Friday, January 29, 2010

The Meaning of "Nurse" -- Part 2

Rosemary Flanigan
January 29, 2010

In the latest Hastings Center REPORT an article by Stephen R. Latham, “Too Few Physicians, or Too Many?” supports a decades-old research finding that “medical need is not the sole (or even the primary) determinant of health care service provision” and concludes that increasing the numbers of allied health professionals is a better method of addressing a shortage of primary care clinicians, rather than expensively educating new M.D.s.

If nurses, for example, are more present, might they wrest some power in health reform decision-making? Or are increased numbers irrelevant in the power structure?

I thought of the role of nurses especially in end-of-life situations. In the same report, an M.D. tells of letting her demented mother who was dying be moved from the nursing home to the hospital for “initial stabilization and assessment” although the accompanying caveats to hospital staff would fill a page.

In the New York Times a daughter (who is the surrogate) remembers that years ago the father had wanted everything possible done in his dying and so she made that decision even though she knew it was not “reasonable.” And it wasn’t: the father never recovered and died six months later. But she wrote, “My role was to support my father. . . .” As if surrogacy is akin to blind obedience!

An empowered nurse--a skilled health provider, sympathetic caregiver, capable interpreter of complicated medical instructions--could have been of immeasurable help—and saved suffering and resources.

Or will emotion win out over reason every time?


Thursday, January 28, 2010

The Meaning of "Nurse"

Rosemary Flanigan
January 28, 2010

The president and CEO of the Robert Wood Johnson Foundation, Risa Lavizzo-Mourey, has written a short article in Kaiser Health News that every ethics committee ought to ponder.

Think of the meaning of “nurse”:
Skilled health provider.
Sympathetic caregiver.
Trusted dispenser of medicines.
Capable interpreter of complicated medical instructions.

Yet when RWJ partnered with Gallup to conduct an opinion leader survey, it was found that those opinion leaders say our country is not taking advantage of all that nurses have to offer in areas like reducing medical errors and improving patient safety, improving quality of care, promoting wellness and expanding preventive care, improving health care efficiency and reducing costs, coordinating care through the health care system, helping the health care system adapt to an aging population, and increasing access to health care.

Instead, those same opinion leaders rank nurses seventh behind other stakeholders like government officials, insurance executives, pharmaceutical executives, healthcare executives, doctors, and patients, all of whom are perceived to be more influential.

So she calls for a bigger role for nurses in health policy, planning and management.

Do a little survey of your own institution. Let’s start at home to see if we are are profiting from such a great resource.


Wednesday, January 27, 2010

The Two Faces of a Life or Death Dilemma

Lisa Priest
Globe & Mail
January 27, 2010

The two cases raise identical questions: Who decides when medical treatment is futile? When does life-saving care turn into a superhuman effort to prolong death?

Link to article here.


Tuesday, January 26, 2010

"Extraordinary Messiness"

Summer Johnson, PhD
January 26, 2010

Hollywood has taken up orphan diseases before--remember "Lorenzo's Oil"? And bioethics movies generally have been increasingly common, even just in the last year. Think "My Sister's Keeper".

So why all the fuss about "Extraordinary Measures"?

But maybe its the star power, maybe it's actually that it's a decent movie (although very few have said so except New York Magazine), but Extraordinary Measures is getting a great deal of attention as the father-turned-biotech startup investor-turned underdog against the pharmaceutical industry story has hit the big screen.

The only part that is of interest to me about this movie is that it has put a bright light on the path to drug development--and that it is anything but smooth and fraught with politics, financial calculations, and very little to do, ultimately, with saving the most vulnerable and sick among us.

For more click here.


Monday, January 25, 2010

Ashley X Revisited

Norman Fost, MD

John Lantos, MD

8 minutes 20 seconds

The Ashley X case created headlines and raised a host of ethical questions in 2007. Those issues are revisited in the January 2010 issue of The American Journal of Bioethics.

In this edition of The Bioethics Channel, Lorell LaBoube visits with Norman Fost, MD, co-author of the target article in the journal, and John Lantos, MD, who wrote a peer review commentary.

