Assessment procedures regarding end-of-life decisions in neonatology in the Netherlands

This paper describes the position of Dutch law concerning end-of-life decisions in neonatology consequent on rulings of the Dutch appeals court in two cases. The concept of a multidisciplinary assessment committee is explored. The European Convention on Human Rights in its articles 2 and 13 is relevant to this concept. The author provides a detailed discussion of the current situation and draws conclusions based on his perception of future developments in regulating thanatic practices in neonatology.     

A model for decision making at the end-of-life: Queensland and beyond

This paper addresses when it is legal to withdraw or withhold medical treatment that is needed to keep a patient alive. It draws on cases and legislation from the common law world (including Australia, England and New Zealand) and considers the various legal tests applied in the different jurisdictions. Two of the most common tests employed in this situation are the "best interests of the patient" test and the "substituted judgment" test. Some jurisdictions also include other criteria as well, such as a requirement that withdrawing or withholding of medical treatment is "not inconsistent with good medical practice". This paper analyses these different legal tests, and after identifying the factors that are judged to be legally relevant to consider when deciding to withdraw or withhold treatment, outlines a preferred model. This model addresses who the relevant decision maker should be, and the criteria that should govern their decision. It suggests that family members are better equipped and more appropriate to act as decision makers than health professionals, and also questions the appropriateness of responsible medical opinion as the decisive factor in such cases, preferring instead an approach more consistent with the principles of self determination. The model also proposes a method for resolving any disputes that arise.     

The developing stroke: management decisions.

Radiologists have become important members of a multidisciplinary team aimed at treating stroke. New studies such as the NINDS (National Institute of Neurological Disorders and Stroke) intravenous and PROACT II (prolyse in acute cerebral thromboembolism II) intra-arterial thrombolytic trials for acute stroke have focused attention on the need for rapid management. Radiologists play a key role in the diagnosis and selection of patients who may benefit from these therapies. We review current issues in the computed tomographic and magnetic resonance imaging diagnosis of acute stroke and the data supporting the various treatment options.     

A new framework for facilitating decisions on death and dying

The troubling public, moral and legal issues surrounding questions of death and dying need a new focus on the virtues of compassion and respectfulness, on a better understanding of a person as someone who has deep emotional, spiritual, and social aspects and needs, and whose body is more than "physical machine," but is "lived body" which gives persons the capacity to act in the world and to feel and suffer deeply. Western medicine needs to re-humanize death; physicians need to see themselves as "assisting" persons in dealing with health, life and death in the context of being able to assert their values and beliefs and to realize their goals. Western medicine's concepts of 'benefit' and 'harm,' are too narrow, as is their fight to 'preserve life' at all costs. Finally, the present approach to death and dying, except for the Hospice movement, neglects the patient's emotional, psychological, social, and existential suffering.     

A graphical method for the analysis of decisions in clinical oncology

A technique is proposed for the graphical analysis of clinical decision making. This technique has been applied to two problems in clinical oncology: the respective roles of surgery and radiotherapy in early carcinoma of the larynx; and the assessment of the optimal management policy for patients with clinical Stage I teratoma of the testis. The technique is simple to apply, it could be developed to incorporate patients' preferences and draws attention to the lack of data on treatment-related morbidity.     

The right of psychiatric patients to access to their records: Dutch developments

It is usual for therapists in health care to keep records on the patients they treat, in which they collect the medical data concerning those patients. There is much debate on whether the patient has any right to access to those records. A summary is given of recent developments in the Netherlands with regard to such a right, especially in the field of psychiatry. The current result of these developments has been to afford patients in psychiatric hospitals a far-reaching right of direct access to their hospital records.     

COVID-19 and venous thromboembolism: Known and unknown for imaging decisions

As we continue to fight against the current coronavirus disease-2019 (COVID-19) pandemic, healthcare professionals across the globe are trying to answer questions surrounding how to best help patients with the up-to-date available science while awaiting the development of new therapies and mass vaccination. Since early in the pandemic, studies indicated a heightened risk of venous thromboembolism (VTE) in COVID-19 infected patients. There have been differing expert opinions about how to assess pretest probability of VTE in this patient population. This has been partly due to the high prevalence of respiratory failure in this patient population and the use of D-dimer as a prognostic test which is also frequently elevated in patients with COVID-19 in absence of VTE. Some experts have argued for an approach similar to usual care with testing if clinical suspicion is high enough. Some have argued for more routine screening at different points of care. Others have even suggested empiric therapeutic anti-coagulation in moderate to severely ill COVID-19 patients. In the following article, we review and summarize the most current literature in hopes of assisting clinicians in decision making and guidance for when to be concerned for VTE in COVID-19 patients. We also discuss research gaps and share pathways currently being used within our institution.     

Case-based reasoning computer algorithm that uses mammographic findings for breast biopsy decisions

OBJECTIVE: We present case-based reasoning computer software developed from mammographic findings to provide support for the clinical decision to perform biopsy of the breast. SUBJECTS AND METHODS: The case-based reasoning system is designed to support the decision to perform biopsy in those patients who have suspicious findings on diagnostic mammography. Currently, between 66% and 90% of biopsies are performed on benign lesions. Our system is designed to help decrease the number of benign biopsies without missing malignancies. Clinicians interpret the mammograms using a standard reporting lexicon. The case-based reasoning system compares these findings with a database of cases with known outcomes (from biopsy) and returns the fraction of similar cases that were malignant. This malignancy fraction is an intuitive response that the clinician can then consider when making the decision regarding biopsy. RESULTS: The system was evaluated using a round-robin sampling scheme and performed with an area under the receiver operating characteristic curve of 0.83, comparable with the performance of a neural network model. If only the cases returning a malignancy fraction of greater than a threshold of 0.10 are sent to biopsy, no malignancies would be missed, and the number of benign biopsies would be decreased by 25%. At a threshold of 0.21, 98%, of the malignancies would be biopsied, and the number of benign biopsies would be decreased by 41%. CONCLUSION: This preliminary investigation indicates that the case-based reasoning approach to computer-aided diagnosis has the potential to improve the accuracy of breast cancer diagnosis on mammography.     

Trauma angiography of the extremity: The impact of injury mechanism on triage decisions

A review of angiographic studies of 227 consecutive injured patients suspected of having sustained extremity arterial trauma was done to determine whether knowledge of the mechanisms of injury was of use in the establishment of priority in multiply injured patients. Stab wounds and other lacerations occurred in 32 patients. Major arterial injury occurred in only 3 (12%) cases; in no case was arterial occlusion present or limb viability threatened. These injuries may be angiographically evaluated on a nonurgent basis. Alternatively, patients with gunshot wounds (130 patients) and blunt injuries (63 patients) had a high incidence of major arterial injury (18 and 38%, respectively), especially arterial occlusion (15 and 24%, respectively) as well as a significant incidence of threatened limb viability (5 and 21%, respectively). Disproportionately increased risk of arterial injury occurred in patients with high-energy gunshot wounds (75%), motorcycle accidents (62%), and crush injuries (63%). Patients who sustain gunshot wounds or blunt injuries and have an abnormal vascular physical examination should be evaluated angiographically on an urgent basis.