Cardiac disease is the leading cause of death worldwide. Cardiovascular diseases can be prevented if an effective diagnostic is made at the initial stages. The ECG test is referred to as the diagnostic assistant tool for screening of cardiac disorder. The research purposes of a cardiac disorder detection system from 12-lead-based ECG Images. The healthcare institutes used various ECG equipment that present results in nonuniform formats of ECG images. The research study proposes a generalized methodology to process (...) all formats of ECG. Single Shoot Detection MobileNet v2-based Deep Neural Network architecture was used to detect cardiovascular disease detection. The study focused on detecting the four major cardiac abnormalities with 98% accuracy results were calculated. The work is relatively rare based on their dataset; a collection of 11,148 standard 12-lead-based ECG images used in this study were manually collected from health care institutes and annotated by the domain experts. The study achieved high accuracy results to differentiate and detect four major cardiac abnormalities. Several cardiologists manually verified the proposed system’s accuracy result and recommended that the proposed system can be used to screen for a cardiac disorder. (shrink)

Donation after cardiac death (CDC) is an important issue in the spiritual care and hospital chaplaincy ministry to patients, staff, and families in the Pittsburgh Mercy Health System. Key members of the interdisciplinary care teams must be well informed about the facts of this controversial issue. Ethical decisions made in particular cases contribute to the development of hospital policies and the establishment of “best practices” in large Catholic health care systems throughout the United States, and must (...) be made with the utmost care. This article provides a brief history and overview of donation after cardiac death and discusses the major ethical issues that were addressed during CDC policy development for the Pittsburgh Mercy Health System. The issues center on questions of whether donors are really dead. Specific issues include death criteria, including the time of pronouncement of death; conflicts of interest; treatment of patients and their loved ones; and organ preservation techniques. National Catholic Bioethics Quarterly 7.3 (Autumn 2007): 527–543. (shrink)

Background The recent proliferation of health care report cards, especially in cardiac care, has occurred in the absence of an ethical framework to guide in their development and implementation. An ethical framework is a consistent and comprehensive theoretical foundation in ethics, and is formed by integrating ethical theories, relevant literature, and other critical information (such as the views of stakeholders). An ethical framework in the context of cardiac care provides guidance for developing cardiac report (...) cards (CRCs) that are relevant and legitimate to all stakeholders. The purpose of this study is to develop an ethical framework for CRCs. Methods Delphi technique – 13 panelists: 2 administrators, 2 cardiac nurses, 5 cardiac patients, 2 cardiologists, 1 member of the media, and 1 outcomes researcher. Panelists' views regarding the ethics of CRCs were analyzed and organized into themes. Results We have organized panelists' views into ten principles that emerged from the data: 1) improving quality of care, 2) informed understanding, 3) public accountability, 4) transparency, 5) equity, 6) access to information 7) quality of information, 8) multi-stakeholder collaboration, 9) legitimacy, and 10) evaluation and continuous quality improvement. Conclusion We have developed a framework to guide the development and dissemination of CRCs. This ethical framework can provide necessary guidance for those generating CRCs and may help them avoid a number of difficult issues associated with existing ones. (shrink)

The management of children born with trisomy 18 is controversial, and both providers and parents often have differing opinions. Many parents choose to terminate the pregnancy while others go forward, making decisions based on their beliefs, understanding, and physician recommendations. Physicians are similarly divided regarding treatment of these children, as some feel that aggressive treatments are futile while others defer to the parents' wishes.Interrupted aortic arch with ventricular septal defect in children with trisomy 18 presents an ethical dilemma that highlights (...) the kinds of controversies in medical decision making facing physicians on a daily basis. Repair of interrupted aortic arch with ventricular septal defect poses a high risk to newborns with or without trisomy 18. Therefore, the option for surgery should be treated as with any routine informed consent process. Parents should be counseled about the risks, benefits, alternatives, and the likelihood of success both short and long term and be should offered a choice between surgery and palliative care. (shrink)

When information on a coma patient’s expected outcome is uncertain, a moral dilemma arises in clinical practice: if life-sustaining treatment is continued, the patient may survive with unacceptably poor neurological prospects, but if withdrawn a patient who could have recovered may die. Continuous electroencephalogram-monitoring is expected to substantially improve neuroprognostication for patients in coma after cardiac arrest. This raises expectations that decisions whether or not to withdraw will become easier. This paper investigates that expectation, exploring cEEG’s impacts when it (...) becomes part of a socio-technical network in an Intensive Care Unit. Based on observations in two ICUs in the Netherlands and one in the USA that had cEEG implemented for research, we interviewed 25 family members, healthcare professionals, and surviving patients. The analysis focuses on the way patient outcomes are constructed, the kind of decision support these outcomes provide, and how cEEG affects communication between professionals and relatives. We argue that cEEG can take away or decrease the intensity of the dilemma in some cases, while increasing uncertainty for others. It also raises new concerns. Since its actual impacts furthermore hinge on how cEEG is designed and implemented, we end with recommendations for ensuring responsible development and implementation. (shrink)

Exercise-based rehabilitation forms a key part of the UK National Health Service patient-care pathway for cardiac rehabilitation (CR). Only around half of all eligible patients attend core CR, however, with social inequalities affecting participation. Few qualitative studies have explored in-depth the key factors influencing engagement with CR, specifically from a sociological theoretical, and ethnographic perspective. Utilising an ethnographic approach allowed us to get a sense of the embodied experiences of 10 participants attending or declining core CR, together with (...) a further seven family members/significant others. This provided in-depth appreciation of participants’ lifeworld contexts as key influences on CR participation. The article draws on these qualitative data and focuses on 1) participants’ initial thoughts about CR; and 2) navigating the field of CR, analysed via thematic analysis. We utilise a Bourdieusian theoretical perspective to theorise the findings, including salient socio-cultural factors influencing attendance/non-attendance and (non)adherence. The article findings highlight how perceptions of CR and the ability to navigate the field are strongly influenced by habitus and capital, and how personal biographies and socio-material conditions affect adherence to CR programmes. The study provides original insights into embodied experiences of exercise-based CR, and novel understandings of the reasons for drop-out/poor adherence, theorised from a Bourdieusian perspective. (shrink)

