Limits of advance directives in decision-making around food and nutrition in patients with dementia

Advance directives are critically important for capable individuals who wish to avoid the burdens of life-prolonging interventions in the advanced stages of dementia. However, this paper will argue that advance directives should have less application to questions about feeding patients during the clinical course of dementia than often has been presumed. The argument will be framed within the debate between Ronald Dworkin and Rebecca Dresser regarding the moral authority of precedent autonomy to determine an individual's future end-of-life care plan. We will use a brief analysis of the positions taken in two important papers that come out of the Dworkin/Dresser debate and a hypothetical patient, John, who will be followed from diagnosis of dementia to death, to show how advance directives should apply to key points in the progression of his disease, particularly in relation to food and nutrition.

Is There a Case for Palliative Care Addiction Psychiatry?

This commentary on a case suggests how palliative care psychiatry can facilitate compassionate resolution of ethical conflicts in end-of-life care decision making with persons with substance use disorders.

Veterans Health Administration response to 2021 recall of Philips Respironics devices: A case study

This case study describes, for the time frame of June 2021 through August 2022, the U.S. Veterans Health Administration (VHA) organizational response to a manufacturer's recall of positive airway pressure devices used in the treatment of sleep disordered breathing. VHA estimated it could take over a year for Veterans to receive replacement devices. Veterans awaiting a replacement faced a dilemma. They could continue using the recalled devices and bear the product safety risks that led to the recall, or they could stop using them and bear the risks of untreated sleep disordered breathing. Using a program monitoring approach, we report on the processes VHA put in place to respond to the recall. Specifically, we report on the strategic, service, and operational plans associated with VHA's response to the recall for Veterans needing replacement devices. In program monitoring, the strategic plan reflects the internal process objectives for the program. The service plan articulates how the delivery of services will intersect the customer journey. The operational plan describes how the program's resources and actions must support the service delivery plan. VHA's strategic plan featured a clinician-led, as opposed to primarily legal or administrative response to the recall. The recall response team also engaged with VHA's medical ethics service to articulate an ethical framework guiding the allocation of replacement devices under conditions of scarcity. This framework proposed allocating scarce devices to Veterans according to their clinical need. The service plan invited Veterans to schedule visits with sleep providers who could assess their clinical need and counsel them accordingly. The operational plan distributed devices according to clinical need as they became available. Monitoring our program processes in real time helped VHA launch and adapt its response to a recall affecting more than 700,000 Veterans.

Crossing State Lines: Ethical and Clinical Considerations in Treating a Child With Catatonia

Catatonia is a complex constellation of symptoms presenting with abnormalities in movement and behavior and arises from multiple medical, neurologic, and psychiatric conditions. In recent years, there has been a call to move catatonia from a classifier to a diagnosis of its own in the DSM-5.^1,2 Catatonia is often underdiagnosed in the hospital and carries with it substantial morbidity and mortality.³ Malignant catatonia, characterized by autonomic instability, hyperactivity, mutism, and stuporous exhaustion, is a medical emergency requiring intensive care.⁴ Early diagnosis and treatment are imperative, as untreated malignant catatonia may be fatal in up to 10% to 20% of cases, sometimes only days from onset.⁵ The combination of lorazepam and electroconvulsive therapy (ECT) is a safe and effective treatment for catatonia in both adults and children, although the body of literature pertaining to children remains limited.^6,7 In addition, there are multiple case reports of improvement in catatonia with ECT regardless of etiology.⁸ However, laws in some US states prohibit ECT's use despite evidence of its effectiveness and safety in children and adolescents.⁹ Here, we describe a case presentation that was both prolonged and complicated by state laws pertaining to the use of ECT in children and adolescents.

Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures

Much of the sustained attention on pandemic preparedness has focused on the ethical justification for plans for the "crisis" phase of a surge when, despite augmentation efforts, the demand for life-saving resources outstrips supply. The ethical frameworks that should guide planning and implementation of the "contingency" phase of a public health emergency are less well described. The contingency phase is when strategies to augment staff, space, and supplies are systematically deployed to forestall critical resource scarcity, reduce disproportionate harm to patients and health care providers, and provide patient care that remains functionally equivalent to conventional practice. We describe an ethical framework to inform planning and implementation for COVID-19 contingency surge responses and apply this framework to 3 use cases. Examining the unique ethical challenges of this mediating phase will facilitate proactive ethics conversations about healthcare operations during the contingency phase and ideally lead to ethically stronger health care practices.

From implementation to sustainment: A large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration

In 2008, the Veterans Health Administration published a groundbreaking policy on disclosing large-scale adverse events to patients in order to promote transparent communication in cases where harm may not be obvious or even certain. Without embedded research, the evidence on whether or not implementation of this policy was generating more harm than good among Veteran patients was unknown. Through an embedded research-operations partnership, we conducted four research projects that led to the development of an evidence-based large-scale disclosure toolkit and disclosure support program, and its implementation across VA healthcare. Guided by the Consolidated Framework for Implementation Research, we identified specific activities corresponding to planning, engaging, executing, reflecting and evaluating phases in the process of implementation. These activities included planning with operational leaders to establish a shared research agenda; engaging with stakeholders to discuss early results, establishing buy-in of our efforts and receiving feedback; joining existing operational teams to execute the toolkit implementation; partnering with clinical operations to evaluate the toolkit during real-time disclosures; and redesigning the toolkit to meet stakeholders' needs. Critical lessons learned for implementation success included a need for stakeholder collaboration and engagement, an organizational culture involving a strong belief in evidence, a willingness to embed researchers in clinical operation activities, allowing for testing and evaluation of innovative practices, and researchers open to constructive feedback. At the conclusion of the research, VA operations worked with the researchers to continue to support efforts to spread, scale-up and sustain toolkit use across the VA healthcare system, with the final goal to establish long-term sustainability.

A new Collinear Apparatus for Laser Spectroscopy and Applied Science (COALA)

We present a new collinear laser spectroscopy setup that has been designed to overcome systematic uncertainty limits arising from high-voltage and frequency measurements, beam superposition, and collisions with residual gas that are present in other installations utilizing this technique. The applied methods and experimental realizations are described, including an active stabilization of the ion-source potential, new types of ion sources that have not been used for collinear laser spectroscopy so far, dedicated installations for pump-and-probe measurements, and a versatile laser system referenced to a frequency comb. The advanced setup enables us to routinely determine transition frequencies, which was so far demonstrated only for a few cases and with lower accuracy at other facilities. It has also been designed to perform accurate high-voltage measurements for metrological applications. Demonstration and performance measurements were carried out with Ca⁺ and In⁺ ions.

The Role of Communication and Interpersonal Skills in Clinical Ethics Consultation: The Need for a Competency in Advanced Ethics Facilitation

Clinical ethics consultants (CECs) often face some of the most difficult communication and interpersonal challenges that occur in hospitals, involving stressed stakeholders who express, with strong emotions, their preferences and concerns in situations of personal crisis and loss. In this article we will give examples of how much of the important work that ethics consultants perform in addressing clinical ethics conflicts is incompletely conceived and explained in the American Society of Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation and the clinical ethics literature. The work to which we refer is best conceptualized as a specialized type of interviewing, in which the emotional barriers of patients and their families or surrogates can be identified and addressed in light of relevant ethical obligations and values within the context of ethics facilitation.