Link: Podcast, Ashley X Revisited


Friday, January 22, 2010

Replacing the Medicare Hospice Benefit

Rosemary Flanigan
January 22, 2010

Because of a query from a friend in Liberty, MO I have just read a Health Affairs article, “A New Medicare End-of-Life Benefit for Nursing Home Residents” by Haiden Huskamp, David Stevenson, et al. (29, No. 1 (2010): 130-135).

The authors allege that high-quality end-of-life care, which is an important component of the final days of many patients in nursing homes, would be better provided by removing the current Medicare hospice benefit and instituting a separate Medicare end-of-life care benefit which would not require that beneficiaries elect it nor would they have to forgo curative care; payment would be folded into the existing nursing home payment; and measurement of the quality of the care would be improved.

Oh, you wise ones out there, this new proposal sounds good to me, even with the potential drawbacks the authors point to. Has this issue come up in your practice?


Wednesday, January 20, 2010

Reasoning through the rationing of end-of-life care

An opinion piece in the January issue of the Journal of Medical Ethics starts with the premise that futile and expensive care at the end of life is widespread, that it has been a major contributor to the increasingly unaffordable cost of healthcare and that the nation is unable to provide it equitably to all.


News Release: Reasoning through the rationing of end-of-life care

Abstract, “Rights, respect for dignity and end-of-life care: time for a change in the concept of informed consent,” John Freeman, MD, Journal of Medical Ethics, January 2010

Rationing Healthcare for the Elderly: Justified?, Practical Bioethics blog, January 15


Tuesday, January 19, 2010

Making or Having a Baby: The Ethics of Genetic Testing

Glenn McGee, PhD
January 15, 2010

A decade ago Molly Nash made headlines when her parents had a baby brother to save her life. Are the ethics of that decision any more clear today than ten years ago?

Glenn McGee thinks not. He explains in this conversation with Lorell LaBoube on The Bioethics Channel. Dr. McGee holds the John B. Francis Chair in Bioethics at the Center for Practical Bioethics.


Podcast: Making or Having a Baby: The Ethics of Genetic Testing, 16 minutes 5 seconds

Embryo genetic screening controversial - and successful, USA Today, January 10, 2010


Monday, January 18, 2010

Honoring Martin Luther King

For many years, the Center for Practical Bioethics has observed Martin Luther King, Jr. Day with both internal and public programs honoring the principles for which he stood.

Our program this year featured Rosemary Flanigan leading a special discussion of “The Pastor’s Wife” which is from the Center’s Bioethics Forum issue Trusting Our Differences.

Below you will find links to audio and video from last year’s program, along with a podcast featuring Helen Emmott.


A Sister of Selma Celebrates Martin Luther King’s Birthday, You Tube, 3 minutes 1 second

A Priest Reflects on Dr. Martin Luther King, You Tube, 3 minutes 12 seconds

Sisters of Selma – Bearing Witness to Change,, 1 hour 17 minutes

Trusting Our Differences, The Bioethics Channel, Helen Emmott, 14 minutes 25 seconds

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Friday, January 15, 2010

Rationing Healthcare for the Elderly: Justified?

Rosemary Flanigan
January 15, 2010

The new issue of Cambridge Quarterly has an excellent short article by philosopher Leonard Fleck, himself 65 years of age, justifying some rationing of healthcare for the elderly besides what is being done now.

First of all, he stakes out his claim carefully: rationing of healthcare based on age is not intrinsically discriminatory. So he makes a careful analysis and comes to a good argument for “surgically precise age-based rationing protocols that have been fairly and democratically legitimated in a range of rationing circumstances where an age-based criterion would yield a more just outcome.”
Take Dr. Michael Debakey, the famed cardiac surgeon who had an aortic aneurysm at age 98. At first he resisted surgery but family and friends wore down his objections. He spent eight months in the hospital—at a cost of $1 million, and survived for a year.

Ought he have consented? Ought society permitted him to assent?

I know, I know, anything goes until we have those “democratically legitimated protocols” but we had better start the process or such protocols will be imposed.

Anyone disagree? And, needless to say, Congress is NOT the place to start!


Thursday, January 14, 2010

Did Anyone Know It Was National Vaccination Week?

