Faculty Bibliography

Recent instances of governments and others refusing humanitarian assistance to refugees and IDPs (internally-displaced persons) unless they agreed to polio immunization for their children raise difficult ethical challenges. The authors argue that states have the right and a responsibility to require such vaccinations in instances where the serious vaccine-preventable disease(s) at issue threaten others, including local populations, humanitarian workers, and others in camps or support settings.

BACKGROUND: Unilateral Do-Not-Resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. We investigated whether electrophysiology practitioners believe medical futility justifies unilateral ICD deactivation. METHODS AND RESULTS: Email invitations to take an online survey were sent to 1,894 EP practitioners. 384 responses were collected (response rate 20.6%). Though the sample included respondents from Europe, Asia, Australia, South American and Africa, the majority were from North American (78%), were academically affiliated (64%) and practiced in an urban setting (67.8%). Deactivation of ICD shock function in agreement with patient wishes and a pre-existing DNR was not considered physician assisted suicide (93.2%, 358/384). However, a majority of the sample responded that it was not ethical/moral for doctors to deactivate ICDs against patients' wishes (77.1%, 296/384) or against family/surrogates' wishes (72.4%, 278/384), even in the context of medical futility. A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding CPR or external defibrillation in a code (72.7%, 277/381) but was different than deactivating pacing in a pacemaker-dependent patient (82.8%, 318/384). In the classification of interventions, a plurality (43.0%, 165/383) regarded ICD's to be unlike any other intervention. Concerning pacemakers, 50% (191/382) considered them to be like dialysis (a therapy which keeps patients alive). CONCLUSIONS: This international sample of electrophysiology practitioners considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not

STUDY OBJECTIVE: Frequent emergency department (ED) users with severe alcohol use disorders are often excluded from research, in part because assessing capacity to provide consent is challenging. We aim to assess the feasibility of using the University of California, San Diego Brief Assessment of Capacity to Consent, a 5-minute, easy-to-use, validated instrument, to screen for capacity to consent for research in frequent ED users with severe alcohol use disorders. METHODS: We prospectively enrolled a convenience sample of 20 adults to assess their capacity to provide consent for participation in 30-minute mixed-methods interviews using the 10-question University of California, San Diego Brief Assessment of Capacity to Consent. Participants were identified through an administrative database, had greater than 4 annual ED visits for 2 years, and had severe alcohol use disorders. The study was conducted with institutional review board approval from March to July 2013 in an urban, public, university ED receiving approximately 120,000 visits per year. Blood alcohol concentration and demographic data were extracted from the medical record. RESULTS: We completed assessments for 19 of 20 participants. One was removed because of agitation. Sixteen of 19 participants passed each question and were deemed capable of providing informed consent. Interventions to improve understanding (prompting and material review) were required for 15 of 19 participants. The mean duration to describe the study and perform the assessment was 10.4 minutes (SD 3 minutes). The mean blood alcohol concentration was 211.5 mg/dL (SD 137.4 mg/dL). The 3 patients unable to demonstrate capacity had blood alcohol concentrations of 226 and 348 mg/dL, with 1 not obtained. CONCLUSION: This pilot study supports the feasibility of using the University of California, San Diego Brief Assessment of Capacity to Consent to assess capacity of frequent ED users with severe alcohol use disorders to participate in research. Blood alcohol concentration was not correlated with capacity.

'Calling' a code can be an ambiguous undertaking. Despite guidelines and the medical literature outlining when it is acceptable to stop resuscitation, code cessation and deciding what not to do during a code, in practice, is an art form. Familiarity with classic evidence suggesting most codes are unsuccessful may influence decisions about when to terminate resuscitative efforts, in effect enacting self-fulfilling prophesies. Code interventions and duration may be influenced by patient demographics, gender or a concern about the stewardship of scarce resources. Yet, recent evidence links longer code duration with improved outcomes, and advances in resuscitation techniques complicate attempts to standardise both resuscitation length and the application of advanced interventions. In this context of increasing clinical and moral uncertainty, discussions between patients, families and medical providers about resuscitation plans take on an increased degree of importance. For some patients, a 'bespoke' resuscitation plan may be in order.

OBJECTIVE:Fertility preservation (FP) is a widespread practice in paediatric oncology when gonadotoxic medications such as cyclophosphamide (CPO) are used. FP practice outside of oncology has not been studied, although nephrologists regularly use CPO. This is the first study to explore FP practice by paediatric nephrologists when CPO is used. DESIGN/METHODS:Survey study. Descriptive statistics and chi-squared analyses were employed to analyse the data. PARTICIPANTS/METHODS:US paediatric nephrologists were sent a survey via email. The survey queried participants about FP practice behaviours, FP attitudes and barriers to practice. MAIN OUTCOME MEASURES/METHODS:Of 579 nephrologists invited, 32% responded to the survey. RESULTS:CPO was dosed in mg/kg by 23% of physicians, g/m(2) by 40% and both by 37%. About 80% agreed that pubertal females should be offered a fertility referral, while 58% report that they actually refer. Factors negatively associated with referral include lack of training, lack of referral network and adherence to gonadotoxic dose limits. Results were similar for male patients. CONCLUSION/CONCLUSIONS:The survey showed that FP practice in the United States is widespread among nephrologists. Lack of referral networks is a notable barrier for nephrologists. Perceived adherence to dose limits may be problematic given the variable dosing regimens utilised. This is due to the risk of unintended overdose in large adolescents dosed in mg/kg whose cumulative dose exceeds gonadotoxic limits in g/m(2) . This paper has implications for nephrology care providers and other specialists who utilise CPO, generalists who care for these patients and oncologists with extant FP referral networks.

BACKGROUND:Quality reporting is increasingly used as a tool to encourage health systems, hospitals, and their practitioners to deliver the greatest health benefit. However, quality reporting systems may have unintended negative consequences, such as inadvertently encouraging "cherry-picking" by inadequately adjusting for patients who are challenging to take care of, or underpowering to reliably detect meaningful differences in care. There have been no reports seeking to identify a minimum level of accuracy that ought to be viewed as a prerequisite for quality reporting. METHOD/METHODS:Using a decision analytic model, we seek to delineate minimal standards for quality measures to meet, using the simplest assumptions to illustrate what those standards may be. RESULTS:We find that even under assumptions regarding optimal performance of the quality reporting system (sensitivity and specificity of 1), we can identify a minimal level of accuracy required for the quality reporting system to "do no harm": the increase in health-related quality of life from a higher rather than lower quality practitioner must be greater than the number of practitioners per patient divided by the proportion of patients willing to switch from a lower to a higher quality provider. CONCLUSION/CONCLUSIONS:Quality measurement systems that have not been demonstrated to improve health outcomes should be held to a specific standard of measurement accuracy.

Various strategies have been pushed to solve the problem, such as creating medical schools that emphasize educating primary-care providers, increasing the number of residencies for medical school graduates, and expanding the number and authority of non-physician providers of primary care to include nurse practitioners, physician assistants, psychologists and pharmacists. The real question is, can someone who successfully got through four years of medical school, including a lot of clinical time, who is supervised and certified by another doctor for a month and by the state board but who is probably not near the top of their class, deliver high-quality primary care to people who currently have nothing? I think we don't know