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Maboloc CR, Cutillas A. An Ethics of Justice in Elderly Care: Ageism and the Covid-19 Pandemic. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2023:2752535X231219017. [PMID: 38016043 DOI: 10.1177/2752535x231219017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
BACKGROUND The study looks into the condition of elderly Covid-19 patients regarding the kind of attention they received during the pandemic given the scarcity of medical resouces in the countries mentioned in this investigation. In this case, we apply the bioethical principle of justice on the age-based criteria in determining which patient must receive treatment The argument is that the same is a form of discimination against the elderly. PURPOSE The purpose of this study is to emphasize that the age-based criteria in deciding whether to treat elderly Covid-19 patients or not is violative of the bioethical principle of justice since it discriminates against them. METHOD This study uses the interpretive method. The authors analyzed the literature and the arguments pertaining to the issue of ageism at the height of the Covid-19 Pandemic. We mentioned the countries where the issue of prioritization was a big concern. The qualitative analysis in this paper is meant to respond to such medical dilemma. ANALYSIS In our analysis, we determined that when age is used as a criterion, it violates the bioethical principle of justice. The principle is meant to ensure that physicians are fair in dealing with patients. Using age in deciding whether a life is worth saving or not is a prejudice against old people who require care and attention. DISCUSSION Medical doctors must treat patients equally and without bias. The challenge, however, is that due to the unprecedented nature of the pandemic, a triage is put in place to be able to manage the overwhelming influx of Covid-19 patients. Some age-based medical treatment criteria that recommend age-based cutoffs for specific treatments are morally untenable. This is because the same is bereft of any acceptable justification that warrants the judgment that the elderly must have less priority when medical resources are scarce. CONCLUSION In conclusion, doctors must not discriminate patients on the basis of age. All lives are equal in moral worth. We argue that governments must promulgate non-discriminatory policies when it comes to medical treatment during a global public health emergency.
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Berkman E, Clark J, Diekema D, Jecker NS. A world away and here at home: a prioritisation framework for US international patient programmes. JOURNAL OF MEDICAL ETHICS 2022; 48:557-565. [PMID: 33753472 DOI: 10.1136/medethics-2020-106772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 02/10/2021] [Accepted: 02/13/2021] [Indexed: 06/12/2023]
Abstract
Programmes serving international patients are increasingly common throughout the USA. These programmes aim to expand access to resources and clinical expertise not readily available in the requesting patients' home country. However, they exist within the US healthcare system where domestic healthcare needs are unmet for many children. Focusing our analysis on US children's hospitals that have a societal mandate to provide medical care to a defined geographic population while simultaneously offering highly specialised healthcare services for the general population, we assume that, given their mandate, priority will be given to patients within their catchment area over other patients. We argue that beyond prioritising patients within their region and addressing inequities within US healthcare, US institutions should also provide care to children from countries where access to vital medical services is unavailable or deficient. In the paper, we raise and attempt to answer the following: (1) Do paediatric healthcare institutions have a duty to care for all children in need irrespective of their place of residence, including international patients? (2) If there is such a duty, how should this general duty be balanced against the special duty to serve children within a defined geographical area to which an institution is committed, when resources are strained? (3) Finally, how are institutional obligations manifest in paradigm cases involving international patients? We start with cases, evaluating clinical and contextual features as they inform the strength of ethical claim and priority for access. We then proceed to develop a general prioritisation framework based on them.
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Affiliation(s)
- Emily Berkman
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jonna Clark
- Division of Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Douglas Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
- Division of Pediatric Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Nancy S Jecker
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Close E, White BP, Willmott L. Balancing Patient and Societal Interests in Decisions About Potentially Life-Sustaining Treatment : An Australian Policy Analysis. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:407-421. [PMID: 32964352 DOI: 10.1007/s11673-020-09994-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND This paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources. METHODS All publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation. RESULTS Four resource-related themes were identified: (1) doctors' ethical duties to consider resource allocation; (2) balancing ethical obligations to patient and society; (3) fair process and transparent resource allocation; and (4) legal guidance on distributive justice as a rationale to limit life-sustaining treatment. CONCLUSION Of the policies that addressed resource allocation, this review found broad agreement about the existence of doctors' duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia.
