Perspectives in biology and medicine
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Unprecedented advances in biomedical research and the upheaval in health care economics have converged to cause seismic changes in the traditional organization of medical schools and academic health centers. This process is particularly evident in departments of internal medicine. The activities and functions of academic medicine are in the midst of separation and realignment along lines that do not honor historical departmental and divisional boundaries. The organization of a successful medical school or department must be dynamic, constantly serving its constituents to accommodate progress and change and to promote optimal structure for academic productivity.
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Families making difficult end-of-life decisions in the intensive care unit often do not exercise their autonomy in accord with the individualistic philosophic and legal models that currently prevail. Instead, they try to avoid responsibility and deny complicity, even for decisions that they ultimately approve. ⋯ Dostoevsky's The Brothers Karamazov and Kenzaburo Oe's A Personal Matter explore the patterns of communication by which people in such situations test complicity and share or submerge accountability. The psychological similarities between the novelists' portrayals and the actual processes that families undergo in the ICU have practical clinical implications for the ways physicians approach discussions about do not resuscitate (DNR) orders with patients' family members.