BackgroundThe emergence of artificial intelligence (AI) in medicine has prompted the development of numerous ethical guidelines, while the involvement of patients in the creation of these documents lags behind. As part of the European PROFID project we explore patient perspectives on the ethical implications of AI in care for patients at increased risk of sudden cardiac death (SCD).AimExplore perspectives of patients on the ethical use of AI, particularly in clinical decision-making regarding the implantation of an implantable cardioverter-defibrillator (ICD).MethodsSemi-structured, (...) future scenario-based interviews were conducted among patients who had either an ICD and/or a heart condition with increased risk of SCD in Germany (n = 9) and the Netherlands (n = 15). We used the principles of the European Commission’s Ethics Guidelines for Trustworthy AI to structure the interviews.ResultsSix themes arose from the interviews: the ability of AI to rectify human doctors’ limitations; the objectivity of data; whether AI can serve as second opinion; AI explainability and patient trust; the importance of the ‘human touch’; and the personalization of care. Overall, our results reveal a strong desire among patients for more personalized and patient-centered care in the context of ICD implantation. Participants in our study express significant concerns about the further loss of the ‘human touch’ in healthcare when AI is introduced in clinical settings. They believe that this aspect of care is currently inadequately recognized in clinical practice. Participants attribute to doctors the responsibility of evaluating AI recommendations for clinical relevance and aligning them with patients’ individual contexts and values, in consultation with the patient.ConclusionThe ‘human touch’ patients exclusively ascribe to human medical practitioners extends beyond sympathy and kindness, and has clinical relevance in medical decision-making. Because this cannot be replaced by AI, we suggest that normative research into the ‘right to a human doctor’ is needed. Furthermore, policies on patient-centered AI integration in clinical practice should encompass the ethics of everyday practice rather than only principle-based ethics. We suggest that an empirical ethics approach grounded in ethnographic research is exceptionally well-suited to pave the way forward. (shrink)

BackgroundConsent for data research in acute and critical care is complex as patients become at least temporarily incapacitated or die. Existing guidelines and regulations in the European Union are of limited help and there is a lack of literature about the use of data from this vulnerable group. To aid the creation of a patient-centred framework for responsible data research in the acute setting, we explored views of patients and next-of-kin about the collection, storage, sharing and use of genetic (...) and health-related data for observational research.MethodsWe conducted qualitative interviews (n = 19) with Dutch sudden cardiac arrest survivors who donated clinical and socio-economic data and genetic samples to research. We also interviewed their next-of-kin. Topics were informed by ethics literature and we used scenario-sketches to aid discussion of complex issues.ResultsSudden cardiac arrest survivors displayed limited awareness of their involvement in health data research and of the content of their given consent. We found that preferences regarding disclosure of clinically actionable genetic findings could change over time. When data collection and use were limited to the medical realm, patients trusted researchers to handle data responsibly without concern for privacy or other risks. There was no consensus as to whether deferred consent should be explicitly asked from survivors. If consent is asked, this would ideally be done a few months after the event when cognitive capacities have been regained. Views were divided about the need to obtain proxy consent for research with deceased patients’ data. However, there was general support for the disclosure of potentially relevant post-mortem genetic findings to relatives.ConclusionsSudden cardiac arrest patients’ donation of data for research was grounded in trust in medicine overall, blurring the boundary between research and care. Our findings also highlight questions about the acceptability of a one-time consent and about responsibilities of patients, researchers and ethics committees. Finally, further normative investigation is needed regarding the (continued) use of participants’ data after death, which is of particular importance in this setting. Our findings are thought to be of relevance for other acute and life-threatening illnesses as well. (shrink)

A number of studies show that when doctors become ill, there is often ambiguity in the division of roles and responsibilities in the medical encounter. Yet little is known about how the dilemma of the sick doctor has changed over time. This article explores the experience of illness among physicians by applying an historical, narratological approach to three doctor’s narratives about personal cases of cardiac disease: Max Pinner’s from the 1940s, Robert Seaver’s from the 1980s, and John Mulligan’s from (...) 2015. Drawing on Erving Goffman’s principles of social interaction, I argue that part of the challenge in the analysed narratives is because when doctors seek medical attention for themselves, the ensuing medical ‘drama’ suffers. I compare the three narratives to argue that the experience of becoming a patient while simultaneously remaining a doctor is a challenge that has changed over time. In Pinner’s narrative, the patient identity is both undesirable and inaccessible; in Seaver’s, role ambivalence between doctor and patient is the most salient feature; for Mulligan, his personal rather than professional experience of illness is the overarching theme of the narrative. Finally, I suggest that an awareness of how the medical drama often changes when doctors are patients might prove beneficial both for the doctor-patients and providers of medical care. (shrink)

The demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act (LSTDA) in February 2018. This legislation may influence emergency medical procedures and the availability of organs from brain-dead donors. This study aimed to assess LSTDA’s impact, introduced in February 2018, on organ donation status in out-of-hospital cardiac arrest (OHCA) patients in a metropolitan city and identified related factors. We (...) conducted a retrospective analysis of a regional cardiac arrest registry. This study included patients aged 16 or older with cardiac arrest and a cerebral performance category (CPC) score of 5 from January 2015 to December 2022. The exclusion criteria were CPC scores of 1–4, patients under 16 years, and patients declared dead or transferred from emergency departments. Logistic regression analysis was used to analyse factors affecting organ donation. Of the 751 patients included in this study, 47 were organ donors, with a median age of 47 years. Before the LSTDA, there were 30 organ donations, which declined to 17 after its implementation. In the organ donation group, the causes of cardiac arrest included medical (34%), hanging (46.8%), and trauma (19.2%). The adjusted odds ratio for organ donation before the LSTDA implementation was 6.12 (95% CI 3.09–12.12), with non-medical aetiology as associated factors. The enactment of the LSTDA in 2018 in South Korea may be linked to reduced organ donations among patients with OHCA, underscoring the need to re-evaluate the medical and legal aspects of organ donation, especially considering end-of-life care decisions. (shrink)

