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AMA Journal of Ethics

Tracy Shamas, Sarah Gillespie-Heyman
One aspect of palliative medicine that has been underexplored is the perspective of veterans either facing critical life-limiting illness or at the end of life. The needs of veterans differ not only because military culture affects how veterans cope with their illness but also because exposure-related factors (combat and environmental) differ between military branches. In this paper, we describe two cases involving end-of-life care for veterans with combat trauma and describe individualized approaches to their care...
August 1, 2018: AMA Journal of Ethics
Nora W Wong
This article addresses whether physicians' close ties to their patients might play an unexamined role in their reluctance to initiate palliative care. In cases characterized by uncertainty, physicians' emotional investment in their patients and patients' families might unduly promote decisions to continue aggressive treatment rather than transition to comfort care. Continued evaluation and communication of patient status, including scheduled objective consultations, can align compassionate actions with patients' best interests...
August 1, 2018: AMA Journal of Ethics
Cheyanne Silver
When I told people I was pursuing a career in medicine, the statistics of female physician suicide were mentioned. When I professed an interest in surgery, I was told to choose a specialty for lifestyle, because as a woman I would need a career that would allow me to raise my future children. All around me, I have been assaulted by doubt, as senior physicians whisper to students of my generation to turn away while we still can.
August 1, 2018: AMA Journal of Ethics
Nathan A Gray
In this graphic narrative, a clinician illustrates an experience of caring for an undocumented patient suffering from end-stage renal disease (ESRD). Cruel Carousel tells one of the stories that most profoundly shaped the author's own views on health care for undocumented immigrants. Graphic narrative was chosen to tell this story because words alone couldn't capture the patient's experience or the author's distress about what happened to him.
August 1, 2018: AMA Journal of Ethics
Munir H Buhaya
This image represents a physician unilaterally completing a do-not-resuscitate order for an unrepresented patient.
August 1, 2018: AMA Journal of Ethics
Tracy A Brader
After a goals-of-care conversation, this patient's chart listed his status as "full-code." As shown in this image, resuscitation was initiated for a 92-year-old man with metastatic malignancy after being found pulseless by the rounding team.
August 1, 2018: AMA Journal of Ethics
Peter T Hetzler, Lydia S Dugdale
Before antibiotics, cardiopulmonary resuscitation (CPR), and life-sustaining technologies, humans had little choice about the timing and manner of their deaths. Today, the medicalization of death has enabled patients to delay death, prolonging their living and dying. New technology, the influence of the media, and medical professionals themselves have together transformed dying from a natural part of the human experience into a medical crisis from which a patient must be rescued, often through the aggressive extension of life or through its premature termination...
August 1, 2018: AMA Journal of Ethics
Bryan A Sisk, Jennifer W Mack
We propose that effective prognostic communication requires attention to the process and purpose of communication, where purpose represents the will and process the ability to communicate. Prognostic communication has historically challenged clinicians and patients. Few interventions have been developed to improve prognostic communication, and those that have been developed largely target the process of communication. We argue that more work is needed to address the purpose of prognostic communication, because the first step in all effective communication is desiring to communicate well...
August 1, 2018: AMA Journal of Ethics
Carin van Zyl, Dawn M Gross
Whether at the beginning, middle, or end of life, health care delivery choices abound. Yet only recently have conversations specifically regarding preferences for care at the end of life become a reimbursable intervention, deemed equivalent in importance to a medical procedure. Quite distinct from other procedures, in which expectations for outcomes are explicit and measurable, outcomes have been left intentionally vague for advanced care planning (ACP) conversations. This article will explore the inherent challenges of and opportunities for developing formalized outcomes, methods of measurement, and training to ensure excellence in the performance of ACP conversation procedures...
August 1, 2018: AMA Journal of Ethics
Sabhyta Sabharwal, Jason W Mitchell, Victoria Y Fan
With advances in antiretroviral therapies, perinatally infected children are now living with HIV well beyond adolescence. Parents and health care practitioners thus face the challenge of deciding how best to disclose positive serostatus to children living with HIV. Although many adolescents living with HIV are sexually active, parents often delay disclosure, which presents US physicians with an ethical dilemma because there is no legal requirement to follow clinical guidelines recommending disclosure prior to adolescence...
August 1, 2018: AMA Journal of Ethics
Helen Stanton Chapple
"Clinical momentum" refers to the curious expansion of interventions applied to patients in the intensive care unit (ICU) without pause or design, leading to extensions of care that can violate patient wishes and distress clinicians. In this article, clinical momentum is placed in a wider context that includes ritual, reimbursement patterns, and actor network theory. These contextual features help motivate understanding of one way in which dying patients are underserved in intensive care settings...
