Treating patients with narcotic analgesics is not simple. Narcotics can be very effective at relieving pain, but they come with a whole set of problems, including risk of adverse effects such as nausea, constipation, and altered mental status; overdose; and dependence. As I've written before, narcotic-dependent patients can be a challenge to treat. One of the tools we use is the "narcotic contract", a document which explicitly states the rights and responsibilities of the health care provider and the patient (although in practice, it tends to put more emphasis on the rights of the provider and the responsibilities of the patient). Two typical examples of such contracts can be found here and here.
Archive for the 'Medical ethics' category
This is a special shout out to the doctors and scientists out there. Everything we do in our fields has repercussions, often unexpected ones. Because of this, we strive to practice ethically to help prevent or minimize negative repercussions.
This discussion comes up specifically as an epiphenomenon of the release of The Immortal Life of Henrietta Lacks (my full review can be found here.) How one reacts to this book would, I suppose, depend on your perspective. A neighbor of the Lacks's might react quite differently than a 22 year old doctoral student. And that's really the point.
This book should be required reading for young scientists and medical students. Ethical practice is important because it recognizes the fact that many negative outcomes are unexpected, and that we as physicians and scientists cannot always anticipate these negative outcomes.
It's good to see some of the comments appearing online about the book, even though many of these are from folks who haven't read it (it's being released on February 2nd). It's natural to become defensive when your beliefs are questioned. Some of the more interesting comments appeared at Ed Yong's place. To catch you up, HeLa is cell culture used in labs around the world. It was derived from a young woman named Henrietta Lacks, a woman dying of cervical cancer in a segregated hospital in 1950's America.
I have to say I completely disagree. Cell lines are derived from Humans on a regular basis, I use cells from a man who died from colon cancer and a young girl who had neuroblastoma. What exactly is the issue here? Would this fuss be made if she hadn't been black and poor? I doubt it.
Her cells were useful but they're not unique and why should her family get money for her cells when other families don't? I've read an article by the author of this book and it was self aggrandising overblown nonsense.
Trying to conflate the real racially motivated problems in the US with this type of cancer research is just insulting to everyone involved, in my opinion.
There has been much written about the doctor-patient relationship, and specifically how to best maintain a clinical distance while at the same time being empathic and compassionate. This is something individual doctors work on throughout their careers, but something else interests me here.
Most physicians derive enjoyment from helping people. Altruism (a topic way too complex for me to pretend to understand in depth) feels good both from the act itself and from the response one gets from the object of the altruism. This last bit has comes with potential pitfalls.
Next week, Val Jones and I are leading a discussion of professional ethics as they intersect with a professional's online life.
Each profession has its own set of ethics and draws its own lines but medicine is what I know best. I'd like to invite participants (or anyone, actually) to proffer ethical dilemmas related to having an online presence.
Some things to think about:
- Some professionals bypass the issue by either staying off the internet or remaining anonymous/pseudonymous. To abandon the internet is like practicing abstinence for STD and pregnancy prevention. To stay offline without considering the problem of "outing" is dangerous.
- Many professionals are entrusted with personal or proprietary information. Aside from legal implications, how should you approach the problem of disclosing too much?
- A professional's reputation is fluid. How can your online life affect this?
These are just a few of the questions I'm hoping people wish to discuss.
No matter how you feel about incarceration, it's a dangerous business. Inmates have high rates of serious transmissible diseases which aren't turned into the warden when they are released. Around 2.5 million people are held in American correctional facilities. HIV rates for imprisoned men 1.6% and for women is 2.4% (compared to about 0.4% among Americans as a whole). About 4.5% of inmates reported sexual victimization. Of the facilities that provide hepatitis B vaccination, 65% target "high risk" groups only. Tuberculosis rates are also very high. This is just a sampling of the horrifying health conditions in jails and prisons.
Prisons are a set up for the transmission of infectious diseases, and when prisoners are released, they return these infections to the public at large. This is one of the many reasons to pay better attention to health care in prisons.
In his latest comment, Philip H has accelerated my reluctant discussion of health care reform. In fact, it was Philip who bullied me into writing about this topic in the first place. I've been avoiding wading into this mess, but being on the front line, it's in my face every day.
What he says in his latest comment is this:
[T]he idealogical leap PalMD is asking for is a good one, but it misses the mark. The leap we need to make is that healthcare is not a good, like Cheerios, or cars, or flatscreen tv's, that exists in anything like a free marketplace.
Commenter Donna B. makes a tangent assertion, that in fact health care is, "a service, a good to be purchased, and is therefore not a "right" as such (she also does not have a problem with government subsidizing or being involved in some way, so don't stomp all over her without reading her full words).
If health care isn't a "good" in the sense of "commodity", and it isn't a "right", then what is it?
Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. --PalMD
A 35 year old man was brought to the Emergency Department(ED) after being found unconscious on a sidewalk. On initial evaluation by emergency personnel, he was otherwise medically stable, with normal vital signs, a clear airway which he was guarding well, and no obvious evidence of trauma. On arrival at the ED, a CT of the brain and X-rays of the neck were normal.
On exam, the patient was initially lethargic, but eventually perked up. He was able to state his name, but did not know the date or location. His physical exam was essentially normal except for occasional low-grade fevers. His neurologic function was intact except for his memory, and some speech difficulties which included difficulty naming objects. The content of his speech was sparse and vague. Further laboratory results revealed some liver and kidney abnormalities, and low blood counts (trilineage).
A close relative was found who noted that the patient did not have any significant medical or substance abuse problems. As the patient's condition did not improve, permission was sought from the relative to perform a bone marrow biopsy to aid in diagnosis and treatment. Permission was refused. When questioned why, the relative noted his own previous bad experiences with "doctors and tests".
What are the ethical issues here, and how might they be resolved?
You can count on the Wall Street Journal for pretty good reporting and for extremist right-wing wackaloonery on the OpEd page. Today, they deliver the latter, with bonus fear-mongering at no extra charge.
The piece is entitled, "GovermentCare's Assault on Seniors" and that pretty much sums up the content of the article. Unfortunately (at least, for the moral health of the author), there is little below the headline to justify the inflammatory headline.
Since I abhor the entombment of real news beneath the Michael Jackson story, I didn't think I'd be posting about it, but here I am. You see, Jackson was reportedly under the "care" of a privately hired physician when he died, and was being treated with medications not normally used outside the hospital. I have a problem with this.
According to the Times, authorities are looking for records at the doctor's Houston office. That's not a bad idea.
I'm not a lawyer, and I don't know if: 1) the doctor was licensed to practice in California, or 2) if a doctor from Texas may practice in California on a Texas license (doubtful). Certainly, a doctor may render emergency care to someone, one human being to another, but the use of injectable medications such as propofol and merperidine in an unmonitored setting seems pretty outside the norm no matter where your license is from.
In order to practice medicine legally in my state, I must hold a valid physician's license, a valid controlled substance license, and in order to prescribe medications, a valid DEA license. In order to avoid disciplinary actions, I must also practice in a way congruent with standard medical practice, for example, maintaining proper documentation. The specific section of the Public Health Code says:
An individual licensed under this article shall keep and maintain a record for each patient for whom he or she has provided medical services, including a full and complete record of tests and examinations performed, observations made, and treatments provided.
If this doc was treating Jackson, he should have been recording Jackson's complaints, his own physical exam findings including vital signs, medication administration including amount, route, and timing---really, everything. This is Medicine 101. Of course, if he was practicing without a valid license, who knows what kind of paper trail he would or would not wish to have.
In the news crapnami that is the Michael Jackson story, one useful lesson might be learned; that of the fatal intersection of power, fame, and medicine. It's not a new lesson, but one that may require quite a bit of repetition. Unfortunately, I think we will have many future opportunities for review.
Everyone who uses the internet leaves some sort of footprint, even if it's just a string of visited addresses. This presence is magnified if you've ever been in the news, been listed on a website (e.g., as faculty), or if you write a blog. Social networking sites such as facebook and Twitter add a whole new dimension of online presence. Everyone should be concerned about what their online presence says about them (if your public Amazon wish list is full of sex toys, for example...) but physicians should have special concerns which fall into some broad categories. First, we'll briefly discuss types of online presence.
Your online life
Who hasn't vanity googled? Googling yourself can be interesting and instructive. If you have publications, are listed on a website as a contributor to a charity, or anything else searchable, someone can find this out. It's probably better to find out for yourself before you hear about it. As mentioned above, public profiles and wish lists at places like facebook, Amazon, and eBay are often included in search results, as are basic components of facebook profiles. Your online presence is dramatically larger if you are involved in web-related activities such as blogging. Even if you blog anonymously, it's likely that eventually, a search will link your real name to your blog and everything you've written there even if you've deleted it. Different types of online presence present different challenges.
- facebook: parts of your profile are visible publicly, and depending on your privacy settings, a great deal of information about you is visible to "friends" and many other members. Critically, this includes your status updates. If you write, "I LOVE CHEEZE!!!" people may think you quirky, but there's little harm. If you write, "I LOVE BONG HITZ!!11!!!" this is information that is going to be available to many others, and there is a good chance that it may become available to colleagues and patients. This would generally be a bad thing.
- Twitter: twitter is like having only the status updates from facebook, but relationships with other tweeters tends to be looser, and many people have hundreds of followers whom they do not know.
- MySpace: if you are on MySpace it's probably past your bedtime (or you're on a special "list").
- Blogs: blogs contain an enormous amount of information about how you think and what you believe, and this information is, for all intents and purposes, permanent.