Farewell to Prognosis in Shared Decision-Making

Whether because of a cultural pattern or personal preference, palliative care clinicians encounter persons approaching the end of life who wish to limit or forego prognostic information relating to their situation. This scenario has received attention in a recent motion picture as well as a newly available advance directive modification—the Prognosis Declaration form. The ordinary expectation for end-of-life shared decision-making with a capable person is clinician disclosure of the best effort at prognostic assessment. The optimal match between the expressed values, goals, and preferences of the person with available clinician expertise is hopefully achieved. For the clinician, a person’s choice to modify information disclosure and participation in shared decision-making represents a significant challenge of balancing key ethical principles of intervention with tolerance and compassion for these different preferences. Attention to communication strategies that elicit and appropriately reassess individual information and decision-making wishes, flexibility in information disclosure patterns with capable persons and their representatives, and recognition that a respect for autonomy includes the choice to opt out can approach this challenge while providing compassionate and ethical end-of-life care

Reference Notes for Palliative Care Consultation

The interprofessional health care specialty of palliative care employs holistic evaluation and person-centered communication in the care of people with life-threatening illness. Palliative care clinicians are consulted for one or more of the following reasons: Symptom assessment and management Assistance with making difficult decisions about continued use or withdrawal of life-sustaining interventions Communication for planning the most appropriate care setting to meet person/family goals for end-of-life care Assessment of suitability and eligibility for hospice care This resource is a compilation of previously published documents and tools useful to palliative care clinicians in preparing for and conduction these consultations. In addition, it can be a reference for students and clinical trainees doing course work, analyzing case studies, or simulating clinical communication scenarios. The materials are indexed for easy retrieval, referenced to acknowledge sources and allow further exploration, and organized into the following categories: Palliative Care Definitions/Domains/Dimensions Communication Symptom Assessment Functional Status Evaluation Prognostication End-of-Life Assessment and Management Symptom Management Hospice Eligibility Criteria Withholding and Withdrawing Life-Sustaining Interventions Pediatric End-of-Life Issueshttps://scholarworks.gvsu.edu/books/1017/thumbnail.jp

The Death Debate: Penumbra Conundrum

Determination and declaration of death by neurologic criteria, brain death, is an established and legally accepted clinical practice with profound implications. Concerns regarding the accuracy of this diagnosis raise important clinical, ethical, and legal issues. A recent magazine article highlights these concerns by describing a poignant example of a patient meeting accepted clinical and ancillary testing criteria for brain death in the setting of post cardiac arrest hypoxic ischemic encephalopathy (CA-HIE). With continuation of ventilatory and nutritional support, this patient not only survived but over time demonstrated findings that were no longer consistent with brain death. Offered here is a review of the course of events described in the article, an overview of the variable clinical implications of CA-HIE and their relationship to the diagnosis of brain death, a proposed pathophysiologic correlation, and recommendations for palliative clinicians providing consultation with regard to goals of care and intervention options in cases of CA-HIE with severe neurologic injury

It’s not about you—it’s about me

Hold Me, a film written and directed by Teace Snyder (2016) was distributed by email to palliative care clinicians and educators. The viewpoint presented here is not a review of this movie as a drama for entertainment. Rather it reviews the film to address the suggestion by its producers that it could serve as an adjunct to palliative care professional education

Why it’s not OK for doctors to participate in executions

A plea for direct physician participation in executions was presented by Sandeep Jauhar in a New York Times Op-Ed (“Why It’s OK for Doctors to Participate in Executions”—April 21, 2017). Jauhar’s article is not a discussion of the ethics of capital punishment. He describes his own opposition “as a matter of principle, as a doctor.” However, since capital punishment is legal in 31 states, with required physician participation in several, he acquiesces to a utilitarian stance rather than the principled approach he acknowledges is expected of a physician in this circumstance

Going beyond ‘do no harm’: a critical annotation

The Op-Ed article in the New York Times (November 4th, 2016), “On Assisted Suicide, Going Beyond Do No Harm” by Haider Javed Warraich provided an articulate and timely plea for more widespread availability and application of physician-assisted dying, or “suicide”, as part of end-of-life medical care. While this profound intervention should be considered by physicians and others as an option for those able to express their wishes at the end-of-life, it must be considered in the context of the ethical principles appropriate for all health care interventions and recognized for its limited role in the overall approach to compassionate care for terminally ill people

The trophic dynamics of summer flounder (Paralichthys dentatus) in Chesapeake Bay

Data on the trophic dynamics of fishes are needed for management of ecosystems such as Chesapeake Bay. Summer flounder (Paralichthys dentatus) are an abundant seasonal resident of the bay and have the potential to impact foodweb dynamics. Analyses of diet data for late juvenile and adult summer flounder collected from 2002−2006 in Chesapeake Bay were conducted to characterize the role of this flatfish in this estuary and to contribute to our understanding of summer flounder trophic dynamics throughout its range. Despite the diversity of prey, nearly half of the diet comprised mysid shrimp (Neomysis spp.) and bay anchovy (Anchoa mitchilli). Ontogenetic differences in diet and an increase in diet diversity with increasing fish size were documented. Temporal (inter- and intra-annual) changes were also detected, as well as trends in diet reflecting peaks in abundance and diversity of prey. The preponderance of fishes in the diet of summer flounder indicates that this species is an important piscivorous predator in Chesapeake Bay

A Case History of Titanium Stress Corrosion in Nitrogen Tetroxide

An investigation of the incompatibility of titanium in certain grades of nitrogen tetroxide will be discussed as a case history. The methodology used in its resolution will point out some of the dangers associate with compatibility testing. The methodology also will present some of the difficulties associated with coordinating an investigation involving many contractors and U. S. Government agencies. The techniques employed in this investigation are described in considerable detail for the benefit of investigators with similar problems

Comment on "Plasma ionization by annularly bounded helicon waves" [Phys . Plasmas 13, 063501 (2006)]

The neoclassical calculation of the helicon wave theory contains a fundamental flaw. Use is made of a proportional relationship between the magnetic field and its curl to derive the Helmholtz equation describing helicon wave propagation; however, by the fundamental theorem of Stokes, the curl of the magnetic field must be perpendicular to that portion of the field contributing to the local curl. Reexamination of the equations of motion indicates that only electromagnetic waves propagate through a stationary region of constant pressure in a fully ionized, neutral medium.Comment: 7 pages, 1 figure, to be published in Phys. Plasmas, http://link.aip.org/link/?PHPAEN/16/054701/