Background: Within oncology and hematology care, patients are sometimes considered to have such a poor prognosis that they can receive a do not resuscitate order from the physician responsible, stipulating that neither basic nor advanced coronary pulmonary rescue be performed in the event of a cardiac arrest. Studies on do not resuscitate decisions within oncology and hematology units, focusing on the specific role of the nurse in relation to these decisions, are scarce. Objective: The aim of this study (...) was to investigate hematology and oncology nurses’ experiences and perceptions of do not resuscitate orders, in order to achieve a deeper understanding of the nurses’ specific role in these decisions. Research design: A qualitative, descriptive methodology with individual semi-structured interviews was used. Participants and research context: A total of 15 nurses from eight hematology/oncology wards in four hospitals in Sweden were interviewed individually. Ethical considerations: In accordance with national regulations, an ethical review was not required for this study. The research followed international guidelines for empirical research, as outlined in the Helsinki Declaration. Findings: The nurses strived for good nursing care through balancing harms and goods and observing integrity and quality of life as important values. Experienced hindrances for good care were unclear and poorly documented decisions, uninformed patients and relatives, and disagreements among the caregivers and family. The nurses expressed a need for an ongoing discussion on do not resuscitate decisions, including all concerned parties. Conclusion: In order to provide good nursing care, nurses need clear and well-documented do not resuscitate orders, and patients and relatives need to be well informed and included in the decisions. To increase the understanding for each other’s opinions within the medical team, regular ethical discussions are required. (shrink)

Two potentially lifesaving protocols, emergency preservation and resuscitation and uncontrolled donation after circulatory determination of death, currently implemented in some U.S. emergency departments, have similar eligibility criteria and initial technical procedures, but critically different goals. Both follow unsuccessful cardiopulmonary resuscitation and induce hypothermia to “buy time”: one in trauma patients suffering cardiac arrest, to enable surgical repair, and the other in patients who unexpectedly die in the ED, to enable organ donation. This article argues that to fulfill patient-focused fiduciary (...) obligations and maintain community trust, institutions implementing both protocols should adopt and publicize policies to guide ED physicians to utilize either protocol for particular patients, in order to address the appearance of conflict of interest arising from the protocols' similarities. It concludes by analyzing ethical implications of incentives that may influence institutions to develop the expertise required for uDCDD but not EPR. (shrink)

Different approaches have been proposed in order to achieve knowledge integration for coronary care monitoring applications, usually in the form of expert systems. The clinical impact of these expert systems, which are based only on "shallow" knowledge, has not been remarkable due to the difficulties associated with the construction and maintenance of a complete knowledge base. Model-based systems represent an alternative to these problems because they allow efficient integration of the "deep" knowledge on the underlying physiological phenomena being monitored. (...) In this work, a brief review of existing model-based systems for cardiac rhythm interpretation is presented, followed by the description of a new system forCardiac Arrhythmia Recognition by Model-Based ECG Matching (CARMEM). Fundamental characteristics of CARMEM are presented; in particular, its ability to provide on-line parameter adaptation to simulate complex rhythms and to match observed ECG signals. The proposed model can be useful for the explanation of the origin of cardiac arrhythmias and contribute towards their robust characterization in the context of coronary care units. (shrink)

The ability to sequence individual genomes is leading to the identification of an increasing number of genetic risk factors for serious diseases. Knowledge of these risk factors can often provide significant medical and psychological benefit, but also raises complex ethical and social issues. This paper focuses on one area of rapid progress: the identification of mutations causing long QT syndrome and other cardiac channel disorders, which can explain some previously unexplained deaths in infants (SIDS) and children and adults (SUDS) (...) and prevent others from occurring. This genetic knowledge, discovered posthumously in many cases, has implications for clinical care for surviving family members who might carry the same mutations. The information obtained from genetic testing, in the context of personal and family history, can guide individually tailored interventions that reduce risk and save lives. At the same time, obtaining and disclosing genetic information raises difficult issues about confidentiality and decision making within families. We draw on the experience of the Montefiore-Einstein Center for Cardiogenetics, which has played a leading role in the genetic diagnosis and clinical management of cardiac channel diseases, to explore some of the challenging ethical questions arising in affected families with adolescent children. We focus on the related issues of (1) family confidentiality, privacy and disclosure and (2) adolescent decision making about genetic risk, and argue for the value of interdisciplinary dialogue with affected families in resolving these issues. (shrink)

An individual’s right to refuse life-sustaining treatment is a fundamental expression of patient autonomy; however, supporting this right poses ethical dilemmas for healthcare providers when the patient has attempted suicide. Emergency physicians encounter patients who have attempted suicide and are likely among the first medical providers to face the dilemma of honoring the patient’s DNR or intervening to reverse the effects of potentially fatal actions. We illustrate this issue by introducing a case example in which the DNR of a terminally (...) ill woman was not honored because the cause of her cardiac arrest was suicide. We argue that although a terminal diagnosis should change the way health care providers respond to a suicide attempt, many of the theoretical underpinnings for how one should treat suicide attempts—especially the criterion of external reasonability, that is the action to withhold or withdraw life-sustaining measures is reasonable independent of the precipitating event—are common to all situations :3–12, 2013). The presumption that patients who attempt suicide lack capacity due to acute mental illness is flawed because it fails to account for a competent individual’s reasonable preference to not be forced to live in an unbearable, terminal condition. In states without legislation allowing physician aid in dying, patients and providers must grapple with these limitations on a case-by-case basis. In cases where the patient has a limited life expectancy and there is not concern for psychiatric illness as the primary cause of the suicidal action, we argue that the negative right to refuse life-sustaining treatment should prevail. (shrink)

