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Biomedical subjects

K V Iserson

Publications and source records attributed to K V Iserson.

At least 37 records · Page 2Linked to original sources
PubMed1998

Nonstandard advance directives: a pseudoethical dilemma.

Critically injured patients occasionally present with indicators that they do not want resuscitation. What should clinicians do if these indicators come to light during resuscitations? This question is explored in the case of an unconscious and unresponsive adult woman with life-threatening injuries from a motor vehicle crash who was wearing a "DNR" medical necklace. The normal use of standard advance directives, including the use of prehospital advance directives, is discussed and contrasted with that of nonstandard directives, including verbal directives. The differing standards required to withhold and withdraw treatments in acutely injured patients are discussed, as are methods for assessing a patient's decision-making capacity at the bedside and a process to rapidly determine ethical courses of action in crisis situations. This discussion emphasizes that patients in life-threatening situations should normally be treated if the only available instructions are nonstandard directives. The patient gives her perspective on why she wore the directive and on the surgeons' actions.

Adult↗
PubMed1996

Managed care ethics: an emergency?

The rapid expansion of cost-consciousness and managed care into the medical marketplace has challenged the autonomy of physicians and patients. These challenges have taken a variety of forms, including limitations on reimbursement and restrictions on the amount and type of emergency care patients may receive. Challenges aside, the economic agenda of managed care must not threaten the primacy of patient welfare. The fidelity of the emergency physician-patient relationship and the integrity of the medical profession hangs in the balance.

Emergency Medical Services↗
PubMed1996

Withholding and withdrawing medical treatment: an emergency medicine perspective.

In emergency medicine, a significant difference rightfully persists between the withholding and withdrawal of life-sustaining medical treatment. The justification for this difference stems part from the nature of emergency medical practice and the unique manner in which clinicians apply many ethical principles. In the usual setting, the decision to withhold further medical treatment is done quietly, often without input from the patients surrogate decisionmaker, whereas withdrawal of ongoing medical treatment can be more obvious and difficult. This situation is reversed in the emergency medicine setting. The withholding of emergency medical treatment is much more problematic than later withdrawal of unwanted or useless interventions. Emergency physicians and prehospital providers often lack vital information about their patients' identities, medical conditions, and wishes. Society also has specific expectations of emergency physicians. Because of the nature of emergency medicine, both in the prehospital and the emergency department settings, the distinction between withdrawal and withholding of medical treatment has never disappeared and is not likely to do so in the future.

Emergency Medicine↗
PubMed1996

Are emergency departments really a "safety net" for the medically indigent?

This study was designed to quantify the willingness of emergency departments (EDs) and private care practitioners to see medically indigent patients. Three case scenarios were developed to represent severe, moderate, and mild problems that typically confront ED physicians. A female investigator made telephone calls using these scenarios, each time declaring herself to be medically indigent. All EDs received calls about all three scenarios, but only the least severe scenario was used for private practitioners. The timing and order of all calls were randomized. A control survey of the same population was subsequently performed in which the caller related that she had third-party insurance and had the minimal (rash) problem. The participants were all 54 nonmilitary EDs in Arizona and 69 randomly chosen private primary care practitioners in the same locales as the EDs. Calls to EDs were made during all time periods and days of the week; private practitioners were called only during their weekday office hours. The majority of all EDs were willing to see medically indigent patients, recommending that the caller come to the ED immediately 76% of the time. This response did not vary by geography or the facility's size, although ED personnel suggested initial home treatment more commonly at smaller hospitals (P = .02), and suggested coming to the ED more often on weekends (P < .02). Some EDs, however, clearly did not comply with their own telephone advice policies, and some ED personnel failed to give medically appropriate advice. In contrast to the EDs (P < .001), 62% of private practitioners' staffs stated they were not taking new patients or required at least $30 in advance. Private practitioners in the largest communities were significantly more reluctant to see the medically indigent than their peers in smaller communities (P < .05). For an insured caller, 55% of private practitioners would see the caller for < $30 and only 35% were not taking new patients or provided referral. In contrast to most private primary care practitioners, EDs are at least willing to serve as a triage point for the medically indigent and are often the primary-care "safety net" for the medically indigent.

Arizona↗