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
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Rubin MA, Bonnie RJ, Epstein L, Hemphill C, Kirschen M, Lewis A, Suarez JI. AAN position statement: The COVID-19 pandemic and the ethical duties of the neurologist. Neurology 2020; 95:167-172. [PMID: 32414880 DOI: 10.1212/wnl.0000000000009744] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022] Open
Abstract
Patients, clinicians, and hospitals have undergone monumental changes during the coronavirus disease 2019 (COVID-19) pandemic. This crisis has forced us to consider the obligations that we neurologists have to our individual patients as well as the greater community. By returning to our fundamental understanding of these duties, we can ensure that we are providing the most ethically appropriate contingency and crisis care possible. We recommend specific adaptations to both the inpatient and outpatient settings, as well as changes to medical and trainee education. Furthermore, we explore the daunting but potentially necessary implementation of scare resource allocation protocols. As the pandemic evolves, we will need to adapt continuously to these rapidly changing circumstances and consider both national and regional standards and variation.
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Affiliation(s)
- Michael A Rubin
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Richard J Bonnie
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Leon Epstein
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Claude Hemphill
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Kirschen
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ariane Lewis
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jose I Suarez
- From the Department of Neurology & Neurotherapeutics and Neurological Surgery (M.A.R.), University of Texas Southwestern Medical Center, Dallas; Schools of Law, Medicine, and Public Policy (R.J.B.), University of Virginia, Charlottesville; Department of Pediatrics (L.E.), Northwestern University Feinberg School of Medicine, Chicago, IL; Departments of Neurology and Neurological Surgery (C.H.), University of California, San Francisco; Departments of Anesthesiology, Critical Care Medicine, Pediatrics and Neurology (M.K.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Departments of Neurology and Neurosurgery (A.L.), New York University Langone Medical Center, New York; and Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery (J.I.S.), The Johns Hopkins University School of Medicine, Baltimore, MD
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Close E, White BP, Willmott L, Gallois C, Parker M, Graves N, Winch S. Doctors' perceptions of how resource limitations relate to futility in end-of-life decision making: a qualitative analysis. JOURNAL OF MEDICAL ETHICS 2019; 45:373-379. [PMID: 31092631 DOI: 10.1136/medethics-2018-105199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility. SETTING Three tertiary hospitals in metropolitan Brisbane, Australia. DESIGN Qualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis. RESULTS Doctors' perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing. CONCLUSIONS Doctors' ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors' role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- Faculty of Social and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Berkman ER, Clark JD, Diekema DS, Lewis-Newby M. "We Can Do Anything but We Can't Do Everything": Exploring the Perceived Impact of International Pediatric Programs on U.S. PICUs. Front Pediatr 2019; 7:470. [PMID: 31803696 PMCID: PMC6873788 DOI: 10.3389/fped.2019.00470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/28/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose: Every year, an increasing number of international patients seek medical care in the United States (U.S.), yet little is known about their impact. Based on single institution experiences, we wanted to explore the perceived impact of international pediatric patients on large academic U.S. pediatric intensive care units (PICUs), as they are already taxed systems. Methods: To explore current perceptions, seven geographically diverse institutions who advertise care for international patients on their websites and have ≥24 PICU beds were identified after IRB approval was obtained. We consented and interviewed PICU division chiefs or medical directors from each institution regarding their demographics and international patients. Common themes were identified. Results: Participating institutions were diverse in geographic location, census, and resource allocation strategies. Five of the seven institutions reported the presence of a formal international patient program. Four of those five reported an increase in international patients receiving PICU care over the past 5 years. International patients sought complex surgeries, advanced cancer treatments and metabolic/genetic evaluations. We identified three primary domains that require further exploration and research: (1) cultural and language differences leading to barriers in providing optimal care to international patients (2) institutional financial considerations, and (3) perceived positive and negative impact on the care of local/domestic patient populations. Conclusions: The presence of international programs raises a number of important ethical questions, including whether clinicians have a greater duty to serve residents of the local community as opposed to international patients when resources are limited. Further exploration is warranted.
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Affiliation(s)
- Emily R Berkman
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States
| | - Jonna D Clark
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States
| | - Douglas S Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Emergency Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
| | - Mithya Lewis-Newby
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Critical Care Medicine, Section of Pediatric Cardiac Critical Care, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States
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McDonald MJ. The Muddied Understanding of Brain Death. J Pediatr Intensive Care 2017; 6:227-228. [PMID: 31073454 DOI: 10.1055/s-0037-1604011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Mark J McDonald
- Division of Pediatric Critical Care, Department of Pediatrics, Norton Children's Hospital, University of Louisville, Louisville, Kentucky, United States
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