Technology is pervasive and overwhelming in the intensive care setting. It has the power to inform and direct the nursing care of critically ill patients. Technology changes the moral and social dynamics within nurse—patient encounters. Nurses use technology as the main reference point to interpret and evaluate clinical patient outcomes. This shapes nurses’ understanding and the kind of care provided. Technology inserts itself between patients and nurses, thus distancing nurses from patients. This situates nurses into positions of (...) power, granting them epistemic authority, which constrains them as moral agents. Technology serves to categorize and marginalize patients’ illness experience. In this article, moral agency is examined within the technologically-mediated context of the intensive care unit. Uncritical use of technology has a negative impact on patient care and nurses’ view of patients, thus limiting moral agency. Through examination of technology as it frames cardiac patients, it is demonstrated how technology changes the way nurses understand and conceptualize moral agency. This article offers a new perspective on the ethical discussion of technology and its impact on nurses’ moral agency. Employing reflective analysis using the technique of embodied reflection may help to ensure that patients remain at the centre of nurses’ moral practice. Embodied reflection invites nurses critically to examine how technology has reshaped conceptualization, understanding, and the underlying motivation governing nurses’ moral agency. (shrink)

BackgroundIn cancer care, do not resuscitate (DNR) orders are common in the terminal phase of the illness, which implies that the responsible physician in advance decides that in case of a cardiac arrest neither basic nor advanced Coronary Pulmonary Rescue should be performed. Swedish regulations prescribe that DNR decisions should be made by the responsible physician, preferably in co-operation with members of the team. If possible, the patient should consent, and significant others should be informed of the decision. (...) Previous studies have shown that physicians and nurses can experience ethical dilemmas in relation to DNR decisions, but knowledge about what ethical reasoning they perform is lacking. Therefore, the aim was to describe and explore what ethical reasoning physicians and nurses apply in relation to DNR-decisions in oncology and hematology care.MethodsA qualitative, descriptive and explorative design was used, based on 287 free-text comments in a study-specific questionnaire, answered by 216 physicians and nurses working in 16 oncology and hematology wards in Sweden. Comments were given by 89 participants.ResultsThe participants applied a situation-based ethical reasoning in relation to DNR-decisions. The reasons given for this were both deontological and utilitarian in kind. Also, expressions of care ethics were found in the material. Universal rules or guidelines were seen as problematic. Concerning the importance of the subject, nurses to a higher extent underlined the importance of discussing DNR-situations, while physicians described DNR-decisions as over-investigated and not such a big issue in their daily work.ConclusionThe study revealed that DNR-decisions in oncology and hematology care gave rise to ethical considerations. Important ethical values described by the participants were to avoid doing harm and to secure a peaceful and “natural” death with dignity for their dying patients. A preference for the expression “allow for natural death” instead of the traditional term “do not resuscitate” was found in the material. (shrink)

The aim of this study was interpret the existential construct of family caring following Acute Coronary Syndrome. Family support is known to have a positive impact on recovery and adjustment after cardiac events. Few studies provide philosophically-based, interpretative explorations of carer experience following a spouse’s ischaemic event. As carer experiences, behaviours and meaning-making may impact on the quality of the support they provide to patients, further understanding could improve both patient outcomes and family experience. Fourteen spouses of people experiencing (...) Acute Coronary Syndrome in Sydney, Australia were engaged in a single, semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Data were analysed using hermeneutic interpretation within a Heideggerian phenomenological framework. Acute Coronary Syndrome disrupts lived temporality, and the projected potential for carers’ being-alongside. Carers experienced an existential uncertainty that arose from difficulty in diagnosis, and situated fear as an attuned, being-towards-death. They constructed protective strategies to insulate their partner and themselves from further stress and risk, however, unclear boundaries for protection heightened carer anxiety. The existential structure of care included one of two possible Heideggerian modes: leaping-in care was a dominating mode that required a high level of carer vigilance; leaping-ahead care was a metaphorical walking alongside, as carers gave back control, freeing opportunities for the person to ‘own’ care. Supporting carers through the intensive phase of leaping-in care, and equipping them for informed leaping-ahead care should be a focus in both the acute and post-discharge care phases. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Explode and Die!A Fat Woman’s Perspective on Prenatal Care and the Fat Panic EpidemicJennifer HansenClassifying obesity as a disease provides more ammunition for the “war on obesity.” I gather that this is supposed to be a good thing. The problem is that obesity isn’t a germ or a crime; it’s a word applied to a particular kind of body—and thus to the person inhabiting it.From a fat person’s (...) perspective, the “war on obesity” is a war on fat people. It’s a license to bully, shame, and ostracize fat people and deny us employment, medical care, and even ordinary family life because we don’t look right. Fat people, proclaimed by medical authority to be the enemy and identifiable on sight as outsiders, are made into targets for all kinds of free–floating anger. For example, I am apparently sucking away people’s tax dollars via my fat, and it’s also my fault that men expecting to fantasize about every woman they see on the street encounter my distasteful fatness instead. But no matter how many times we get told that we are wrong just for existing, we go on existing, in public even. How dare we? The answer, obviously, is to keep at us. If we would just admit that we have no right to exist, then we would all either vanish or become socially acceptably thin, and then the whole world would be unicorns and butterflies and everyone would be rich and nobody would get old. Or something like that. If obesity is a disease, then phrenology is a science.Of course, we get a lot of well–meaning flak along with the bullying; after all, concentrating on weight loss can only be good for us, because fat people are always about to explode and die. This assumption has definitely affected my relationship with the only medical practice I can reach that’s in my network. During the 20–plus years since I became visibly obese, I have gotten used to the constant drone of “You’re fat, you’re fat, you’re about to explode and die, we don’t care about what you actually came in for because it’s vitally important that we bug you yet again about your pants size,” but some things can still shock me. For example, during all three of my pregnancies, I never had a result that was even borderline for gestational diabetes (GD). And yet, some time after my last baby was born, someone wrote “HISTORY OF GESTATIONAL DIABETES” in my file. I first heard about it during my annual checkup, when the doctor referred to it when talking about my increased risk of Type 2 diabetes due to age (unavoidable), my first–ever non–whitecoat–syndrome borderline blood pressure (BP) reading (taken with a standard cuff, gee how could it possibly have been inaccurate), and GD (gosh, I felt so safe and supported at this fine reality–based practice). And of course my weight.Whoever wrote that felt free to make things up because I’m fat. To repeat, somebody with access to my file at my only source for affordable health care felt free to write things in it that were completely contradicted by the facts just a few sheets below. There’s no need to fact–check your assumptions when you can tell by looking at her that she’s F–A–T, and everybody knows what they are. They’ll explode and die, every last one of them. Better medicate them now before they inevitably break down!Speaking of which, there’s a particular OB at the practice who I’ll call Doctor Eeyore. At every appointment, Doctor Eeyore would take measurements, stare, and say, “Hmm … tch.” If I asked him to tell me what he had found, he would say, “Too big,” or, “Too small,” or indicate some other inadequacy in his glum, word–miserly way. He only bothered to produce complete sentences when he enthusiastically told me that I would die if I didn’t give birth with an IV in place to administer the life–saving drugs for my inevitable cardiac event... (shrink)

