Ethical dilemmas and nursing

Professional responsibilities, tradition, and personal conscience along with legal, philosophical, and religious convictions dictate nursing interventions. Inevitably, these factors embrace life-sustaining therapies; however, in view of complications, prognosis, pain and suffering, and their own views of quality of life, some patients express wishes inconsistent with life-sustaining measures. In other situations, the health care provider as well as the patient may view heroic efforts as more debilitating than resortative. Resolving the conflict while preserving the patient's best interests requires a confrontation with the status of "do-not resuscitate" policies within th e nurse's institution, informed consent, refusal, and competency as the necessary underpinnings for the development of an ethical and legal posture within the profession, with which to approach significant decisions regarding life-sustaining therapies. Literally every hour of every day nurses are immediately and directly involved with resolving ethical dilemmas based upon judgements and interpretations of oral or written orders, patient and family wishes, professional training, and an infinite number of other factors. When clear policies or orders are lacking, the nurse is left with the burden of making a life or death decision. It is imperative that professional nurses assess the administrative, legal, and ethical ramifications of their actions in terms of ethical codes of practice, patients' rights, institutional and personal liability, civil and criminal laws, and private conscience. An understanding of these issues, passive and active euthansia, state and national trends, and uniform legislation can assist in resolutions of the no-code dilemma. Nursing as a profession must strive to develop sound and consistent guidelines and rationale for the scope of practice in ethical dilemmas.     

Ethical dilemmas in pediatrics

This paper examines briefly the rights and vulnerabilities of children and young people. It brings together themes relative to respect for individuals, maintaining trust and competence to make valid decisions. It also echoes discussion of conflicting rights and duties and mentions legal as well as ethical views about consent and refusal of treatment. It looks at the criteria for "best interests" judgements. Also, the role of the doctor is considered in regard to the whole family.     

Nurses' responses to moral dilemmas

Using six typical dilemma situations a study testing the morality and reasons for the reactions of subjects was conducted and the responses investigated.     

The dilemmas of leadership.

What kind of a leader are you? According to Ms. Godderidge, it's important for managers to assess their own leadership style, as well as its effect on others. She analyzes the "Dilemmas of Leadership" in this article based on her presentation at the 9th World Congress of the International Society of Radiographers and Radiological Technicians.     

Diagnostic dilemmas in surgical pathology

In the majority of presented cases persisted certain diagnostic perplexities even after the careful investigations were performed, which required surgical exploration. For example, carcinomatous pericarditis as the sequel of metastasis from occult thyroid carcinoma and two cases of double malignity (papillary carcinoma and Hodgkin's lymphoma of the thyroid), retroperitoneal leiomyosarcoma and the clear cells renal carcinoma. All the cases were not successfully solved until the application of highly sophisticated and precise methods of immunohistochemical staining, which without a mistake confirmed our assumed histopathologic diagnosis. Metastatic lesion of folicular thyroid carcinoma in the adrenal gland should be mentioned because of the long remission period of 15 years following total thyroidectomy and neck irradiation during the primary therapy of thyroid carcinoma. It is very significant to point out that pathologic disorders such as undifferentiated neoplasm, strange inflammatory conditions, endocrine proliferative lesions deserve special attention because in certain cases consultative approach is necessary for obtaining the definite finding that can in some degree histoprognostically predict the outcome of pathologic process.     

腐蚀性食管炎的病因与X线研究

腐蚀性食管炎是常见的食管炎性疾患之一。本文报道了１９例，其中男９例，女１０例，年龄１～６０岁，平均４５．３岁。分析研究表明，腐蚀性食管炎之Ｘ线表现是以食管狭窄程度重，范围较广为特征，且多见于中下段。本文阐述了腐蚀性药物（强碱，强酸及农药等）对食管损伤的病理演变过程，说明其损伤程度与服入药物的性质、浓度、服入量及吞服速度有明显关系。并对食管腐蚀性损伤的并发症，Ｘ线检查注意事项等，做了较为详细的讨论     

Long-term survivors of childhood malignancies--aeromedical dilemmas and implications

Survival rates from childhood cancer have dramatically improved over the past three decades; average overall 5-yr survival rates are now > 75%. However, this has been achieved by treatments associated with significant morbidity that may present many years later. This review seeks to delineate the basic information necessary to evaluate flight-training candidates with a history of childhood cancer. We performed a literature review using the Medline database with appropriate search terms related to delayed morbidity and mortality associated with childhood cancer; we did not attempt to evaluate the risk of recurrent cancer. The neurological, cardiovascular, and pulmonary systems were identified areas of aeromedical concern. Central nervous disease and treatment-related effects may increase the risk of seizures or other neurocognitive sequelae. The cardiac toxicity of chemotherapeutic agents such as anthracyclines and radiation may cause late-occurring arrhythmia, cardiac failure, and sudden death, while available screening modalities are of limited value. Pulmonary disease and related treatment effects may cause a 9-fold increase of late-occurring pulmonary fibrosis and lung cancer, with increasing prevalence as long as 25 yr following the cancer diagnosis. Additionally, second malignancies may occur in up to 12.5% of cancer survivors at 25 yr after cancer diagnosis, affecting medical clearance for flight training. In summary, this review discusses the relevant aeromedical issues, including disabilities with specific relevance to the flying environment, risk estimation of late-occurring treatment complications, and possible interactions with occupational exposures in aircrew.     

