest, explicit, appropriate, and complete letters.

Authorship↗
PubMed2001

The Emergency Medical Treatment and Labor Act as a federal health care safety net program.

Despite the greatest economic expansion in history during the 1990s, the number of uninsured U.S. residents surpassed 44 million in 1998. Although this number declined for the first time in recent years in 1999, to 42.6 million, the current economic slow-down threatens once again to increase the ranks of the uninsured. Many uninsured patients use hospital emergency departments as a vital portal of entry into an access-impoverished health care system. In 1986, Congress mandated access to emergency care when it passed the Emergency Medical Treatment and Labor Act (EMTALA). The EMTALA statute has prevented the unethical denial of emergency care based on inability to pay; however, the financial implications of EMTALA have not yet been adequately appreciated or addressed by Congress or the American public. Cuts in payments from public and private payers, as well as increasing demands from a larger uninsured population, have placed unprecedented financial strains on safety net providers. This paper reviews the financial implications of EMTALA, illustrating how the statute has evolved into a federal health care safety net program. Future actions are proposed, including the pressing need for greater public safety net funding and additional actions to preserve health care access for vulnerable populations.

Delivery of Health Care↗
PubMed2001

Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department.

The determination of decision-making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision-making capacity should be determined on some level during each patient encounter. Decision-making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.

Beneficence↗
PubMed2000

Impact of gender and having children in the household on ambulatory blood pressure in work and nonwork settings: a partial replication and new findings.

Ambulatory blood pressure (ABP) has been shown to differ for men and women across work and nonwork settings. For men, ABP is higher at work than at home on workdays or on nonworkdays. For women, ABP levels in different settings depend on whether they have children in the household. Women without children at home exhibit the "male" pattern of higher ABP at work than at home. Women with children at home show either similar ABP levels in the two locations or higher ABP at home. These different patterns have been assumed to represent different stress levels in the two locations, but this assumption has rarely been tested. Also, few studies have examined ABP levels on a nonworkday in women or the effect of having children in the household for men. The present study monitored ABP in men and women during two workdays and one nonworkday. Comparisons were made between ABP levels in three settings (workday at work, workday at home, nonworkday) using mixed random effects regression models. Psychosocial variables (e.g. mood, stress) that might mediate the different ABP patterns were also assessed. ABP differences were analyzed by gender and whether children were living in the household using mixed random effects regression models. Results indicated that diastolic blood pressure was higher at work versus home for men with children and higher at work and on nonworkdays than at home for women without children. ABP did not differ across settings for women with children or men without children. These results were not mediated by mood or stress levels in the three settings.

Adult↗
PubMed2000

Ethics seminars: case studies in "futility"-challenges for academic emergency medicine.

The concept of "futility" and its determination in emergency medicine pose unique challenges to emergency physicians, patients, and society. The term "futility," although commonly used, is problematic in its scope, meaning, and interpretation. To bridge this gap in understanding, the authors suggest the construct of clinically nonbeneficial interventions (CNBI), instead of "futility. " This language better informs discussions of nonbeneficial interventions across the risk spectrum of emergency medical practice, while retaining the focus on the patient's interests. Two cases are presented, which underscore the need for prudence and empathetic communication when addressing issues of CNBI. Determinations of expected benefit should be based on established scientific evidence, and the goals and values of patients, not on individual biases regarding quality of life or other subjective matters. While physicians are under no ethical obligation to provide treatments that they judge have no realistic likelihood of clinical benefit, the context in which these determinations take place is of critical importance. When certain interventions are appropriately withheld, concerted efforts should be made to maintain effective communication, comfort, support, and counseling for patients, friends, and families. In all aspects of clinical decision making, the value of various interventions and therapies must be based on expected risks and benefits to the patients, first and foremost.

Academic Medical Centers↗
PubMed2000

Research ethics: ethical issues of data reporting and the quest for authenticity.

The search for truth and its unbiased reporting are ultimate goals of conducting scientific research. Ideally, the reporting of research data ought to be an objective task. In practice, however, it is fraught with numerous statistical and ethical pitfalls, seldom addressed in formal emergency medicine training. The lure of academic celebrity and related influences may persuade researchers to report results in ways that make data appear more interesting, or worthy of publication. Several examples of potentially misleading data reporting are illustrated, including using inappropriate statistical tests, neglecting negative results, omitting missing data points, failing to report actual numbers of eligible subjects, using inappropriate graph labels or terminology, data dredging, and others. Although potentially inaccurate or inflated methods of data reporting may not constitute overt scientific misconduct, the intentional misrepresentation of data is a form of fraud or deception. Publicly funded academic inquiry is a privilege and honor enjoyed by a trusted few. Regardless of outcome, every effort should be made to report data in the most scientifically accurate method. To this end, the Society for Academic Emergency Medicine Code of Conduct and American College of Emergency Physicians Code of Ethics provide important guidance toward the accurate, compassionate, competent, impartial, and honest conduct of scientific research. Accuracy and authenticity in data reporting are first and foremost a matter of individual integrity, and are crucial to the preservation of academic credibility, the protection of future patients, and the public's trust in the medical research enterprise.

Emergency Medicine↗
PubMed2000

Determination of "futility" in emergency medicine.

The practice of emergency medicine routinely requires rapid decisionmaking regarding various interventions and therapies. Such decisions should be based on the expected risks and benefits to the patient, family, and society. At times, certain interventions and therapies may be considered "futile," or of low expected likelihood of benefit to the patient. Various interpretations of the term "futility" and its practical application to the practice of emergency medicine are explored, as well as background information and potential application of various legal, ethical, and organizational policies regarding the determination of "futility. "Decisions regarding potential benefit of interventions should be based on scientific evidence, societal consensus, and professional standards, not on individual bias regarding quality of life or other subjective matters. Physicians are under no ethical obligation to provide treatments they judge to have no realistic likelihood of benefit to the patient. Decisions to withhold treatment should be made with careful consideration of scientific evidence of likelihood of medical benefit, other benefits (including intangible benefits), potential risks of the proposed intervention, patient preferences, and family wishes. When certain interventions are withheld, special efforts should be made to maintain effective communication, comfort, support, and counseling for the patient, family, and friends.