August 1, 2018: AMA Journal of Ethics
Mark Pfeifer, Barbara A Head
Conversations about dying and end-of-life (EOL) care are the most challenging of all communication scenarios. These conversations include discussions about diagnosis and prognosis, treatment goals, and EOL wishes, goals of care, and plans for the future. Research has identified critically important skills involved in holding such conversations, and protocols have been established that can assist those discussing these important issues. Often several discussions and professionals from multiple disciplines are needed to ensure that EOL conversations are effective and comprehensive...
August 1, 2018: AMA Journal of Ethics
Indrany Datta-Barua, Joshua Hauser
Palliative care and psychiatry share a number of the same priorities, including careful attention to communication skill development. In this article, we identify 4 communication skills helpful in both fields: (1) attending to countertransference, (2) practicing active listening and active reflection, (3) remaining silent and neutral, and (4) naming the emotion. We then describe strategies for teaching these skills.
August 1, 2018: AMA Journal of Ethics
James L Bernat, Nathaniel M Robbins
Organ donation after the circulatory determination of death (DCDD) accounts for a growing percentage of deceased organ donations. Although hospital DCDD protocols stipulate donor death determination, some do not adhere to national guidelines that require mechanical, not electrical, asystole. Surrogate decisions to withdraw life-sustaining therapy should be separated from decisions to donate organs. Donor families should be given sufficient information about the DCDD protocol and its impact on the dying process to provide informed consent, and donors should be given proper palliative care during dying...
August 1, 2018: AMA Journal of Ethics
Shyoko Honiden, Jennifer Possick
Although new cancer therapies have changed the prognosis for some patients with advanced malignancies, the potential benefit for an individual patient remains difficult to predict. This uncertainty has impacted goals-of-care discussions for oncology patients during critical illness. Physicians need to have transparent discussions about end-of-life care options that explore different perspectives and acknowledge uncertainty. Considering a case of a new physician's objections to an established care plan that prioritizes comfort measures, we review physician practice variation, clinical momentum, and possible moral objections...
August 1, 2018: AMA Journal of Ethics
Alexander Craig, Elizabeth Dzeng
We discuss physician aid in dying, euthanasia, and other dimensions of palliative care decision making and define relevant terms raised by this case of a dying patient with amyotrophic lateral sclerosis in Washington State who is unable to self-administer a lethal prescription. We then present a concrete framework that clinicians can directly apply when faced with difficult cases such as this one. We outline how exploring motivations, obtaining informed consent, defining goals, and examining alternatives can help guide physicians like the one in this case...
August 1, 2018: AMA Journal of Ethics
Katherine Gentry, Aaron Wightman
Here we present a case of a patient in terminal respiratory failure refusing to consent to emergent tracheostomy in the setting of an anticipated difficult intubation. We examine ethical concerns that arise from deviations from the standard of care in the operative setting and the anesthesiologist's sense of culpability. Finally, we will review the ethical arguments and guidelines that support anesthesiologists' participation in palliative operative procedures when limitations on resuscitation are in place.
August 1, 2018: AMA Journal of Ethics
Susan Harris
Chaplains provide spiritual care and support to patients, families, and hospital staff. What may be less familiar is that chaplains also help mediate decisions among patients, family members, and clinical teams. How clinicians, patients, and families formulate and articulate their goals and concerns can be informed either directly or indirectly by religious values. Finding common ground and common language can be helpful for both the medical team and the family. Physicians can use their clinical and social authority to try to ameliorate distress and offer recommendations based on patients' and families' goals and values; conversely, physicians' hesitancy to use their authority in these ways can generate moral distress among patients, families, and caregivers...
July 1, 2018: AMA Journal of Ethics
Ariana Ellis
This drawing considers how achieving balance between allopathic, Western medical practices and spiritual practices can be critical for clinicians hoping to offer compassionate health care. Ethical and clinical challenges of consistently offering compassionate care to patients from all backgrounds requires cultivating and practicing spiritual awareness while maintaining professional boundaries.
July 1, 2018: AMA Journal of Ethics
Karl Lorenzen
Each work in this collection explores, from patients' or their loved ones' points of view, balance between patients' experiences and one or more of 4 well-known principles of ethics in health care.
July 1, 2018: AMA Journal of Ethics
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