January 14, 2010

Thank goodness for good ole local KMBC here in Kansas City ( who reported yesterday that in fact it is the national week of vaccination!

Certainly not me (and I have a PhD in public health). To boot, this news report ( reminded us that influenza (including H1N1) often comes in waves, and this would be the nation's third one, so if you haven't received either the H1N1 or the seasonal flu vaccine yet--get out and get your shots.

Darn right. Because if you get the flu on the third time around and you haven't availed yourself of getting your vaccines, it's your own fault, isn't it, when you get sick? Honestly, how many chances does a person get to escape illness before it's your own responsibility when you get sick?

The third time may be the charm, my dear unvaccinated friends, and the flu bug just may catch you if it hasn't yet. So if you haven't been vaccinated--hop to it. You may not be able to escape the flu bug one last time--and you won't have anyone to blame but yourself.

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Paradoxes in advance care planning

More on studies indicating physician reluctance to talk about end of life. This from our friends at Pallimed.


We've expressed some AD skepticism on the blog before (e.g. where's the data they do anything), and I sometimes wonder when reading research like this that patients view ADs as some sort of abstraction and don't really understand why us clinicans care about them so much.

Which is not to say that most physicians do care about them much.

Part of what I'm saying is that for us as doctors to tell patients they should consider an AD we also need to be talking with them about their expected future, and that the AD is less important to patient care than that actual discussion about what's going to happen, or what will happen if consolidation chemotherapy for your acute leukemia fails.

Link: Paradoxes in advance care planning

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Wednesday, January 13, 2010

Who is Practicing Medicine Here?

Rosemary Flanigan
January 13, 2010

A 72-year old African American woman is brought to the hospital by her 45 year old son. Upon admission she is diagnosed with renal failure, congestive heart failure, and a fever of unknown origin. She is unconscious. She is sent to the ICU and put on dialysis, a ventilator, and vasopressors. A few days later, while she is still unconscious, a PEG tube is inserted.

After a week the patient is showing no signs of improvement and is still unconscious so her family is invited to an ethics consultation on her case. Her family consists of her 45 year old son who is single, her 40 year old daughter, and a ten year old grandson who is autistic.

The entire family lives together in a home owned by the patient. The son says he is employed part-time but does not say where. The daughter is employed full-time but does not have health insurance so the cost of caring for her son takes everything she earns. The main income for the family is the patient’s social security and small pension.

All the caregivers are in agreement that further aggressive care is futile, but the family will not agree to withdraw care. They react angrily to all suggestions that their mother is dying. The consult ends in an impasse.

Two weeks later a hospice nurse calls the family and asks if their mother can be moved to hospice care. The daughter says, “No! and don’t call me again!”

My problem with this case is answering the question, “Who is practicing medicine?” here. The family has duties and responsibilities as does the institution and its practitioners. From what we know, the patient is receiving custodial care, but such care can be provided elsewhere more inexpensively.

Why would practitioners ask the family if the patient can be moved? Why doesn’t the case manager find a facility that will provide the level of care and the family be informed of the move?
Call me MEAN AND HEARTLESS—or call me a good steward of resources. BUT CALL ME SOMETHING!!!


Tuesday, January 12, 2010

No Incentives for Docs to Talk about End of Life

John Carney
January 12, 2010

The reasons doctors don't discuss advanced progressive disease and declining health status with patients more often is that there is no incentive to do so.

Providers get paid to treat, and patients who are willing to undergo progressively burdensome interventions, hoping against hope, get their treatments covered. Docs rarely talk about acute or chronic disease process in stages (early, mid and advanced) even with patients of advanced age.

Patients don't ask. Doctors don't tell.

For years, those of us who've dedicated our lives to improving life in its final chapters resort to blue humor and sad references that Americans are the only people on earth who consider death an optional event. It isn't a laughing matter.

Redirecting goals of treatment to realistic achievable outcomes isn't rocket science Neither is is talking about progressive disease, realistically and compassionately. It may take longer than not talking, but until we value the professional relationship enough to pay for the conversation, it will remain elusive.

We must reframe the conspiracy of silence from its current notion of acceptability to the deceptive practice it is, depriving all of us of the patient autonomy we claim as sacred.

