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Biomedical subjects

P A Singer

Publications and source records attributed to P A Singer.

At least 55 records · Page 3Linked to original sources
PubMed1998

Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment.

Demands by Patients or their Families for treatment thought to be inappropriate by health care providers constitute an important set of moral problems in clinical practice. A variety of approaches to such cases have been described in the literature, including medical futility, standard of care and negotiation. Medical futility fails because it confounds morally distinct cases: demand for an ineffective treatment and demand for an effective treatment that supports a controversial end (e.g., permanent unconsciousness). Medical futility is not necessary in the first case and is harmful in the second. Ineffective treatment falls outside the standard of care, and thus health care workers have no obligation to provide it. Demands for treatment that supports controversial ends are difficult cases best addressed through open communication, negotiation and the use of conflict-resolution techniques. Institutions should ensure that fair and unambiguous procedures for dealing with such cases are laid out in policy statements.

Adult↗
PubMed1998

Bioethics for clinicians: 15. Quality end-of-life care.

A physician who receives a call from the emergency department to see a patient with heart failure will have a clear framework within which to approach this problem. The thesis of this article is that physicians do not have an analogous conceptual framework for approaching end-of-life care. The authors present and describe a framework for end-of-life care with 3 main elements: control of pain and other symptoms, the use of life-sustaining treatments and support of those who are dying and their families. This 3-part framework can be used by clinicians at the bedside to focus their effort in improving the quality of end-of-life care.

Advance Care Planning↗
PubMed1998

Reconceptualizing advance care planning from the patient's perspective.

BACKGROUND: Traditional academic assumptions about advance care planning (ACP) include the following: (1) the purpose of ACP is preparing for incapacity; (2) ACP is based on the ethical principle of autonomy and the exercise of control; (3) the focus of ACP is completing written advance directive forms; and (4) ACP occurs within the context of the physician-patient relationship. These assumptions about ACP have never been empirically validated. OBJECTIVE: To examine the traditional academic assumptions by exploring ACP from the perspective of patients actively participating in the planning process. METHODS: Forty-eight patients (30 men and 18 women with a mean age of 48.3 years) who were undergoing hemodialysis were interviewed 6 months after receiving an advance directive form. Their experience of ACP was noted in interviews that were audiotaped, transcribed, and analyzed. RESULTS: The participants said that their purpose in ACP was to prepare for death and dying, and their underlying goals included the exercise of control and an attempt to relieve burdens placed on loved ones. Advance care planning was viewed as a social process, and completing a written advance directive form was often regarded as unnecessary. Participants often involved close loved ones, but physicians infrequently. CONCLUSIONS: The traditional academic assumptions are not fully supported from the perspective of patients involved in ACP. The patients we interviewed stated that (1) the purpose of ACP is not only preparing for incapacity but also preparing for death; (2) ACP is not based solely on autonomy and the exercise of control, but also on personal relationships and relieving burdens placed on others; (3) the focus of ACP is not only on completing written advance directive forms but also on the social process; and (4) ACP does not occur solely within the context of the physician-patient relationship but also within relationships with close loved ones.

Adult↗
PubMed1998

The cancer specific advance directive.

BACKGROUND: Advance directives are an important part of end of life care, but current advance directive documents do not address the specific issues facing cancer patients. The authors' purpose was: 1) to develop a cancer specific advance directive, 2) determine whether oncology outpatients find this directive more acceptable than a generic advance directive, and 3) describe oncology outpatient preferences for life-sustaining treatment. METHODS: A cancer specific advance directive ("The Cancer Living Will"; the full text of the updated version is available at the University of Toronto Joint Centre for Bioethics website [URL: www.utoronto.ca/jcb]) was developed in four steps: 1) literature search, 2) key informant interviews, 3) focus groups, and 4) evaluation of face and content validity. Subsequently, 91 volunteer oncology patients were given copies of the cancer specific advance directive and the generic advance directive ("The University of Toronto Centre for Bioethics Living Will") from which it was adapted. Acceptability of the advance directive was measured by determining the participants' preferred directive. Participants recorded their treatment preferences in both the cancer specific and generic advance directives. RESULTS: Of 60 patients who returned their questionnaires, 50 expressed a preference for the advance directive. Thirty-two patients (64%; 95% confidence interval (CI), 49-77%) preferred the disease specific Cancer Living Will and 18 patients (36%; 95% CI, 23-51%) preferred the generic Centre for Bioethics Living Will. Most participants who preferred the Cancer Living Will did so because it was more specific and relevant to their situation. CONCLUSIONS: The authors have developed and evaluated a cancer specific advance directive that they believe can be recommended for clinical use with cancer patients.

Aged↗
PubMed1998

Thyroid nodules: malignant or benign?

Palpation of a thyroid nodule should initiate a workup to exclude the rare but dangerous possibility of malignancy or autonomous function. Clinical evaluation will at times provide clues to malignancy, but the diagnostic cornerstone is fine-needle aspiration biopsy. Treatment may include observation, surgery, levothyroxine, or radioactive iodine.

Adult↗
PubMed1998

Serum thyroglobulin autoantibodies: prevalence, influence on serum thyroglobulin measurement, and prognostic significance in patients with differentiated thyroid carcinoma.