Background: Maintaining patient’s dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units. Objectives: The aim of this study was to uncover the cultural factors that impeded maintaining patients’ dignity in the cardiac surgery intensive care unit. Research Design: The study was conducted using a critical ethnographic method proposed by Carspecken. Participants and research context: Participants included all physicians, nurses and staffs working in the study setting (...) (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace. Ethical Consideration: Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained. Findings: The findings of the study fell into the following main themes: “Presence: the guarantee for giving enough attention to patients’ self-esteem”, “Instrumental and objectified attitudes”, “Adherence to the human equality principle: value-action gap”, “Paternalistic conduct”, “Improper language”, and “Non-interactive communication”. The final assertion was “Reductionism as a major barrier to the maintaining of patient’s dignity”. Discussion: The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches. Conclusion: Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships. (shrink)

Background: Decision-making and assessment in emergency situations are complex and result many times in ethical conflicts between different healthcare professionals. Aim: To analyse and describe situations that can generate ethical conflict among nurses working in emergency situations. Methods: Qualitative analysis. A total of 16 emergency nurses took part in interviews and a focus group. Ethical considerations: Organisational approval by the University Hospital, and informed consent and confidentiality were ensured before conducting the research. Result/conclusion: Two categories emerged: one in ‘ethical issues’ (...) and one in ‘emotions and feelings in caring’. The four ethical subcategories are presented: Autonomy, the first sub category: first, the nurse’s ability to practise care on an emergency ward and, second, to support the patient and/or relatives in terms of care and medical treatment. The conflicts arise when the nurse ends up in the middle between the patient and the physician responsible for the diagnosis and treatment from a nature scientific perspective. Reification of injured body: patient was often reified and fragmented, becoming just a leg or arm. Different factors contributed in this perspective. Pain: pain relief was often inadequate but more effectively treated in the emergency medical services than at the emergency department. The nurses highlighted the phenomenon of suffering because they felt that pain was only an object, forgetting the patients’ care need, like separating mind from body. Death: the nurses felt that the emergency services are only prepared to save lives and not to take care of the needs of patients with ‘end-of-life’ care. Another issue was the lack of ethical guidelines during a cardiac arrest. Resuscitation often continues without asking about the patient’s ‘previous wishes’ in terms of resuscitation or not. In these situations, the nurses describe an ethical conflict with the physician in performing their role as the patient’s advocate. The nurses express feelings of distress, suffering, anger and helplessness. (shrink)

Yearly pediatric cardiac surgery missions to Ghana are of tremendous benefit to local children, but may create thorny ethical dilemmas for local clinicians who refer and screen children for the mission and who provide care to the children after the mission concludes for the year. This article presents the experiences and concerns of a pediatrician who is a local member of the Hearts and Minds of Ghana project.

In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy (...) surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation. (shrink)

The aim of this paper is to investigate whether or not ethical conflicts can be identified, analysed and solved using ethical principles. The relation between the physician and the patient with ischemic heart disease (IHD) as life style changes are recommended in a secondary prevention program is used as an example. The principal persons affected (the patient and his or her spouse) and the ethical principles (respect for autonomy, non-maleficence, beneficence and justice) are combined in a two dimensional model. The (...) most important person affected by the recommendations is the patient. His or her autonomy is challenged by the suggested life style changes, the purpose of which is to promote the future wellbeing and health of the patient. The spouse is indirectly involved in and affected by the process. He or she often feels neglected by caregivers. Ethical conflicts can both be identified and analysed using ethical principles, but often no solution is implied. Most (if not all) physicians would strongly encourage life style changes, but surprisingly there is no uncontroversial justification for this conclusion using principles. (shrink)

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining (...) treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives. (shrink)

Extracorporeal membrane oxygenation (ECMO) is a form of life support for cardiac and/or pulmonary failure with unique ethical challenges compared to other forms of life support. Ethical challenges with ECMO exist when conventional standards of care apply, and are exacerbated during periods of absolute ECMO scarcity when “crisis standards of care” are instituted. When conventional standards of care apply, we propose that it is ethically permissible to withhold placing patients on ECMO for reasons of technical futility (...) or when patients have terminal, short-term prognoses that are untreatable by ECMO. Under crisis standards of care, it is ethically permissible to broaden exclusionary criteria to also withhold ECMO from patients who have a low likelihood of recovery, to maximize the overall number of lives saved. Unilateral withdrawal of ECMO against a patient’s preferences is unethical under conventional standards of care, but is ethical under crisis standards of care to increase access to ECMO to others in society. ECMO should only be rationed when true scarcity exists, and allocation protocols should be transparent to the public. When rationing must occur under crisis standards of care, it is imperative that oversight bodies assess for inequities in the allocation of ECMO and make frequent changes to improve any inequities. (shrink)

An anencephalic infant, who came to be known as Baby K, was born at Fairfax Hospial in Falls Church, Virginia, on October 13, 1992. From, the moment of birth and repeatedly thereafter, the baby's mother insisted that aggressive measures be pursued, including cardiopulmonary resuscitation and ventilator support, to keep the baby alive as long as possible. The physicians complied. However, following the baby's second admission for respiratory failure, the hospital sought declaratory relief from the court permitting it to forgo emergency (...) life support on the grounds that “a requirement to provide respiratory assistance would exceed the prevailing standard of medical care,” and that “because any treatment of their condition is futile, the prevailing standard of medical care for infants with anencephaly is to provide warmth, nutrition, and hydration.” The United States Court of Appeals for the Fourth Circuit ruled in favor of the baby's mother, citing the federal Emergency Medical Treatment and Active Labor Act , which contained no “standard of care” exception to the requirement to provide “treatment necessary to prevent the material deterioration of the individual's condition.” An appeal to the United States Supreme Court was rejected. The baby died some two and one-half years later of cardiac arrest during her sixth visit to the emergency department of Fairfax Hospital for respiratory failure. (shrink)

