To compare the erythropoietic effects of nandrolone decanoate, testosterone enanthate, oxymetholone, and fluoxymesterone, we performed a randomized clinical trial in patients with anemia who were ...receiving maintenance hemodialysis (the women were not given testosterone enanthate). After a control period of at least two months, patients received one of the drugs for six months and then returned to control status; a second and third drug were administered in a similar fashion. Seventy-seven patients completed the first drug period, 56 the second, and 35 the third. The response to nandrolone and testosterone enanthate, the two drugs given by injection, was clearly superior to the response to oxymetholone or fluoxymesterone, given by mouth, in terms of the percentage of patients responding and the mean rise in hematocrit. Approximately half the patients had an increase of at least 5 percentage points in hematocrit after an injectable androgen was given; more than half the women responded. Patients who required transfusions regularly and those who had bilateral nephrectomies did not respond.
By examining the ethical features of dialysis withdrawal as well as transcultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and ...community-based values on medical decision-making. Three distinctive patterns of withdrawal are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. When a patient or health care surrogate decision maker requests cessation of therapy because it fails to be beneficent for the patient in his or her totality, the physician should be prepared to cooperate, in accord with beneficence and nonmalfeasance as well as autonomy. The second pattern occurs when the patient loses decisional capacity, and the surrogate decision maker makes unreasonable requests for nonbeneficial care. At issue is what constitutes nonmaleficence and beneficence in this setting, the provider and surrogate differing on whether continuing dialysis constitutes beneficence. Such a dilemma can alleviated by community-based consensus guidelines with consent of the patient before losing capacity. The dialysis network is potentially a unit of patient and professional community. In third pattern, the patient's decision to withdraw appears to be inappropriate to their potential for benefit from continued therapy. The nephrologist and patient are conflicted on what constitutes beneficence, with the former holding that continuation is morally superior. In such cases, the physician must mediate the situation in a beneficent fashion not solely dictated by a constraining view of patient autonomy.
Randomized Clinical Trials Gordon, James; Tucker, Richard M; Newcomer, Lee N ...
The New England journal of medicine,
11/1991, Letnik:
325, Številka:
21
Journal Article
Recenzirano
To the Editor:
In their Sounding Board article on problems of the randomized clinical trial (May 30 issue),
1
Hellman and Hellman begin with a dichotomy: a physician must act in the patient's best ...interest, and a scientist must act to promote knowledge. Treatment according to the doctor's best judgment is a patient's irrevocable right, and unproved notions may be valued more by sick patients than by scientists. Even when a trial begins in equipoise, a perceived advantage of one treatment later obligates physicians to treat patients according to what now seems best, because scientific discovery is subordinate to the patient's . . .
Hypocomplementemic urticarial vasculitis (HUV) is often misdiagnosed. The response to drug therapy may be unsatisfactory, and immunosuppressive therapy may be associated with significant side ...effects. A 35-year-old patient whose condition was resistant to cyclophosphamide, corticosteroids, pentoxyphylline, cyproheptadine, sulindac, and colchicine was maintained in remission with dapsone, which may be the drug of choice for HUV. Emphysema has been reported to complicate HUV, but this is the first account of vasculitis-related emphysema with no confounding history of tobacco smoke exposure. The relationship of proteolytic injury to the pulmonary and other manifestations is considered, as is the possible role for dapsone in reducing it.
This report proposes a policy for discontinuing dialysis in persistent vegetative state (PVS) patients and attempts to address autonomy and community-based values while maintaining professional moral ...agency. It is recommended that the policy be adopted at a regional level (eg, the ESRD Network). The involved physicians and ethicists would communicate with the next-of-kin and surrogate decision-makers, and the local ethics committee would perform a double review of the case to assure the appropriateness of the policy to the case. Given the unique nature of PVS with its permanent loss of consciousness and autonomy, we hold that a community-based consensus can form a guideline that limits futile dialysis while respecting patient and professional moral agency. Prior consent of dialysis patients to the regional policy at a time shortly after initiating dialysis will add to its ethical impetus.
There is a growing interest in the use of multimedia educational materials for individuals with chronic diseases. However, there is little data available regarding the use by underserved populations, ...particularly urban African-Americans and Latinos. The purpose of this pilot study was to create a multimedia lesson providing instruction on preventive care (i.e. dilated eye examinations) and investigate its ability and interest among specific targeted outpatients. A touch screen 'kiosk' was incorporated into a clinical waiting room specifically for patient education. Results demonstrated ability and interest in computer use for patient education regardless of educational background or computer experience. Patient attitudes collected regarding diabetic eye disease and eye exams will assist in further development of the tool. Future implementation of similar educational interventions may likely require addressing the same barriers related to difference in culture, educational background, literacy level, language, and computer expertise.
Experience with electronic communication in ethics committees at two hospitals is reviewed and discussed. A listserver of ethics committee members transmitted a synopsis of the ethics consultation ...shortly after the consultation was initiated. Committee comments were sometimes incorporated into the recommendations. This input proved to be most useful in unusual cases where additional, diverse inputs were informative. Efforts to ensure confidentiality are vital to this approach. They include not naming the patient in the e-mail, requiring a password for access to the listserver, and possibly encryption. How this electronic communication process alters group interactions in ethics committees is a fruitful area for future investigation. (Journal of Medical Ethics 2001;27 suppl I:i30-i32) Keywords: Clinical ethics committees; electronic communication; confidentiality
