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Biomedical subjects

S H Miles

Publications and source records attributed to S H Miles.

At least 55 records · Page 3Linked to original sources
PubMed1990

The case: a story found and lost.

This first case in our series presents an elderly patient's encounters with the medical system as chronicled in her medical records.

Aged↗
PubMed1989

Autonomy in adolescent medicine. A framework for decisions about life-sustaining treatment.

A broad consensus has been reached in the last decade about the appropriateness of decisions to withhold life-sustaining treatment from competent adult patients. The situation in adolescent medicine is not so straightforward. Legal ambiguity in determining competence and clinical difficulty in assessing decision-making capacity make such decisions in adolescent medicine problematic. A framework for making decisions about withholding or withdrawing life-sustaining therapy from adolescent patients is proposed, and cases are given to illustrate the way the framework may be applied.

Adolescent↗
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

Medical ethics education: coming of age.

Medical ethics education is instruction that endeavors to teach the examination of the role of values in the doctor's relationship with patients, colleagues, and society. It is one front of a broad curricular effort to develop physicians' values, social perspectives, and interpersonal skills for the practice of medicine. The authors define medical ethics education as more clinically centered than human values education and more inclusive of philosophical, social, and legal issues than is interpersonal skills training. The authors review the history of the emergence of medical ethics education over the last 20 years, examine the areas of consensus that have emerged concerning the general objectives and premises for designing medical ethics programs, and describe teaching objectives and methods, course content, and program evaluation used in such programs on both preclinical and clinical levels. The four interrelated requirements for successful institutionalization of medical ethics education programs are defined and discussed, and the paper ends with an overview of the uncertain future of medical ethics education, an accepted but still not fully mature part of physician training in the United States. An extensive reference list accompanies the article.

Bioethical Issues↗
PubMed1989

Ethics consultations masking economic dilemmas in patient care.

The ethical and economic aspects of treatment decisions are often intimately entwined. We demonstrate how clinical economic questions were raised in clinical ethics consultations involving three patients: a 49-year-old retarded man who required short-term tube feeding; a 74-year-old man with metastatic prostatic cancer whose relatives disagreed about whether or not he should have surgical treatment; and a 55-year-old man whose health maintenance organization declined to pay for liver transplantation. Ethics consultants can help to clarify financial constraints and to resolve financial conflicts of interest. All physicians must develop the ability to unmask economic issues in medical care.

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PubMed1988

Survival after cardiopulmonary resuscitation in babies of very low birth weight. Is CPR futile therapy?

We conducted a retrospective study of outcome after cardiopulmonary resuscitation (CPR) in babies of very low birth weight. Of 158 such babies (birth weight, less than 1500 g) admitted to a neonatal intensive care unit in 1985, 49 (31 percent) underwent CPR. Low birth weight, low Apgar scores, birth asphyxia, pulmonary interstitial emphysema, hyaline membrane disease, and severe intraventricular hemorrhage were associated with the need for CPR. None of the 38 babies who received CPR in the first three days of life survived. Four of the 11 babies who received CPR after the first 72 hours survived. Three of the four survivors had residual neurologic deficits. Survival rates after CPR in infants of very low birth weight are lower than those in older children or adults. CPR may therefore be considered a nonvalidated therapy in this population. If the results of our study are confirmed, CPR should not be instituted automatically in very-low-birth-weight babies as though it were a validated treatment. Instead, it should be administered upon parents' advance informed consent to experimental treatment.

Apgar Score↗
PubMed1988

The total artificial heart. An ethics perspective on current clinical research and deployment.

The development of the total artificial heart (TAH) as a support before cardiac transplantation and as a possible permanent prosthesis has generated intense debate. The social commitment to TAH research entails immense health care costs because of the cost of the implant itself and also because of the large number of patients whose interests impel the research. The deployment of the pre-transplant TAH during the current shortage of donor hearts means that the TAH creates its own incentive as a way to compete in an expanded pool of donor heart candidates. Policies to address the orderly deployment and costs of the pretransplant TAH are needed. Research design and current pre-transplant clinical applications require careful consideration of planning for the termination of TAH support for severely injured but not brain dead patients.

Costs and Cost Analysis↗
PubMed1988

The standard of care: a case report and ethical analysis.

Physicians increasingly allow their perceived legal responsibilities to displace their clinical judgment. Misunderstandings that surround the term "standard of care" have encouraged fears of liability and have led to the practice of defensive medicine. Physicians may consider the standard of care to be a technical or legal obligation, but an optimal standard would be one based on detailed knowledge of a patient's medical history and personal condition. It would include the physician's clinical judgment, which integrates specific technical and legal information with clinical experience in caring for patients. Occasionally, such judgment may conflict with the rulings of a court, which considers technical and legal information without the benefit of clinical judgment. Physicians must be prepared to be advocates for their patients, especially when legal proceedings are flawed or injurious. Systematic processes of examination and analysis, such as those used by ethics consultants, can help resolve questions about the standard of care.

Aged↗
PubMed1988

Nursing home policies addressing the use or withdrawal of life-sustaining medical treatments.

There has been increasing interest in the use of nursing home policies and guidelines to improve decisions about the elective use of life-sustaining treatments. Such policies should be based on a sound and complete understanding of the legal and ethical governance responsibilities of health care facilities. Policies should address both the process of decision making and treatment plan implementation. Nursing home administrators should commission policies and monitor their implementation.

Aged↗