A 77-year-old farmer with recurring kidney stones visits his urologist for an annual examination. Prior to seeing the patient, the physician is taken aside by her nurse, who tells her the patient had been in the emergency department the previous night with hematuria. A CAT scan had been done, which indicated that the renal tumor seen on last year's CAT scan was larger and there were now lung metastases. The physician cannot remember ever seeing the radiology report from last year. To her complete surprise, it is found filed in the patient's chart. There is no record in the chart that the results were ever shared with the patient. She considers herself extremely meticulous and has never had such an oversight before. The urologist considers what she should tell the patient.
A 12-year-old boy has cataract surgery at a large teaching hospital. At a critical moment the surgeon's hand slips, severely rupturing the lens capsule. The planned implantation of an intraocular lens has to be abandoned. Instead, the patient will have to use a contact lens. The physician wonders what he should tell the patient and his family about the surgery.
What is medical error?
Well-publicized reports of harm occurring to patients as a result of their medical care in the USA (Patient Safety Foundation, 1998), Canada (Sinclair, 1994) and the UK (Smith, 1998) have raised public concerns about the safety of modern healthcare.
A 70-year-old male patient (Patient E) is admitted to the intensive care unit (ICU) following a road traffic accident in which he suffered severe head and abdominal injuries. After four weeks in the ICU, the patient's neurological condition has stabilized with minimal function (the patient does not communicate but withdraws all four limbs to painful stimuli). Following numerous bouts of sepsis, the patient is developing renal failure. He is anuric, hyperkalemic, and acidotic. He is also ventilator dependent and on high doses of inotropes. The patient's family states that in their culture, life continues until the heart stops beating. The family (that includes a physician) requests that all resuscitative efforts be continued, including dialysis.
In parallel, a second patient (Patient F) with similar injuries, but with metastatic prostate cancer, is admitted to the emergency room and requires an ICU bed. In addition to his traumatic injuries, however, he is wheel-chair bound as a result of dementia. No beds are currently available. According to the assessment of the ICU physician attending, the trauma patient described in case one has the least to benefit from ICU therapy and should be assessed for withdrawal of ventilation, to which the family strenuously objects.
What is critical and intensive care ethics?
Many aspects of medical care practiced today would not be feasible without the support of an intensive care unit (ICU).
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