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Biomedical subjects

M Siegler

Publications and source records attributed to M Siegler.

At least 91 records · Page 5Linked to original sources
PubMed1989

Informed consent in emergency research. Prehospital thrombolytic therapy for acute myocardial infarction.

Can the conscious patient in the midst of a medical emergency provide adequate informed consent for a clinical research protocol? Adequate consent is crucial to the ethical conduct of clinical trials, including those performed in emergency settings. We examine the problem of emergency informed consent. As an illustrative case, we discuss a pilot trial of prehospital thrombolytic therapy for myocardial infarction. Federal regulations for clinical research do not provide clear guidelines on emergency research in the conscious patient. Clinical investigators currently approach emergency consent in four ways: (1) avoid such research, (2) omit the consent process, (3) obtain deferred consent, or (4) obtain customary consent. We suggest a fifth alternative, two-step consent, which permits the conduct of emergency research while protecting the rights of the emergency research subjects. Such a process may serve as an alternative solution for future studies faced with the problem of informed consent in emergencies.

Emergencies↗
PubMed1989

Ethical issues in growth hormone therapy.

Pediatricians face clinical and ethical dilemmas about therapy to augment growth in short children who do not meet classic criteria for growth hormone (GH) deficiency. Biologic norms of health are unhelpful because of the uncertain relationship between stature, GH secretion, health, and disease. Instead, we suggest that GH therapy be evaluated from the perspective of cultural norms. We compare GH therapy for short normal children with currently accepted therapies for non--life-threatening pediatric conditions such as well-child care, cosmetic therapy, treatment of psychological problems, and invasive outpatient therapy for chronic conditions. Based on this analysis, we argue that the burdens of therapy, the uncertainty about long-term risks and benefits, the unclear therapeutic end point, and the implications for child health policy place routine GH therapy for children without documented deficiency of GH secretion outside current pediatric ethical norms. Such therapy is properly administered within a comprehensive clinical research protocol.

Beauty Culture↗
PubMed1989

The illusion of futility in clinical practice.

The claim that a treatment is futile is often used to justify a shift in the physician's ethical obligations to patients. In clinical situations in which non-futile treatments are available, the physician has an obligation to discuss therapeutic alternatives with the patient. By contrast, a physician is under no obligation to offer, or even to discuss, futile therapies. This shift is supported by moral reasoning in ancient and modern medical ethics, by public policy, and by case law. Given this shift in ethical obligations, one might expect that physicians would have unambiguous criteria for determining when a therapy is futile. This is not the case. Rather than being a discrete and definable entity, futile therapy is merely the end of the spectrum of therapies with very low efficacy. Ambiguity in determining futility, arising from linguistic errors, from statistical misinterpretations, and from disagreements about the goals of therapy, undermines the force of futility claims. Decisions to withhold therapy that is deemed futile, like all treatment choices, must follow both clinical judgments about the chance of success of a therapy and an explicit consideration of the patient's goals for therapy. Futility claims rarely should be used to justify a radical shift in ethical obligations.

Attitude of Health Personnel↗
PubMed1989

Development of a teaching program in clinical medical ethics at the University of Chicago.

The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)

Bioethical Issues↗
PubMed1989

Internal medicine residents' preferences regarding medical ethics education.

Three hundred and twenty-three residents in six internal medicine programs in three states were surveyed concerning what they wanted to learn about medical ethics and how they would prefer to learn it; they were also asked to indicate what medical ethics education they had already received. Specifically, the residents were given a list of 35 medical ethics topics and asked to indicate whether they would like more attention to a topic, or whether it had received enough or too much attention. (They could also indicate that they though the topic was inappropriate for attention during residency.) The residents were also given a list of 17 teaching methods for medical ethics and asked to indicate whether each method was very useful, somewhat useful, or not useful. Sixty-one percent of the residents responded. Approximately three-fourths of these had had some formal teaching about medical ethics in both medical school and residency, and nearly all indicated that they wanted more ethics training on specific topics. Certain topics were chosen as particularly suitable or unsuitable for such training; many of those judged as deserving more attention concerned legal issues and end-of-life issues. Most of the responding residents regarded standard clinical teaching formats as very useful for learning about medical ethics but regarded several other methods are not useful. The authors discuss the implications of these and related findings.

Adult↗
PubMed1988

An ethics consultation service in a teaching hospital. Utilization and evaluation.

A newly established formal ethics consultation service in a university teaching hospital was prospectively evaluated. A physician-ethicist interviewed and examined patients, interviewed family and others as needed, and entered a formal consultation note in the medical record. The requesting physician and the consultant independently completed structured questionnaires. Fifty-one consultation requests were received from 45 physicians from seven departments between July 1, 1986, and June 30, 1987. Seventeen (33%) of 51 patients were in the intensive care unit, and 19 patients (37%) were fully oriented at the time of consultation. Overall, 61% of the patients survived to leave the hospital. The requesting physician sought assistance with withholding or withdrawing life-sustaining treatment in 49% of cases, with resuscitation issues in 37%, and with legal issues in 31%. Assistance with more than one issue was sought in 39 cases (76%). In 36 cases (71%), the requesting physician stated that the consultation was "very important" in patient management, in clarifying ethical issues, or in learning about medical ethics. We conclude that ethics consultation performed by physician-ethicists provides useful, clinically acceptable assistance in a teaching hospital.

Adult↗
PubMed1988

Life-sustaining treatment. A prospective study of patients with DNR orders in a teaching hospital.

We conducted a prospective survey of attending, resident, and intern physicians who had written a "do not resuscitate" (DNR) order for 93 patients in their care. After writing a DNR order, 11% of respondents would still use chest compression if their patient experienced a cardiopulmonary arrest. Many physicians did not plan to withdraw therapy except intensive care, but most physicians planned to withhold a spectrum of life-sustaining therapies, from hemodialysis (86%) to intravenous fluids (21%). Attending and house-staff physicians generally agreed on whether to withdraw a given therapy or not but frequently disagreed on whether to withhold a therapy or not. After patient discharge or death, 88 charts were reviewed. None of the 88 patients was coded. Physicians initiated 68 life sustaining therapies in 43 patients and discontinued 64 therapies in 34 patients; there was no change in management in 31 patients. We conclude that individual physicians interpret the DNR order differently. These orders often are associated with the discontinuation or noninitiation of life-sustaining therapies other than emergency CPR.

Adult↗
PubMed1988

Talking to comatose patients.

Physicians may not talk to comatose patients for several reasons. Comatose patients do not seem to hear or respond. Speaking may not affect their clinical outcome; time spent with them takes time away from other, more "viable" patients. Comatose patients may, however, hear; many have normal brain-stem auditory evoked responses and normal physiologic responses to auditory stimuli. Not talking to comatose patients may promote the notion that they are dead or nearly dead; not talking may become a self-fulfilling prophecy, influencing physicians to inappropriately withhold or withdraw therapy. Because comatose patients are especially vulnerable, and because some comatose patients may recover, physicians should consider talking to these patients. Our analysis suggests that families, medical students, and house staff would benefit from the humane example modeled by those clinicians who care for and talk to all patients.

Adolescent↗