Diagnostic dilemmas in parathyroid scintigraphy.

PURPOSE: Tc-99m MIBI scintigraphy can be useful for preoperative localization of parathyroid adenomas, despite its limited sensitivity. To refine interpretation, the authors conducted prospective reviews of the scintigraphic studies of patients with concomitant thyroid nodular disease and revised the false-negative and false-positive results. MATERIALS AND METHODS: Seventy-seven patients with primary hyperparathyroidism, associated with a solitary parathyroid adenoma, underwent dual-phase MIBI scintigraphy with subsequent injection of Tc-99m pertechnetate before surgery. The false-negative and false-positive scintigraphic findings were identified and revised. RESULTS: After surgery, revision of 19 false-negative scans of the total 77 studies led to the demonstration of an adenoma in seven patients. In five of the seven studies, the adenoma had been overlooked as a result of rapid tracer washout. Two additional small focal lesions would have also been identified if subtraction had been used for differences in contour of the MIBI and pertechnetate images. Four studies were interpreted falsely as abnormal, leading to a positive predictive value of 91%; three were associated with thyroid nodular disease. CONCLUSIONS: Differential washout of MIBI from thyroid and parathyroid tissue is not universal. When MIBI is washed out rapidly from parathyroid adenomas, subtraction of a thyroid image should be performed and differences in contour delineated to localize the adenoma accurately. Some, but not all, thyroid lesions account for the false-positive findings.     

Corrosive esophageal stricture: safety and effectiveness of balloon dilation.

The safety and long-term effectiveness of fluoroscopically guided balloon dilation for corrosive esophageal stricture was evaluated in 22 patients with a follow-up period of more than 1 year (range, 13-52 months). The average interval between corrosive agent ingestion and initial balloon dilation was 18 years (range, 2 months to 51 years). Balloons with a diameter of 5-8 mm were used in the initial attempt. The caliber of the balloon catheter was increased gradually over subsequent dilations, up to a diameter that allowed patients to swallow solid foods. Dilation of more than 17 mm in diameter was performed in five patients. Patients underwent one to five sessions. Esophageal rupture occurred in seven patients and was treated nonoperatively in five and surgically in two. With exclusion of these latter two, 11 of 20 could tolerate swallowing all kinds of food and nine could tolerate swallowing most foods. Balloon dilation in corrosive esophageal strictures is effective, but the high rupture rate indicates the need for extra caution.     

Medical confidentiality versus disclosure: Ethical and legal dilemmas

A case is described of a fifty year old single man who made disclosures about criminal sexual practices during a psychiatric assessment. In common practice with other professional men, a doctor is under a duty not to disclose, without the consent of his patient, information which he has gained in his professional capacity other than in exceptional circumstances. We discuss the ethical and legal considerations surrounding issues of medical confidentiality and the dilemma that sometimes face clinicians, when they feel obliged, in the public interest, to disclose information they have gained in confidence. Breach of confidences can have deleterious consequences; particularly for the doctor–patient relationship, but failure to disclose in some situations could have serious implications for the well-being of the wider society. Doctors should be aware of the basic principles of confidentiality and the ethical and legal framework around which they are built.     

Columnar cell thyroid carcinoma - diagnostic dilemmas and pitfalls

BACKGROUND: Columnar cell carcinoma is a rare variant of papillary thyroid carcinoma associated with aggressive clinical behaviour. A CASE REPORT: of a 34-year-old male patient, who presented with the rapidly growing mass in the neck, extending to the anterior and middle mediastinum, tightly closing the upper thoracic apperture and causing tracheal and oesophageal deviation, with minimal compression and stenosis. A diagnosis of columnar cell carcinoma, arising from the ectopic thyroid tissue just adjacent to the left thyroid lobe was based on histological and intraoperative findings. Near total thyroidectomy and lymph-node dissection were followed by external beam radiotherapy of the neck and mediastinum, chemotherapy and radioiodine ablation of the remaining functional thyroid tissue. Pre-and post-operative radionuclide imaging (99mTc(V)-DMSA, 99mTc-MIBI, 123-I-mIBG and Octreoscan findings are discussed, with a special emphasis given to the dilemmas in histological characterisation of the tumor, the problems in therapeutic approach and the dilemmas and pitfalls in the interpretation of radionuclide findings in this patient, especially the ones performed post radiotherapy of the neck and mediastinum.     

Ethical dilemmas in today's nuclear medicine and radiology practice.

Throughout history, societies have developed their own codes of ethics, including those pertaining to the practice of medicine. In the United States, physicians have adopted a set of ethics based on religious values and historical teachings. We, as physicians, have been presented several codes of ethics, including the American Medical Association Code of Ethics and the American College of Radiology Code of Ethics. Over time, we have learned to appropriately apply these codes to our daily practice. With the advent of new technologies in imaging, we may lose sight as to the transfer of these principles to reflect current conditions. Recent history has shown a trend of new technology leading to potential misuse of this technology and further leading to stricter governmental regulations. It is the purpose of this review to give guidelines for dealing with new technologies, such as PET imaging, and we describe a radiologist's ethical responsibility in a doctor-patient relationship. A historical review of medical ethics will lead to discussions about various issues affecting radiologists and nuclear physicians. To be sure, not all ethical situations are black and white, and therefore there are many gray areas. The opinions expressed in this article are those of the authors and are based on extension of already established rules of ethical conduct.