Background Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care. Objective To explore nurses’ experiences of ethical and legal issues in post-resuscitation care. Research design This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis. Participants and research context In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data were (...) analyzed by conventional content analysis. Ethical considerations The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected. Findings Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care. Conclusion There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges. (shrink)

This book examines the many ethical issues that are encountered in the Pediatric Intensive Care Unit. It supports pediatricians, nurses, residents, and other providers in their daily management of critically ill children with the dilemmas that arise. It begins by examining the evolution of pediatric critical care, and who is now impacted by this advancing medical technology. Subsequent chapters explore specific ethical concerns and controversies that are commonly encountered. These topics include how to conduct end-of-life discussions with families (...) facing a myriad of challenging choices. It goes on to explore the concept of futility, and what that does and does not mean in the pediatric ICU setting. Controversial subjects such as children as organ donors, particularly using donation after cardiac death, in addition to issues surrounding the declaration of brain death are covered. Additional chapters address resource allocation, and also analyze the use of long-term technology in chronically critically ill children. Chapters include case examples with guidance on how to work through similar difficulties and decision-making. While this book is specifically targeted for care providers at the ICU bedside, it is also of benefit to medical students, students in bioethics, practicing ethical consultants and families who are dealing with critically ill children. (shrink)

Hospitalization is a unique health-illness transition for most elderly people. Whether the patient's health-related needs are met or not often iiifluence his or her appraisal of quality of life during hospitalization. This qualitative study explored the health needs of elderly Chinese male cardiac patients during their hospitalization. Eighteen subjects were recruited from a veterans' hospital in northern Taiwan. These men all lived alone before their hospital admission. Data were gathered using semistructured interviews and then analysed by content analysis. Ninety-four (...) per cent of the subjects described up to three categories of needs: met needs (72%), unmet needs (78%), and expected needs (50%0). Needs that participants believed were met were those for psychological support, spiritual support, tangible support and information. Unmet needs were those for participation in decision making, maintaining daily activities and resuming a preadmission lifestyle. The expected needs included those for learning self-care strategies to maintain their daily activities after discharge from the hospital. The factors that framed the participants' perceptions of different health needs were identified to be lack of family support and locus of control. Finally, a discussion of the context background of this phenomenon, as well as some suggestions for its implications, are provided from a culturally sensitive ethical aspect. (shrink)

Background: The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation. Research objective: To explore what the nurse’s advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain). Research design: An exploratory critical (...) qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data. Participants: Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5). Ethical considerations: Approval was obtained from the Basque Country Clinical Research Ethics Committee. Findings: Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns. Discussion: The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses’ advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team. Conclusion: This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians. (shrink)

This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis (...) of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to ‘bare life’ in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a ‘regime of death’, and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises. (shrink)

Background This analysis is about practical living bioethics and how law, ethics and sociology understand and respect children’s consent to, or refusal of, elective heart surgery. Analysis of underlying theories and influences will contrast legalistic bioethics with living bioethics. In-depth philosophical analysis compares social science traditions of positivism, interpretivism, critical theory and functionalism and applies them to bioethics and childhood, to examine how living bioethics may be encouraged or discouraged. Illustrative examples are drawn from research interviews and observations in two (...) London paediatric cardiac units. This paper is one of a series on how the multidisciplinary cardiac team members all contribute to the complex mosaic of care when preparing and supporting families’ informed consent to surgery. Results The living bioethics of justice, care and respect for children and their consent depends on theories and practices, contexts and relationships. These can all be undermined by unseen influences: the history of adult-centric ethics; developmental psychology theories; legal and financial pressures that require consent to be defined as an adult contract; management systems and daily routines in healthcare that can intimidate families and staff; social inequalities. Mainstream theories in the clinical ethics literature markedly differ from the living bioethics in clinical practices. Conclusion We aim to contribute to raising standards of respectful paediatric bioethics and to showing the relevance of virtue and feminist ethics, childhood studies and children’s rights. (shrink)

Recent commentaries by Verheijde et al, Evans and Potts suggesting that donation after cardiac death practices routinely violate the dead donor rule are based on flawed presumptions. Cell biology, cardiopulmonary resuscitation, critical care life support technologies, donation and transplantation continue to inform concepts of life and death. The impact of oxygen deprivation to cells, organs and the brain is discussed in relation to death as a biological transition. In the face of advancing organ support and replacement technologies, the (...) reversibility of cardiac arrest is now purely related to the context in which it occurs, in association to the availability and application of support systems to maintain oxygenated circulation. The 'complete and irreversible' lexicon commonly used in death discussions and legal statutes are ambiguous, indefinable and should be replaced by accurate terms. Criticism of controlled DCD on the basis of violating the dead donor rule, where autoresuscitation has not been described beyond 2 minutes, in which life support is withdrawn and CPR is not provided, is not valid. However, any post mortem intervention that re-establishes brain blood flow should be prohibited. In comparison to traditional practice, organ donation has forced the clarification of the diagnostic criteria for death and improved the rigour of the determinations. (shrink)

Written by cardiac surgeons, cardiologists, and pediatric intensive care physicans and nurses, this text offers a multidisciplinary approach to the care of children with critical heart disease. Throughout, Dr. Nichols and colleagues provide practice-oriented guidance on: * scientific principles * diagnostic and therapeutic techniques * specialized equipment * managing congenital and acquired special conditions * anesthesia, CPR, and respiratory care...... all with more than 400 illustrations to help you visualize anatomy and techniques, numerous charts and tables (...) to summarize critical data, and much more. (shrink)

Unlike critically ill neonates, care of children with complex cardiac disease increasingly involves use of invasive technologies—such as ventricular assist devices (VAD)—or emergent surgical proced...

