Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study.

BACKGROUND: Ethical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients. OBJECTIVE: We asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress. DESIGN: Semi-structured in-depth qualitative interviews. PARTICIPANTS: Twenty-two internal medicine residents and fellows across three American academic medical centers. APPROACH: This study uses systematic qualitative methods of data gathering, analysis and interpretation. KEY RESULTS: Physician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life. CONCLUSIONS: Moral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful.This study was funded by the Health Resources and Service Administration T32 HP10025-20 Training Grant, the Gates Cambridge Scholarship, Society of General Internal Medicine Founders Grant, and the Ho-Chiang Palliative Care Research Fellowship at the Johns Hopkins School of Medicine.This is the author accepted manuscript. The final version is available from Springer via http://dx.doi.org/10.1007/s11606-015-3505-

Case Study: The Axel Patents-A Case Study in University-Technology Transfer

The Axel Patents are among the most lucrative university patents in history, earning $790 million in royalty revenues for Columbia University. This paper tells the story of the Axel Patents, from the initial scientific discovery, through the decision to patent, to the non-exclusive licensing strategies Columbia used to spread the technology, the measures Columbia took to extend the life of the patents, and the controversy that erupted when another patent was issued in 2002. Columbia plowed most of the revenues back into research, including Richard Axel's work that earned him a Nobel Prize. Columbia's aggressive pursuit of extended patent duration, however, also led it to considerable legal expenditures that have proven fruitless to date, and brought criticism for behavior unbecoming a nonprofit academic institution. This case study showcases a highly successful example of university entrepreneurship, and provides a cautionary tale of an attempted patent extension.Full text of a case study report of Columbia U axel patents. Written by A. Colaianni (2007) and submitted to a journal. (.doc, one doc, 28 pages

Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life.

ContextThe American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals.ObjectiveThe objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior.MethodsSemi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior.ResultsThe interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes.ConclusionInstitutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients

Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study

BackgroundEthical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients.ObjectiveWe asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress.DesignSemi-structured in-depth qualitative interviews.ParticipantsTwenty-two internal medicine residents and fellows across three American academic medical centers.ApproachThis study uses systematic qualitative methods of data gathering, analysis and interpretation.Key resultsPhysician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life.ConclusionsMoral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful

Detection of canine parvovirus type 2c by a commercially available in-house rapid test

Diagnosis of canine parvovirus (CPV) infection is usually carried out by means of rapid immunochromatographic assays, but the ability of these tests to detect all CPV variants, including the recently identified CPV-2c, is still debated. To determine if the assays detect the different CPV variants, 201 CPV PCR-positive faecal samples or rectal swabs were tested using a commercially available in-house test. Specimens (CPV-2a, n = 51; CPV-2b, n = 50; CPV-2c, n = 100), containing CPV DNA loads >10(5) DNA copies/mg faeces, as determined by real-time PCR, were selected from previous studies. The percentage of positive in-house tests was 80.4%, 78.0% and 77.0% for CPV types 2a, 2b and 2c, respectively, confirming the ability of the test to detect the new variant CPV-2c. However, considering the sensitivity limits of the in-house tests that have been observed previously, negative results from the in-house test kit should be confirmed by PCR-based methods

Influence of institutional culture and policies on do-not-resuscitate decision making at the end of life.

IMPORTANCE: Controversy exists regarding whether the decision to pursue a do-not-resuscitate (DNR) order should be grounded in an ethic of patient autonomy or in the obligation to act in the patient's best interest (beneficence). OBJECTIVE: To explore how physicians' approaches to DNR decision making at the end of life are shaped by institutional cultures and policies surrounding patient autonomy. DESIGN, SETTING, AND PARTICIPANTS: We performed semistructured in-depth qualitative interviews of 58 internal medicine physicians from 4 academic medical centers (3 in the United States and 1 in the United Kingdom) by years of experience and medical subspecialty from March 7, 2013, through January 8, 2014. Hospitals were selected based on expected differences in hospital culture and variations in hospital policies regarding prioritization of autonomy vs best interest. MAIN OUTCOMES AND MEASURES: This study identified the key influences of institutional culture and policies on physicians' attitudes toward patient autonomy in DNR decision making at the end of life. RESULTS: A hospital's prioritization of autonomy vs best interest as reflected in institutional culture and policy appeared to influence the way that physician trainees conceptualized patient autonomy. This finding may have influenced the degree of choice and recommendations physician trainees were willing to offer regarding DNR decision making. Trainees at hospitals where policies and culture prioritized autonomy-focused approaches appeared to have an unreflective deference to autonomy and felt compelled to offer the choice of resuscitation neutrally in all situations regardless of whether they believed resuscitation to be clinically appropriate. In contrast, trainees at hospitals where policies and culture prioritized best-interest-focused approaches appeared to be more comfortable recommending against resuscitation in situations where survival was unlikely. Experienced physicians at all sites similarly did not exclusively allow their actions to be defined by policies and institutional culture and were willing to make recommendations against resuscitation if they believed it would be futile. CONCLUSIONS AND RELEVANCE: Institutional cultures and policies might influence how physician trainees develop their professional attitudes toward autonomy and their willingness to make recommendations regarding the decision to implement a DNR order. A singular focus on autonomy might inadvertently undermine patient care by depriving patients and surrogates of the professional guidance needed to make critical end of life decisions.This study was funded by the Health Resources and Service Administration T32 HP10025-­‐20 Training Grant, the Gates Cambridge Scholarship, and the Ho-­‐Chiang Palliative Care Research Fellowship at the Johns Hopkins School of Medicine.This is the accepted manuscript of a paper originally published in JAMA Internal Medicine (Dzeng E, Colaianni A, Roland M, Chander G, Smith TJ, Kelly MP, Barclay S, Levine D, JAMA Internal Medicine 2015, doi:10.1001/jamainternmed.2015.0295)