Articles: emergency-medicine.
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Advance directives are becoming more common in the health care system in the United States. Advance directives include "living wills," "durable powers of attorney for health care," "do not resuscitate orders," and the newer "medical directive." They are designed to allow individuals to determine the course of their medical care in the event that they are no longer able to transmit the information to their physician. The US Supreme Court's recent Cruzan decision increased the importance of these legal instruments by declaring that "clear and convincing" evidence may be required by states in order to terminate life support in a patient unable to express his wishes about care. ⋯ Emergency physicians have the opportunity to assist their patients in advance by disseminating advance directives to those who have contact with the emergency department: patients, family members, friends, health care workers, emergency medical services personnel, and police. A plan is suggested that includes education, the availability of advance directives, personnel available to help with completion of the documents, and immediate entry of the directive into a medical chart, if requested. This is in conformance with a recent policy adopted by the American College of Emergency Physicians.
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There are currently 20 autonomous departments of emergency medicine in United States medical schools. EDs seeking autonomous status should institute a faculty development program to channel faculty energy into worthwhile research projects; establish protected time for clinical faculty to increase research productivity; develop expertise to compete for extramural funding; initiate an intramural research program so that faculty can learn the basics of grantsmanship; teach health care issues in ambulatory medicine; become involved in interdisciplinary teaching programs and curriculum development; maintain the present faculty commitment to 24-hour attending coverage; and develop university-based programs that originate from the ED. Program directors should establish liaisons with the medical school dean to acquaint him with the advantages of an autonomous department of emergency medicine; attempt to assess other relationships within the medical school to determine support for emergency medicine and to uncover and address opposition to autonomous departmental status; attempt to serve on medical school committees to meet other faculty, solve problems with them and develop trusting relationships; and develop broad-based support for autonomous departmental status both within and outside of the university. By devising and following a deliberate approach to attaining departmental status, emergency medicine will be assured of continued growth in the important decade ahead.
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Emergency physicians as individuals, as groups, or as corporations, have medical and legal relationships with hospitals, other physicians, and nurses. These relationships sometimes result in liability for alleged negligence being applied in complex and unexpected ways. ⋯ Conversely, other parties, such as hospitals, may be held liable for the acts of emergency physicians. This paper explores the history of hospital responsibility for patient care and examines how hospital policies and actions often impact on emergency care.