Medicine and law
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Developments in legal and medical research concerning end-of-life decisions regarding severely suffering neonates in the Netherlands provide good cause for reflection on specific items of this issue. This article deals with the outcomes of the first national survey on end-of-life practice in Dutch Neonatal Intensive Care Units (NICUs) and examines the legal aspects of the use of medication as a part of this practice. The authors particularly reflect on the application of analgesics and sedatives on the one hand and neuromuscular blockers (NMBs) on the other hand. Furthermore, they focus on different elements of medicinal use such as indication, the moment of administering, dosage, effects of combinations of drugs, the relationship to the causation of death and (failures in) documentation.
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In a public health disaster, such as an influenza pandemic, the focus of medical care shifts from the needs of the individual to those of the community, so that the greatest good for the greatest number may be achieved. In a pandemic it will be necessary to maximize the benefit derived from all available local resources. Triage is the device employed to decide which patients will receive these limited medical resources. ⋯ Yet, based upon the severity of a pandemic it may be necessary and justifiable to include these criteria in making allocation decisions. The extent and manner of inclusion will directly correlate with pandemic severity. This paper considers existing protocols and proposes a manner for fully realizing the goals applicable in a public health crisis.
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Most clinical ethical dilemmas are resolved when the facts are clear, communicated to all involved, and the stakeholders agree on goals consistent with the patient's best interests and values. However, in some instances, participants continue to remember and observe the same situation differently, and resolution remains elusive. This article refers to the classic film, Rashomon, in which the truth remains different for four observers of the same scene. The discussion explores the phenomenon, provides some examples and recommendations for what remain very difficult ethical dilemmas.
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The vast majority of hospitals use clinical ethics consultation (CEC) as a service to address ethical issues in patient care. Both proponents and critics alike recognize a need to evaluate CEC. I review three outcomes of CEC that have been formally evaluated: healthcare cost, clinical indicators in the intensive care unit, and user satisfaction. ⋯ However, the failure of outcomes-based assessment poses no threat to CEC since the service is continually justified by the fundamental necessity of resolving ethical problems in patient care. While outcome indicators can be used as heuristics to investigate quality issues in CEC, process indicators can capture the quality of CEC more directly. Therefore, further research should be directed toward developing process-based conceptual models for CEC and various methods for assessing these processes.