Search

Objective: To compare the effects of change from an open to a closed intensive care unit (ICU) format on clinical outcomes, resource utilization, teaching, and perceptions regarding quality of care., Design: Prospective cohort study; prospective economic evaluation., Setting: Medical ICU at a university-based tertiary care center. For the open ICU, primary admitting physicians direct care of patients with input from critical care specialists via consultation. For the closed ICU, critical care specialists direct patient care., Patients: Consecutive samples of 124 patients admitted under an open ICU format and 121 patients admitted after changing to a closed ICU format. Readmissions were excluded., Main Outcome Measures: Comparison of hospital mortality with mortality predicted by the Acute Physiology and Chronic Health Evaluation II (APACHE II) system; duration of mechanical ventilation; length of stay; patient charges for radiology, laboratory, and pharmacy departments; vascular catheter use; number of interruptions of formal teaching rounds; and perceptions of patients, families, physicians, and nurses regarding quality of care and ICU function., Results: Mean +/- SD APACHE II scores were 15.4 +/- 8.3 in the open ICU and 20.6 +/- 8.6 in the closed ICU (P=.001). In the closed ICU, the ratio of actual mortality (31.4 percent) to predicted mortality (40.1 percent) was 0.78. In the open ICU, the ratio of actual mortality (22.6 percent) to predicted mortality (25.2 percent) was 0.90. Mean length of stay for survivors in the open ICU was 3.9 days, and mean length of stay for survivors in the closed ICU was 3.7 days (P=.79). There were no significant differences between periods in patient charges for radiology, laboratory, or pharmacy resources. Nurses were more likely to say that they were very confident in the clinical judgment of the physician primarily responsible for patient care in the closed ICU compared with the open ICU (41 percent vs 7 percent; P<.Ol), and nurses were the group most supportive of changing to a closed ICU format before and after the study., Conclusions: Based on comparison of actual to predicted mortality, changing from an open to a closed ICU format improved clinical outcome. Although patients in the closed ICU had greater severity of illness, resource utilization did not increase.

The circumstances of liver transplantation are unique among organ transplantation because of the dire, absolute scarcity of donor livers and the predominance of one disease--alcohol-related end-stage liver disease--as the principal cause of liver failure. We propose that patients who develop end-stage liver disease through no fault of their own should have higher priority for receiving a liver transplant than those whose end-stage liver disease results from failure to obtain treatment for alcoholism. We base our proposal on considerations of fairness and on whether public support for liver transplantation can be maintained if, as a result of a first-come, first-served approach, patients with alcohol-related end-stage liver disease receive more than half the available donor livers. We conclude that since not all can live, priorities must be established for the use of scarce health care resources.

The teaching of clinical medicine at the bedside is an enduring legacy of the Oslerian revolution in American education. The advantages of teaching clinical ethics at the bedside including dealing with actual cases to maximize personal accountability, reinforcing the relationship between technical competence and ethical decisions, involving the entire health care team, and possibly decreasing the resistance of the medical profession to formal medical ethics. The proposal to teach clinical ethics at the bedside is intended to indicate a primary role for ethicists and clinicians at different stages in the medical curriculum. During the preclinical years of medical school, ethicist-philosophers, assisted by clinicians, should assume primary responsibility for teaching medical ethics. During the clinical years, physicians, assisted by clinically informed ethicist-philosophers, should accept the primary obligation to teach clinical ethics at the bedside.

Pediatricians face clinical and ethical dilemmas about therapy to augment growth in short children who do not meet classic criteria for growth hormone (GH) deficiency. Biologic norms of health are unhelpful because of the uncertain relationship between stature, GH secretion, health, and disease. Instead, we suggest that GH therapy be evaluated from the perspective of cultural norms. We compare GH therapy for short normal children with currently accepted therapies for non--life-threatening pediatric conditions such as well-child care, cosmetic therapy, treatment of psychological problems, and invasive outpatient therapy for chronic conditions. Based on this analysis, we argue that the burdens of therapy, the uncertainty about long-term risks and benefits, the unclear therapeutic end point, and the implications for child health policy place routine GH therapy for children without documented deficiency of GH secretion outside current pediatric ethical norms. Such therapy is properly administered within a comprehensive clinical research protocol.

Can the conscious patient in the midst of a medical emergency provide adequate informed consent for a clinical research protocol? Adequate consent is crucial to the ethical conduct of clinical trials, including those performed in emergency settings. We examine the problem of emergency informed consent. As an illustrative case, we discuss a pilot trial of prehospital thrombolytic therapy for myocardial infarction. Federal regulations for clinical research do not provide clear guidelines on emergency research in the conscious patient. Clinical investigators currently approach emergency consent in four ways: (1) avoid such research, (2) omit the consent process, (3) obtain deferred consent, or (4) obtain customary consent. We suggest a fifth alternative, two-step consent, which permits the conduct of emergency research while protecting the rights of the emergency research subjects. Such a process may serve as an alternative solution for future studies faced with the problem of informed consent in emergencies.

A newly established formal ethics consultation service in a university teaching hospital was prospectively evaluated. A physician-ethicist interviewed and examined patients, interviewed family and others as needed, and entered a formal consultation note in the medical record. The requesting physician and the consultant independently completed structured questionnaires. Fifty-one consultation requests were received from 45 physicians from seven departments between July 1, 1986, and June 30, 1987. Seventeen (33%) of 51 patients were in the intensive care unit, and 19 patients (37%) were fully oriented at the time of consultation. Overall, 61% of the patients survived to leave the hospital. The requesting physician sought assistance with withholding or withdrawing life-sustaining treatment in 49% of cases, with resuscitation issues in 37%, and with legal issues in 31%. Assistance with more than one issue was sought in 39 cases (76%). In 36 cases (71%), the requesting physician stated that the consultation was "very important" in patient management, in clarifying ethical issues, or in learning about medical ethics. We conclude that ethics consultation performed by physician-ethicists provides useful, clinically acceptable assistance in a teaching hospital.