The prevalence of circulating thyroid autoantibodies (TgAb or antithyroid peroxidase) was increased nearly 3-fold in patients with differentiated thyroid cancers (DTC) compared with the general population (40% vs. 14%, respectively). Serum TgAb (with or without antithyroid peroxidase) was present in 25% of DTC patients and 10% of the general population. Serial postsurgical serum TgAb and serum Tg patterns correlated with the presence or absence of disease. Measurements of serum Tg were made in 87 TgAb-positive sera by a RIA and two immunometric assay (IMA) methods to study TgAb interference. TgAb interference, defined as a significant intermethod discordance (>41.7% coefficient of variation) between the Tg RIA and Tg IMA values relative to TgAb-negative sera, was found in 69% of the TgAb-positive sera. TgAb interference was characterized by higher Tg RIA vs. IMA values and was, in general, more frequent and severe in sera containing high TgAb concentrations. However, some sera displayed marked interference when serum TgAb was low (1-2 IU/mL), whereas other sera with very high TgAb values (>1000 IU/mL) displayed no interference. An agglutination method was found to be too insensitive to detect low TgAb concentrations (1-10 IU/mL) causing interference. Exogenous Tg recovery tests were an unreliable means for detecting TgAb interference. Specifically, the exogenous Tg recovered varied with the type and amount of Tg added and the duration of incubation employed. Further, recoveries of more than 80% were found for some sera displaying gross serum RIA/IMA discordances. The measurement of serum Tg in DTC patients with circulating TgAb is currently problematic. It is important to use a Tg method that provides measurements that are concordant with tumor status. IMA methods are prone to underestimate serum when TgAb is present, increasing the risk that persistent or metastatic DTC will be missed. The RIA method used in this study provided more clinically appropriate serum Tg values in the group of TgAb-positive patients with metastatic DTC. Furthermore, as serial serum TgAb measurements paralleled serial serum Tg RIA measurements, TgAb concentrations may be an additional clinically useful tumor marker parameter for following TgAb-positive patients. Disparities between serial serum Tg and TgAb measurements might alert the physician to the possibility of TgAb interference with the serum Tg measurement and prompt a more cautious use of such data for clinical decision-making.

Adolescent↗
PubMed1997

Bioethics for clinicians: 13. Resource allocation.

Questions of resource allocation can pose practical and ethical dilemmas for clinicians. In the Aristotelian conception of distributive justice, the unequal allocation of a scarce resource may be justified by morally relevant factors such as need or likelihood of benefit. Even using these criteria, it can be difficult to reconcile completing claims to determine which patients should be given priority. To what extent the physician's fiduciary duty toward a patient should supersede the interests of other patients and society as a whole is also a matter of controversy. Although the courts have been reluctant to become involved in allocation decisions in health care, they expect physicians to show allegiance to their patients regardless of budgetary concerns. The allocation of resources on the basis of clinically irrelevant factors such as religion or sexual orientation is prohibited. Clear, fair and publicly acceptable institutional and professional policies can help to ensure that resource allocation decisions are transparent and defensible.

Canada↗
PubMed1997

Bioethics for clinicians: 11. Euthanasia and assisted suicide.

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.

Attitude to Health↗
PubMed1997

Bioethics for clinicians: 7. Truth telling.

The standard of professional candour with patients has undergone a significant change over the past 30 years. Independent of their obligation to disclose information necessary for informed consent, physicians are increasingly expected to communicate important information to patients that is not immediately related to treatment decisions. The purpose of truth telling is not simply to enable patients to make informed choices about health care and other aspects of their lives but also to inform them about their situation. Truth telling fosters trust in the medical profession and rests on the respect owed to patients as persons. It also prevents harm, as patients who are uninformed about their situation may fail to get medical help when they should.

Attitude of Health Personnel↗
PubMed1997

The HIV-specific advance directive.

OBJECTIVE: To determine whether persons living with HIV find a disease-specific advance directive more acceptable than a generic directive. DESIGN: Randomized clinical trial. SETTING: HIV consumer organization and hospital-based HIV clinic. PARTICIPANTS: Volunteer sample of persons with HIV. INTERVENTIONS: The disease-specific HIV Living Will, the generic Centre for Bioethics Living Will, or both. MEASUREMENTS AND MAIN RESULTS: Of 101 participants who received both advance directives, 78 (77.2%) preferred the disease-specific HIV Living Will and 23 (22.8%) preferred the generic Centre for Bioethics Living Will (p < .001). Most participants who preferred the HIV Living Will did so because it was more specific or relevant to their situation. CONCLUSIONS: Persons living with HIV prefer a disease-specific to a generic advance directive. They should be offered a disease-specific advance directive. Our findings should also encourage investigators to develop and evaluate disease-specific advance directives in other clinical settings.

Adult↗
PubMed1996

Bioethics for clinicians: 6. Advance care planning.

Advance rate planning is a process whereby a patient, in consultation with health care providers, family members and important others, makes decisions about his or her future health care. Grounded in the ethical principle of autonomy and the legal doctrine of consent, advance care planning helps to ensure that the norm of consent is respected should the patient become incapable of participating in treatment decisions. Physicians can play an important role by informing patients about advance care planning directing them to appropriate resources, counselling them as they engage in advance care planning and helping them to tailor advance directives to their prognosis.

Adult↗
PubMed1996

Bioethics for clinicians: 5. Substitute decision-making.

Substitute decision-making is a means of making health care decisions on behalf of people who are incapable of making these decisions for themselves. It is based on the ethical principle of respect for autonomy. Substitute decision-making poses two main questions: Who-should make the decision for the incapable person, and, How should the decision be made? Because the applicable statutory and common law varies across Canada, clinicians should become familiar with the legal requirements of their own province or territory.

AIDS Dementia Complex↗