The Surgical clinics of North America
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Surg. Clin. North Am. · Aug 2007
ReviewWithdrawing life-sustaining treatment: ethical considerations.
Withdrawing life-supporting technology from patients who are irremediably ill is morally troubling for caregivers, patients, and families. Interventions that enable clinicians to delay death create situations in which the dignity and comfort of dying patients may be sacrificed to spare professionals and families from their elemental fear of death. Understanding of the limits of treatment, expertise in palliation of symptoms, skillful communication, and careful orchestration of controllable events can help to manage the withdrawal of life support appropriately.
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The role of expert witnesses in medical malpractice litigation is often misunderstood. Much maligned, the expert has been the subject of castigation by a range of people, from his professional colleagues to the jurists who preside over his testimony. From an academic perspective, the expert witness is a necessary evil, and his denigration is his own doing; for the expert is a neutral character who creates his own professional persona. This purpose of this article is to serve as a primer for those interested in understanding the role that the expert is supposed to play in litigation, and the factors surrounding his activities.
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Patient safety and quality of care are inextricably linked. Surgery encompasses such a wide spectrum of diagnosis, treatment, postoperative care, and outpatient follow-up of so many illnesses that quality improvement and patient safety opportunities are numerous and potentially overwhelming. ⋯ In our current climate, this emphasis on quality and safety will remain a high priority. Surgeon leadership at all levels is key to our professional viability.
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Because of better educated patients, more demanding payers, and regulatory agencies, safety and quality have become prominent criteria for evaluating surgical care. Providers are increasingly asked to document these areas, and patients are using this documentation to select surgeons and hospitals. ⋯ Given the complex interplay of structure, process, and outcomes, assessment of surgical quality presents a daunting task. We must firmly establish the links between these elements to validate current and future metrics, while engendering "buy-in'' on the part of surgeons.
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Informed consent plays a major role in forming a therapeutic alliance with the patient. The informed consent process has evolved from simple consent, in which the surgeon needed only to obtain the patient's permission for a procedure, into informed consent, in which the surgeon provides the patient with information about clinically salient features of a procedure, the patient understands this information adequately, and the patient voluntarily authorizes the surgeon to perform the procedure. Special circumstances of informed consent include conflicting professional opinions, consent with multiple physicians, patients who are undecided or refuse surgery, patients with diminished decision-making capacity, surrogate decision making, pediatric assent, and consent for the involvement of trainees.