OBJECTIVE: Following two randomized controlled trials that demonstrated reduced mortality and better neurological outcome in cardiac arrest patients, mild therapeutic hypothermia was implemented in many intensive care units. Up to now, no large observational studies have confirmed the beneficial effects of mild therapeutic hypothermia. DESIGN: Internet-based survey combined with a retrospective, observational study. PATIENTS: All patients admitted to an intensive care unit in The Netherlands after cardiac arrest from January 1, 1999 until January 1, 2009. DATA (...) SOURCE: Dutch National Intensive Care Evaluation database. METHODS: The moment of implementation of mild therapeutic hypothermia for each hospital participating in the Dutch National Intensive Care Evaluation database was determined with an Internet survey. To compare mortality before and after implementation of mild therapeutic hypothermia, the odds ratio adjusted for Simplified Acute Physiology Score II score, age, gender, propensity score, and in- or out-of-hospital cardiac arrest was calculated. Patients were excluded if 1) they were admitted to an intensive care unit that did not respond to the survey, 2) they were admitted within 3 months after implementation of mild therapeutic hypothermia, 3) they had a Glasgow Coma Scale score of >8, or 4) they did not satisfy the Simplified Acute Physiology Score II inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 13,962 patients were admitted to an intensive care unit following cardiac arrest. In total 8,645 patients were excluded, 5,544 because of a Glasgow Coma Scale score of >8. Of the resultant 5,317 patients, 1,547 patients were treated before and 3,770 patients after implementation of mild therapeutic hypothermia. Patients admitted after implementation of mild therapeutic hypothermia had lower minimal and maximal temperatures (p < .0001) during the first 24 hrs on the intensive care unit compared to patients admitted before implementation of mild therapeutic hypothermia. The adjusted odds ratio of the hospital mortality of patients treated after implementation of mild therapeutic hypothermia was 0.80 (95% confidence interval of 0.65-0.98, p = .029). CONCLUSION: The results of this retrospective, observational survey suggest that implementation of mild therapeutic hypothermia in Dutch intensive care units is associated with a 20% relative reduction of hospital mortality in cardiac arrest patients. (shrink)

BackgroundThe success of biobanking is directly linked to the willingness of people to donate their biological materials for research and storage. Ethical issues related to patient consent are an essential component of the current biobanking agenda. The majority of data available are focused on population-based biobanks in USA, Canada and Western Europe. The donation decision process and its ethical applications in clinical populations and populations in countries with other cultural contexts are very limited. This study aimed to evaluate the decision-making (...) experience of the clinical biobank donors, as well as psychological and social motivators and deterrents of this decision and associated ethical risks.MethodsSemi-structured interviews were conducted in two medical institutions, in St Petersburg (Russia), in 2016–2017, among 13 donors of a clinical biobank (pregnant women, cardiac patients, and patients with multiple sclerosis) and three donation organisers—medical specialists involved in recruiting donors for a clinical biobank. Analysis of interview data was based on qualitative content analysis.ResultsDonors of a clinical biobank express beliefs in the absence of risks associated with the donation. The primary motivators for donating to the biobank were: prosocial, indirect reciprocity (response to or anticipation of an act in kind by a third party), intrinsic motivation (to enhance their self-esteem and satisfying their curiosity about the donation process), and comparability with personal values. A high level of trust in biomedical research and the particular physician can contribute to a favourable decision. The overall decision-making process regarding the biobank donation could be described as quick and not based on a careful reading of informed consent documents. The integration of biobank donation decision-making in the process of medical care might prompt patient to donate to biobank without proper consideration. The specific type of therapeutic misconception—the presence of unrealistic hope that donation could provide a direct benefit for a third person in need was discovered.ConclusionsPatients recruited to a clinical biobank in Russia have virtually no concerns as to the storage of their biomaterials. The donation decision is mainly motivated by prosocial attitudes and other factors that are similar to the motivating factors of blood donation. The fact of going through inpatient treatment and poor differentiation between donation for other people's benefit and for research purposes can make the process of obtaining consent more ethically problematic. (shrink)

One day soon it may be possible to replace a failing heart, liver, or kidney with a long-lasting mechanical replacement or perhaps even with a 3-D printed version based on the patient's own tissue. Such artificial organs could make transplant waiting lists and immunosuppression a thing of the past. Supposing that this happens, what will the ongoing care of people with these implants involve? In particular, how will the need to maintain the functioning of artificial organs over an extended (...) period affect patients and their doctors and the responsibilities of those who manufacture such devices? Drawing on lessons from the history of the cardiac pacemaker, this article offers an initial survey of the ethical issues posed by the need to maintain and service artificial organs. We briefly outline the nature and history of cardiac pacemakers, with a particular focus on the need for technical support, maintenance, and replacement of these devices. Drawing on the existing medical literature and on our conversations and correspondence with cardiologists, regulators, and manufacturers, we describe five sources of ethical issues associated with pacemaker maintenance: the location of the devices inside the human body, such that maintenance generates surgical risks; the complexity of the devices, which increases the risk of harms to patients as well as introducing potential injustices in access to treatment; the role of software—particularly software that can be remotely accessed—in the functioning of the devices, which generates privacy and security issues; the impact of continual development and improvement of the device; and the influence of commercial interests in the context of a medical device market in which there are several competing products. Finally, we offer some initial suggestions as to how these questions should be answered. (shrink)

It has been reported as an ethical problem within prehospital emergency care that ambulance professionals administer physiologically futile cardiopulmonary resuscitation (CPR) to patients having suffered cardiac arrest to benefit significant others. At the same time it is argued that, under certain circumstances, this is an acceptable moral practice by signalling that everything possible has been done, and enabling the grief of significant others to be properly addressed. Even more general moral reasons have been used to morally legitimize the (...) use of futile CPR: That significant others are a type of patient with medical or care needs that should be addressed, that the interest of significant others should be weighed into what to do and given an equal standing together with patient interests, and that significant others could be benefited by care professionals unless it goes against the explicit wants of the patient. In this article we explore these arguments and argue that the support for providing physiologically futile CPR in the prehospital context fails. Instead, the strategy of ambulance professionals in the case of a sudden death should be to focus on the relevant care needs of the significant others and provide support, arrange for a peaceful environment and administer acute grief counselling at the scene, which might call for a developed competency within this field. (shrink)

