JAMA : the journal of the American Medical Association
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A newly established formal ethics consultation service in a university teaching hospital was prospectively evaluated. A physician-ethicist interviewed and examined patients, interviewed family and others as needed, and entered a formal consultation note in the medical record. The requesting physician and the consultant independently completed structured questionnaires. ⋯ Assistance with more than one issue was sought in 39 cases (76%). In 36 cases (71%), the requesting physician stated that the consultation was "very important" in patient management, in clarifying ethical issues, or in learning about medical ethics. We conclude that ethics consultation performed by physician-ethicists provides useful, clinically acceptable assistance in a teaching hospital.
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We present in detail a case of a 27-year-old primigravida who was maintained in a brain-dead state for nine weeks. An apparently normal and healthy male infant weighing 1440 g was delivered. The newborn did well and was found to be growing and developing normally at 18 months of age. Although the technical aspects of prolonged life support are demanding and the economic costs are very high (+217,784), there are ample ethical arguments justifying the separation of brain death and somatic death and the maintenance of the brain-dead mother so that her unborn fetus can develop and mature.
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The measurement of arterial blood lactate concentration for the purpose of estimating the severity and prognosis of acute perfusion failure is suspect because of theoretical errors due to systemic "lactate washout" immediately following restoration of perfusion. If arterial lactate concentrations continue to increase following resuscitation, the assumption that increasing lactate concentrations indicate progression of anaerobiosis due to perfusion failure would be invalidated. Lactate washout was therefore investigated in a porcine model of cardiac arrest due to electromechanical dissociation. ⋯ In 24 animals in whom resuscitation efforts failed, arterial lactate concentrations increased throughout the observation period. Lactate washout occurred during an interval of only 2.6 +/- 0.3 minutes (mean +/- SEM). These results indicate that lactate measurements are not invalidated because of a washout phenomenon under the extreme conditions of cardiac arrest.