The principles approach.

High technology interventions near the end of life exact a high cost both in human and economic terms. Breathtaking advances in cardiology have helped to prolong life and improve its quality for many. For some, it has transformed the process of dying into a medical nightmare. The "do everything possible" attitude that prevailed during the past few decades is both inhumane and wasteful. In contrast, in the new era of managed care with its focus on profit, a well meaning physician may become suspect whenever he recommends against a medical intervention that he deems to be futile. More than ever before, there is a pressing need to develop rational guidelines for end of life medical interventions to ensure primacy of patients' best interests, protect the integrity of the doctor-patient relationship and affirm the duty of the medical establishment toward society at large. This weighty issue must not be relinquished to medical ethicists, health care alliances or the courts. It is the domain of physicians and the public at large. Medical futility should be defined as a treatment unlikely to affect the course of illness or that which has failed to achieve its desired effects. Rational guidelines for cardiopulmonary resuscitation and do not resuscitate orders should be formulated for both inhospital and out of hospital victims of cardiac arrest. These guidelines need to be developed through a process similar to those for the treatment of unstable angina, with involvement from all relevant medical specialities. Proposed guidelines must be negotiated, reviewed and ratified by the lay public. Appropriate legislation is necessary to establish the framework and policies to carry out agreed on recommendations. The focus of the "living will" should change so that it covers the last chapter of life rather than its terminal phase. The document should serve to express the person's wishes regarding specific medical interventions when the quality of life is seriously diminished beyond what is uniquely desirable for the particular patient. Living wills must be comprehensive, clear and specific. They must be honored. The Uniform Health Decisions Act, now pending legislation, should enhance the utility of the living will.

Ethics, Medical↗

PubMed1996

Occupationally acquired infections in health care workers. Part I.

BACKGROUND: Health care workers are at occupational risk for a vast array of infections that cause substantial illness and occasional deaths. Despite this, few studies have examined the incidence, prevalence, or exposure-associated rates of infection or have considered infection-specific interventions recommended to maintain worker safety. OBJECTIVES: To review all recent reports of occupationally acquired infection in health care workers in order to characterize the type and frequency of infections, the recommended interventions, and the costs of protecting workers. Part I of this two-part review focuses on the historical and ethical aspects of the problem and reviews data on infections caused by specific airborne organisms. DATA SOURCES: A MEDLINE search and examination of infectious disease and infection control journals. DATA SELECTION: All English-language articles and meeting abstracts published between January 1983 and February 1996 related to occupationally acquired infections among health care workers were reviewed. Outbreak- and non-outbreak-associated incidence and prevalence rates were derived, as were costs to prevent, control, and treat infections in health care workers. DATA SYNTHESIS: More than 15 airborne infections have been transmitted to health care workers, including tuberculosis, varicella, measles, influenza, and respiratory syncytial virus infection. Outbreak-associated attack rates range from 15% to 40%. Most occupational transmission is associated with violation of one or more of three basic principles of infection control: handwashing, vaccination of health care workers, and prompt placement of infectious patients into appropriate isolation. CONCLUSIONS: The risk for occupationally acquired infection is an unavoidable part of daily patient care. Infections that result from airborne transmission of organisms cause substantial illness and occasional deaths among health care workers. Further studies are needed to identify new infection control strategies to 1) improve protection of health care workers and 2) enhance compliance with established approaches. As health care is being reformed, the risk for and cost of occupationally acquired infection must be considered.

Ethics, Medical↗