Few clinical situations arouse more emotion and drama and lead to more conflict in decision-making than cardio-pulmonary resuscitation . The procedure was described as potentially beneficial more than 40 years ago. However, its efficacy and place in the care of the frail elderly have taken a long time to be established. In the world of secular medical practice, there are many situations when CPR may be provided to elderly, frail and cognitively compromised individuals for whom its clinical benefit is (...) questionable. In those patients suffering from dementia, surrogates are responsible for decision-making, which complicates the process. When the clinical uncertainty is coupled with strong cultural and religious influences, as within Orthodox Judaism, the development of an acceptable approach to cardiac arrest is more challenging. A clinically sound, ethically defensible and religiously sensitive approach to CPR requires a deep understanding of all the factors involved in the decision-making process and may require periodic re-evaluation not only by clinicians but by religious scholars and leaders. (shrink)

A recent commentary defends 1) the concept of 'brain arrest' to explain what brain death is, and 2) the concept that death occurs at 2–5 minutes after absent circulation. I suggest that both these claims are flawed. Brain arrest is said to threaten life, and lead to death by causing a secondary respiratory then cardiac arrest. It is further claimed that ventilation only interrupts this way that brain arrest leads to death. These statements imply that brain arrest is not (...) death itself. Brain death is a devastating state that leads to death when intensive care, which replaces some of the brain's vital functions such as breathing, is withdrawn and circulation stops resulting in irreversible loss of integration of the organism. Circulatory death is said to occur at 2–5 minutes after absent circulation because, in the context of DCD, the intent is to not attempt reversal of the absent circulation. No defense of this weak construal of irreversible loss of circulation is given. This means that paents in identical physiologic states are dead (in the DCD context) or alive (in the resuscitation context); the current state of death (at 2–5 minutes) is contingent on a future event (whether there will be resuscitation) suggesting backward causation; and the commonly used meaning of irreversible as 'not capable of being reversed' is abandoned. The literature supporting the claim that autoresuscitation does not occur in the context of no cardiopulmonary resuscitation is shown to be very limited. Several cases of autoresuscitation are summarized, suggesting that the claim that these cases are not applicable to the current debate may be premature. I suggest that brain dead and DCD donors are not dead; whether organs can be harvested before death from these patients whose prognosis is death should be debated urgently. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“Just Because You Can—Doesn’t Mean You Should”Mindy B. StatterAs Albert R. Jonsen stated, “The technological imperative begins to rule clinical decisions: if a technology exists, it must be applied. Patients... are moved to higher and higher levels of care, finally becoming enmeshed in a tangle of tubes that extinguish their identity and needs as persons.” In this case the conflict created by the parental demand for the utilization (...) of technology, extracorporeal support in a neonate will be explored.I was consulted in the care of a newborn with a right–sided congenital diaphragmatic hernia (CDH). In this anomaly the diaphragm, the muscular partition that separates the abdomen and the thorax, forms incompletely, and the viscera migrate up into the chest compressing the developing lung, shifting the medistinum and heart and compressing the contralateral lung. The resulting lung maldevelopment is termed pulmonary hypoplasia. The maldevelopment of the lungs in CDH is variable with the most severe forms resulting in neonatal death. This congenital anomaly is associated with 55% survivability; the poor prognosis is due to the pulmonary hypoplasia. In addition to pulmonary hypoplasia, there is the association of pulmonary hypertension with CDH. Pulmonary hypertension is a condition where the vascular resistance in the lung is high with reduced blood flow within the lung. The physiologic consequence of pulmonary hypertension is hypoxemia, oxygen deficiency in the blood, and reduced oxygen delivery to all organs. Unlike severe pulmonary hypoplasia, pulmonary hypertension is reversible. When an infant with CDH is born and deteriorates due to respiratory failure it can be difficult to determine whether the respiratory failiure is due to pulmonary hypoplasia or pulmonary hypertension. Extracorporeal membrane oxygenation (ECMO) is indicated in the management of reversible respiratory and, or cardiac failure. In the case of neonates with CDH, ECMO addressess the reversible component of the respiratory failure, the pulmonary hypertension. The respiratory failure due to severe pulmonary hypoplasia is not reversible; ECMO is not indicated. There are established criteria to guide the determination of which infant is a candidate for ECMO. Depending upon the ECMO center, the stringency can vary.In this case, the baby had significant respiratory failure with impairment in both oxygenation, hypoxia, and ventilation–the elimination of carbon dioxide, hypercapnea. The neonatologist spoke with the mother who stated that she wanted “everything done” including ECMO in the management [End Page 22] of her baby. When the neonatologist consulted me to put the baby on ECMO I expressed my concern that this infant had irreversible respiratory failure due to pulmonary hypoplasia. And simply from a technical aspect, I could not guarantee that ECMO would “work”. When an infant is “cannulated” for extracorporeal support, cannulas are inserted to allow for the drainage of blood into the ECMO circuit, the blood oxygenated and the carbon dioxide is cleared, and the blood is then returned to the infant. The majority of diaphragmatic hernias are on the left and when the CDH is on the right side, the right heart may be compressed by the viscera in the chest, and venous drainage into the ECMO circuit may be impaired. When this is encountered, the next step in the management algorithm is to fix the hernia–reduce and return the viscera within the chest to the abdomen and eliminate the visceral compression of the right heart. The neonatologist shared my concern and also reiterated that this baby’s mother wanted “everything done”. I had little uncertainty as to the etiology of the respiratory failure in this baby. In meeting the mother’s demands I then suggested that the hernia be repaired first, and if there was improvement in the hypoxia and hypercapnea, then give the baby the benefit of the doubt that there is a component of reversibility to the respiratory failure and then proceed with ECMO cannulation. The neonatologist agreed with this suggested plan.I then went to talk with the baby’s mother. I explained my concerns that based on the profound hypercapnea on the arterial blood gases that the baby’s respiratory failure was due to pulmonary hypoplasia and not reversible with extracorporeal support. She insisted that her baby be put on ECMO. I then explained the operative algorithm and... (shrink)