Arch Intern Med
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Review Practice Guideline Guideline
Ethical considerations in the allocation of organs and other scarce medical resources among patients. Council on Ethical and Judicial Affairs, American Medical Association.
Physicians' efforts on behalf of patients often involve the use of resources that, because of naturally limited supply or economic constraints, are not readily available to all who need them. The dilemma in such cases is how physicians may fulfill their ethical duties to "do all that [they] can for the benefit of the individual patient" when the care that they can provide is constrained by the scarcity of needed resources.
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Review Historical Article
Cardiopulmonary resuscitation. Historical perspectives, physiology, and future directions.
To review the historical evolution and rationale for the development of new techniques of cardiopulmonary resuscitation (CPR). ⋯ Improved methods of CPR are now available. Selective use of CPR in the hospital and community training in the use of these new adjunctive techniques should have the greatest impact on improved survival after sudden cardiac arrest.
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Terminally ill patients often hope that death will come quickly. They may broach this wish with their physicians, and even request assistance in hastening death. Thoughts about accelerating death usually do not reflect a sustained desire for suicide or euthanasia, but have other important meanings that require exploration. ⋯ In all cases, patient requests for accelerated death require ongoing discussion and active efforts to palliate physical and psychological distress. In those infrequent instances when a patient with persistent, irremediable suffering seeks a prompt and comfortable death, the physician must confront the moral, legal, and professional ramifications of his or her response. Rarely, acceding to the patient's request for hastening death may be the least terrible therapeutic alternative.
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Most adults with community-acquired pneumonia are treated as outpatients. Despite this, the majority of studies regarding community-acquired pneumonia have been in hospitalized patients only and may not be applicable to an ambulatory population. This review critically examines the literature regarding the diagnosis, cause, appropriate patient selection, and treatment of nonhospitalized adults with community-acquired pneumonia, including human immunodeficiency virus-infected individuals. ⋯ Viral, mycoplasmal, and chlamydial agents are among the most common pathogens encountered in individuals treated as outpatients, although much variability exists. Many oral antibiotic trials for community-acquired pneumonia have been published, but shortcomings in study design limit their clinical applicability. A treatment algorithm is offered, using the best available data.
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Due to the hormonal and hemodynamic alterations inherent in the surgical experience, acute renal failure is common during the perioperative period. Acute renal failure occurs in 5% of hospital admissions, and the surgical setting is the second most common cause of inpatient acute renal failure. Because this setting has the highest mortality for acute renal failure, recognition of high-risk patients is essential for careful monitoring and prophylactic measures. ⋯ Patients with severe chronic renal failure or end-stage renal disease are at significant risk for development of complications during the perioperative period, due both to renal and nonrenal reasons. Hyperkalemia, infections, arrhythmias, and bleeding commonly occur in these patients during the perioperative period. This population has a reasonable surgical mortality for both general and cardiac surgery, but the extremely high morbidity warrants careful perioperative monitoring and care.