Ethics (clinical and business)

The War That No One Wins

My uncle just died.  He was my mother's brother,  an irascible blowhard, a mercurial bit of a family dictator with a soft spot for small children. He had the unfortunately common clinical course of catastrophic illness followed by steadfast decline into the heartbreaking oblivion of dementia. This dementia was of a steep descent and his daily life was reduced to a nursing home, albeit one where my mother and his wife visited multiple times a day and advocated fiercly for adequate care. On Sunday he suddenly vomited, was noted to be febrile and tachypneic. He was, sensibly enough, a DNR with a "no transfer" to hospital order on the chart-though not in hospice care. His oxygen saturations fell to critical levels despite aggressive supplemental oxygen, and he began to struggle for breath. His breathing was noisy, and he developed tremendous secretions which he was unable to clear. My mother, at…

Yes, Again

OK it's another anti-narcotic rant.  This is directed to all the providers out there.  A couple of things you should know: 1. Don't give narcotics for benign musculoskeletal pain. Give physical therapy and a prescription for weight loss instead. 2.  Don't give narcotics for osteoarthritis. Give physical therapy and Tylenol instead. 3.  Don't give narcotics for functional abdominal pain. Give fiber and a prescription for cognitive behavioral therapy instead. 4.  Don't give narcotics for depression. Give hope, listening and a prescription for cognitive behavioral therapy instead. 5.  Don't give narcotics for a personality disorder.  Give boundaries and a prescription for cognitive behavioral therapy instead. 6.  Don't give narcotics for fibromyalgia.  Give sunshine, aerobic exercise and a prescription for cognitive behavioral therapy instead. 7.  Don't give narcotics for headache.  Unless the headache is due to a brain tumor or metastatic cancer.  Then feel free. 8.  Don't give narcotics to keep the…

Prioritizing Inpatient Geriatric Care Is NOT a Moon Shot.

Most physicians recognize the JNC guideline for blood pressure management, or the ACCP thrombosis guideline for VTE.  Most would agree we use a handful of accepted benchmarks to manage a limited number of conditions.  For the rest, it’s the wild wild west. Try to develop consensus around delirium management or treatment of alcohol withdrawal, and you will likely find yourself on the road to nowhere. If you have never visited The National Guideline Clearinghouse, you should have a peek.  Sometimes I find the site helpful for a management dilemma or patient with a rare presentation. However, for most, the compilation runs endlessly long and you will begin a convoluted journey if you crave a solution.  The same road to nowhere. As of this writing, the database has close to 2400 entries.  Have fun with that: (more…)

“Being Mortal”: Atul Gawande’s Most Ambitious – and Important – Book

“I learned about a lot of things in medical school, but mortality wasn’t one of them.” So begins Being Mortal, Atul Gawande’s fourth and most ambitious book. All of Gawande’s prior books – Complications, Better, and The Checklist Manifesto – were beautifully crafted, lyrical, and fascinating, and all were bestsellers that helped cement his reputation as the preeminent physician-writer of our time. Each blended Gawande’s personal experience as a practicing surgeon with his prodigious skills as an author and journalist. They took readers behind the curtain of the hospital and the operating room, revealing much about some very important matters, like medical training, quality improvement, patient safety, and health policy. But they were only partly revealing of Gawande himself. He told us what we needed to know about his thoughts and biases in order to make his points, but no more. Being Mortal is Gawande’s most personal book, and as…

Ethics and Ebola

by Dr. Bartho Caponi MD, FHM The Ebola panic has died down; while many are under monitoring, there have been no further de novo U.S. cases since October 15, and only two more "imported" cases. Travelers are being screened and resources are heading to areas where they are needed. At my institution, Hospitalists have led the way; over half my division volunteered up-front to provide necessary care. I ended up in a lot of planning and policy meetings, where we internally crafted a comprehensive plan to deal with any Ebola-related eventuality. Nationally, the Centers for Disease Control and Prevention (CDC) have created many useful resources for people and institutions needing them. We now have guidelines for speaking to our children about Ebola and for taking care of Ebola-exposed pets, in addition to more trenchant issues. We now have "Ebola centers," hospitals capable of caring for suspected or confirmed Ebola patients…
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