A right to die or a right to live? Discontinuing medical treatment

This article explores the decision in the case of W v M, S and an NHS Primary Care Trust [2011] EWHC 2443 (Fam) in which an application to withdraw feeding from a woman in a minimally conscious state was rejected by Baker J in the Court of Protection. The article places the case in the context of the development of case law concerning the withdrawal of treatment from patients lacking decision-making capacity, where death will be the inevitable consequence of the withdrawal of treatment after the decision in Airedale NHS Trust v Bland. It questions whether nearly two decades after the Bland decision there is scope for the boundaries of the decision to withdraw treatment from patients in 'futile' conditions to be reconsidered by the Supreme Court.     

Synchronous work: myth or reality? A critical study of teams in health and medical care

Rationale, aims and objectives In this article, ideal conceptions about teamwork are tested. The research question posed is: How are teams in psychiatry formed? Three theoretical concepts that distinguish groups from teams are presented: sequentiality, parallelism and synchronicity. The presumption is that groups cooperate sequentially and teams synchronously, while the parallel work mode is a transitional form between group and team. Methods Three psychiatric outpatient teams at a university hospital specialist clinic were studied. Data were collected through 25 personal interviews and 82 hours of observations. The data collection was carried out over 18 months (2008–2009). Results Results show: (1) that the three theoretical distinctions between group and team need to be supplemented with two intermediate forms, semiparallel and semisynchronous teamwork; and (2) that teamwork is not characterized by striving towards a synchronous ideal but instead is marked by an adaptive interaction between sequential, parallel and synchronous working modes. Conclusions The article points to a new intermediate stage between group and team. This intermediate stage is called semiparallel teamwork. The study shows that practical teamwork is not characterized by a synchronous ideal, but rather is about how to adaptively find acceptable solutions to a series of practical problems. The study emphasizes the importance of the team varying between different working modes, so‐called semisystematics.     

Family-centered critical care: an option or obligation?

The patient was dying after undergoing aggressive treatment for a malignancy. Patient and family wanted "everything" to be done and the patient was transferred to the ICU for treatment of acute respiratory failure. The next day the patient's condition deteriorated further. The family decided against chest compressions or defibrillation; however, other aggressive treatment was continued. A "chemical code" was initiated and the patient was ventilated. The family was informed. As they stood in the hall outside the unit, the patient's wife asked if she could be with her husband. A nurse explained what she would see and accompanied her to the bedside. She stood at the head of the bed, stroked her husband's head and spoke softly in his ear. The patient's son came to the bedside and said his last words to his father. The wife was present when treatment was stopped and the patient was pronounced dead. She said to the nurse who had accompanied her, "You have given me the greatest gift possible--you allowed me to be with my husband at the end."     

Organ and tissue donation: a trustwide perspective or critical care concern?

Organ donation has become an accepted practice within the critical care setting; however, tissue donation is seldom considered within the ICU environment and even less in other hospital departments. This study describes the results from an early base line audit performed as the first stage in a larger action research project following the implementation of the Donor Liaison Scheme in an NHS trust. It was designed to assess the current level of knowledge, confidence and value system staff have, working in all areas of the hospital setting in relation to organ and tissue donation. The results from this audit highlight key areas for practice development across all areas of this NHS trust. Many healthcare professionals working within this trust are unaware that donation can be considered. The respondents identified a lack of knowledge and confidence to be able to identify and discuss the options of donation with a family, yet the majority believe strongly that a person's wishes should be respected after death. People who have signed on the NHS ODR anticipate that healthcare professionals will access the ODR and support their family in following through their wishes; therefore, all healthcare professionals should receive education on donation issues as an integral part of bereavement and end of life decision training. Education strategies that adopt an experiential approach should be developed in order to create confidence in healthcare professionals to offer choice in donation options     

Pre‐registration education: making a difference to critical care?

This paper aims to discuss the development of a pre-registration high-dependency nursing programme and evaluate its effects on student's perceived learning and confidence in managing critically ill patients. The programme consists of two modules that compliment one another, 'Care of the Acutely III Adult' focuses on a variety of disease processes and subsequent nursing care. Whilst the second module titled 'Caring for the Highly Dependant/Critically III Adult' focuses on assessment skills related to critically ill patients. The paper explores the content and delivery of the modules including the advantages and disadvantages of implementing them. Student evaluation from 59 nursing students found that student's knowledge, assessment skills and management of the critically ill patient had improved since completing the modules. Nurse Consultants, intensive therapy unit matrons and Critical Care Outreach nurses have acknowledged an increase in the number of nursing students identifying and referring critically ill patients to outreach teams. They also stated improvements in nurse recruitment in critical care since commencement of the modules.     

Novel biomarkers in critical care: utility or futility?

One of the holy grails of modern medicine, across a range of clinical sub-specialties, is establishing highly sensitive and specific biomarkers for various diseases. Significant success has been achieved in some of these clinical areas, most notably identifying high-sensitivity C-reactive peptide, troponin I/T and brain natriuretic peptide as significant prognosticators for both the acute outcome and the development of cardiovascular pathology. However, it is highly debatable whether this translates to complex, multi-system pathophysiological insults. Is critical care immune from the application of these novel biomarkers, given the numerous confounding factors interfering with their interpretation?     

The shortage of critical care physicians: Is there a solution?

Objective

The objective of this study is to provide a solution to the critical care physician shortage.

Data sources

The data sources are Medline search of published articles regarding the critical care physician shortage, the current training model, and the roll of family physicians.

Data extraction

The US population continues to age, increasing the need for critical care services due to the burden of acute and chronic illnesses. At the same time, it has been suggested that a highly staffed intensive care unit (ICU) including physicians, nurses, and pharmacists promotes standardized care that improves survival and length of stays (hospital and ICU). This has led to a rise in critical care physician staffing.Unfortunately, estimates indicate a shortage of critical care physicians over the next 10 years or even sooner if the Leapfrog initiative is implemented, making apparent the vulnerability of the field. Published estimates indicate that intensivists currently provide care to only 37% of all ICU patients in the United States and that they are located primarily in large hospitals and teaching institutions.Traditionally, to enter a fellowship in critical care, one would have to be trained through the internal medicine, anesthesia, or surgery pathways. Recently, the American Board of Emergency Medicine, in conjunction with The American Board of Internal Medicine, opened the pathway for emergency physicians to enter a critical care fellowship.

Conclusions

Family Practice is the second largest collective group of physicians in the United States—second only to internal medicine. In most of rural America, where there are limited physicians serving the population, family practitioners fill the gap and provide services otherwise unavailable to those patients. This group that can potentially be trained in critical care and help solve the crisis has been prevented from doing so.     

Engendering enthusiasm for sustainable disaster critical care response: why this is of consequence to critical care professionals?

Disaster medical response has historically focused on the pre-hospital and initial treatment needs of casualties. In particular, the critical care component of many disaster response plans is incomplete. Equally important, routinely available critical care resources are almost always insufficient to respond to disasters that generate anything beyond a 'modest' casualty stream. Large-scale monetary funding to effectively remedy these shortfalls is unavailable. Education, training, and improved planning are our most effective initial steps. We suggest several areas for further development, including dual usage of resources that may specifically augment critical care disaster medical capabilities over time.