Faculty Bibliography

CONTEXT/BACKGROUND:Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. OBJECTIVES/OBJECTIVE:To determine if intensity of vasopressor therapy accurately predicts in-hospital death. METHODS:This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. RESULTS:A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. CONCLUSION/CONCLUSIONS:When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family.

With narrow exception, physicians' treatment of incapacitated patients requires the consent of health surrogates. Although the decision-making authority of surrogates is appropriately broad, their moral authority is not without limits. Discerning these bounds is particularly germane to ethically complex treatments and has important implications for the welfare of patients, for the professional integrity of clinicians, and, in fact, for the welfare of surrogates. Palliative sedation is one such complex treatment; as such, it provides a valuable model for analyzing the scope of surrogates' moral authority. Guidelines for palliative sedation that present it as a "last-resort" treatment for severe and intractable suffering yet require surrogate consent in order to offer it are ethically untenable, precisely because the moral limits of surrogate authority have not been considered.

BACKGROUND:Malignant bowel obstruction is a highly symptomatic, often recurrent, and sometimes refractory condition in patients with intra-abdominal tumor burden. Gastro-intestinal symptoms and function may improve with anti-inflammatory, anti-secretory, and prokinetic/anti-nausea combination medical therapy. OBJECTIVE:To describe the effect of octreotide, metoclopramide, and dexamethasone in combination on symptom burden and bowel function in patients with malignant bowel obstruction and dysfunction. DESIGN/METHODS:A retrospective case series of patients with malignant bowel obstruction (MBO) and malignant bowel dysfunction (MBD) treated by a palliative care consultation service with octreotide, metoclopramide, and dexamethasone. Outcomes measures were nausea, pain, and time to resumption of oral intake. RESULTS:12 cases with MBO, 11 had moderate/severe nausea on presentation. 100% of these had improvement in nausea by treatment day #1. 100% of patients with moderate/severe pain improved to tolerable level by treatment day #1. The median time to resumption of oral intake was 2 days (range 1-6 days) in the 8 cases with evaluable data. Of 7 cases with MBD, 6 had For patients with malignant bowel dysfunction, of those with moderate/severe nausea. 5 of 6 had subjective improvement by day#1. Moderate/severe pain improved to tolerable levels in 5/6 by day #1. Of the 4 cases with evaluable data on resumption of PO intake, time to resume PO ranged from 1-4 days. CONCLUSION/CONCLUSIONS:Combination medical therapy may provide rapid improvement in symptoms associated with malignant bowel obstruction and dysfunction.

Moral distress is the experience of cognitive-emotional dissonance that arises when one feels compelled to act contrary to one's moral requirements. Moral distress is common, but under-recognized in medical education and training, and this relative inattention may undermine educators' efforts to promote empathy, ethical practice, and professionalism. Moral distress should be recognized as a feature of the clinical landscape, and addressed in conjunction with the related concerns of negative role modeling and the goals and efficacy of medical ethics curricula.

Proportionality, as it pertains to palliative sedation, is the notion that sedation should be induced at the lowest degree effective for symptom control, so that the patient's consciousness may be preserved. The pursuit of proportionality in palliative sedation is a widely accepted imperative advocated in position statements and guidelines on this treatment. The priority assigned to the pursuit of proportionality, and the extent to which it is relevant for patients who qualify for palliative sedation, have been overstated.

This retrospective of the last quarter century of clinical ethics offers an examination of some of the areas in which it should focus, and refocus, attention in the next.