Emergency Service, Hospital↗
PubMed1999

Ethical issues of resuscitation.

There is a wide variety of ethical issues and dilemmas involving resuscitation, the act of restoring life to a patient in cardiorespiratory arrest. Decisions must be made rapidly and often must be based on suboptimal levels of information available at the time. Certain issues should be considered when one is making decisions in the resuscitation arena, including positive-aspects of resuscitation, not only the possibility of restoring life to the patient but also providing a sense of closure and resolution of guilt for the survivors. During and following resuscitative efforts, the psychologic and emotional well-being of the survivors should also be given close attention.

Activities of Daily Living↗
PubMed1999

Coping with daily events and short-term mood changes: an unexpected failure to observe effects of coping.

This study examined the relationship between coping efforts and stress-related mood changes. Men and women with high levels of work or marital stress reported stress and coping efforts approximately once an hour for 2 days using an electronic diary. Stress episodes were identified as a stress-free time followed by a stressor at the next time point. Analyses examined how appraisals and coping influenced pre- to poststress mood change and how problem appraisals were related to coping efforts. Greater mood changes were associated with appraisals of high stress and high disruptiveness. Appraisals of high control and high desirability were associated with more planning, direct action, and fewer acceptance coping efforts. Coping failed to predict any pre- to poststressor mood changes. Possible explanations for the overall failure of coping to predict momentary mood changes are discussed.

Adaptation, Psychological↗
PubMed1998

A comparison of coping assessed by ecological momentary assessment and retrospective recall.

Recent research suggests that retrospective coping assessments may not correspond well with day-to-day reports. The authors extended this work by examining the correspondence between short-term (within 48 hr) retrospective coping reports and momentary reports recorded via a palm-top computer close in time to when the stressor occurred. There was relatively poor correspondence between the 2 assessments. Some reports of momentary coping were not reported retrospectively, and some coping reported retrospectively was not reported at the time the stressor occurred. Cognitive coping was more likely to be underreported retrospectively; behavior coping was overreported. Participants were consistent in their discrepancies, but there was no correspondence between discrepancy rates and demographic or personality variables.

Adaptation, Psychological↗
PubMed1998

Abdominal pain in geriatric emergency patients: variables associated with adverse outcomes.

OBJECTIVE: To determine the diagnoses and outcomes of geriatric patients with abdominal pain, and to identify variables associated with adverse outcomes. METHODS: Geriatric emergency patients (aged 65 years and older) with a complaint of abdominal pain were participants in this longitudinal case series. Eligible patients were followed by telephone contact and chart review, to determine outcomes and final diagnoses. RESULTS: Of 380 eligible patients, follow-up information was available for 375 (97%), for the two months following the ED visit. Final diagnoses included infection (19.2%), mechanical-obstructive disorders (15.7%), ulcers/hypersecretory states (7.7%), urinary tract disease (7.7%), malignancy (7.2%), and others. Although 5.3% of the patients died (related to presenting condition), most (61.3%) patients ultimately recovered. Surgical intervention was required for 22.1% of the patients. Variables associated with adverse outcomes (death, and need for surgical intervention) included hypotension, abnormalities on abdominal radiography, leukocytosis, abnormal bowel sounds, and advanced age. Most physical examination findings were not helpful in identifying patients with adverse outcomes. This study demonstrated a higher incidence of malignancy (7.2%) and a lower incidence of disease necessitating surgical intervention (22.1%) than previously reported. CONCLUSIONS: The majority of geriatric emergency patients with abdominal pain have significant disease necessitating hospital admission. Morbidity and mortality among these patients are high, and specific variables are strongly associated with death and the need for surgical intervention. Absence of these variables does not preclude significant disease. Physical examination findings cannot reliably predict or exclude significant disease. These patients should be strongly considered for hospital admission, particularly when fever, hypotension, leukocytosis, or abnormal bowel sounds are present.

Abdomen, Acute↗
PubMed1997

Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians.

OBJECTIVE: To determine current practice and attitudes among emergency physicians (EPs) regarding the initiation and termination of CPR. METHODS: An anonymous survey was mailed to randomly selected EPs. Main outcome measures included respondents' answers to questions regarding outcome of resuscitation, and current practice regarding initiation, continuation, and termination of resuscitation for victims of cardiopulmonary arrest. RESULTS: The 1,252 respondents were from all 50 states, a variety of practice settings, and varying board certification. Most (78%) respondents honor legal advance directives regarding resuscitation. Few (7%) follow unofficial documents, or verbal reports of advance directives (6%). Many (62%) make decisions regarding resuscitation because of fear of litigation or criticism. A majority (55%) have recently attempted numerous resuscitations despite expectations that such efforts would be futile. Most respondents indicated that ideally, legal concerns should not influence physician practice regarding resuscitation (78%), but that in the current environment, legal concerns do influence practice (94%). CONCLUSIONS: Most EPs attempt to resuscitate patients in cardiopulmonary arrest, regardless of futility, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than their professional judgment of medical benefit or futility. Compliance with patients' wishes regarding resuscitation is low unless a legal advance directive is present. Possible solutions to these problems may include standardized guidelines for the initiation and termination of CPR, tort reform, and additional public education regarding resuscitation and advance directives.

Advance Directive Adherence↗