If healthcare reform does nothing more than help realign payment incentives to the point that doctors and patients can abandon magical thinking and address advanced disease more honestly, then maybe something good for both patient and provider can come from the last nine months.
For the eventual and humorless outcomes we all face, it's time.



"The Talk" Difficult for Doctors

More data suggesting how difficult end of life discussions are for medical professionals, patients and families.



Facing End-of-Life Talks, Doctors Choose to Wait
Denise Grady
New York Times
January 11, 2010

Advice that sounds good on paper may be no match for the emotions on both sides when it comes to facing patients and their families and admitting that it will soon be over, that all medicine can offer is a bit of comfort while the patient waits to die.

Link: Link: Caring Conversations, a booklet promoting practical preparations for serious illness or the end of life.


Monday, January 11, 2010

Mobility and Transportation for our Aging Population

Scott Helm, PhD

January 8, 2010

Mobility is more of an issue with our aging population than transportation. Scott Helm, PhD of the Midwest Center for Nonprofit Leadership at the University of Missouri-Kansas City explains in this edition of The Bioethics Channel.

Link: Podcast, 10 minutes 48 seconds


Friday, January 8, 2010

Mandatory Vaccinations for Healthcare Workers

This study involved the Center for Practical Bioethics in 2009. Lauren Douville and John Lantos, MD conducted the survey at Childrens Mercy Hospital in Kansas City, MO.

Most Healthcare Workers Support Compulsory Influenza Vaccinations
Nancy Fowler Larson
Medscape Today
January 5, 2010

Authors of a study in the January issue of Archives of Pediatrics & Adolescent Medicine view immunization as a duty of professionalism and an ethical responsibility, even if it carries a small amount of risk.

Link: Abstract, Health Care Worker Knowledge, Attitudes, and Beliefs Regarding Mandatory Influenza Vaccination, Archives of Pediatrics & Adolescent Medicine, January 2010


Thursday, January 7, 2010

Time for the Tubes to Be Tied?

Summer Johnson, PhD
January 7, 2010

A Massachusetts woman, Tessa Savicki, 35, is suing the physicians, nurses and the medical center she says tied her tubes without her consent after the birth of her ninth child. Savicki has been attacked for being a single octo-mom plus one (of course not all at one time) who is on public assistance and who now is outraged at the "medical mistake" made by the medical center.

We don't know if there were good medical reasons for the tubal ligation. As the facts come out, we will learn more, but for now, let's be clear about where the moral responsibility lies.

Link: Blog on

Wednesday, January 6, 2010

Furthering Effective Ethics Committees

Rosemary Flanigan
January 6, 2009

I want to share with you my resolution for 2010: that I shall work as hard as I can to further the effectiveness of ethics committees. We are a valuable resource within healthcare delivery, and we have built our foundation, edged onto the scene, and for the most part, we are partners.

BUT … across the country the trend is that most case reviews center on end-of-life, and often those cases are handled by the palliative care team, not by us.

I am not trumpeting a turf war here; frankly, those palliative care teams need to be educated as much as early ethics committees, because they are doing ethics.

Rather, I hope to point out other areas where we can make a difference as we made a difference in end-of-life care.

Link: Hospital Ethics Committees: Then and Now, Rosemary Flanigan


Tuesday, January 5, 2010

Top Ten Blogs: Practical Bioethics 2009

Monday, January 4, 2010

Top Ten Episodes: The Bioethics Channel 2009

The Center for Practical Bioethics launched The Bioethics Channel in February 2009. The response has been terrific. Here are the Top Ten episodes ranked by the number of downloads in 2009.


Episode Title & Guest

1. The End of Life Scare, Myra Christopher

2. A Quarter Century of Practical Bioethics, Myra Christopher

3. Healthcare Reform: Deja vu all over again?, John Lantos

4. A Physician's Reflections on Bioethics, Robert Potter

5. Hospital Ethics Committees: Then and Now, Rosemary Flanigan

6. The Ethics of Untreated Pain, Richard Payne

7. Ethics of Babies Born at the Borderline of Viability, John Lantos

8. Why do people still suffer at the end of life?, Myra Christopher

9. Balancing Pain Prosections, Bill Colby

10. The Ethics of OctoMom, John Lantos