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Limitations on ECMO in congenital diaphragmatic hernia (CDH): an ethical analysis
ETHICS fetal pulmonary development. This data was the correlated with postnatal outcomes including need for ECMO support and mortality.
Lack of structured mentoring programs in modern academic surgery Melina R Kibbe, MD, FACS, FAHA, Carlos A Pellegrini, MD, FACS, Courtney M Townsend, Jr, MD, FACS, Marco G Patti, MD, FACS University of Chicago, Chicago, IL; Northwestern University, Chicago, IL
RESULTS: We have identified fetal imaging parameters that predict lethal pulmonary hypoplasia in neonates with CDH. We found total lung volume (TLV) to be very sensitive and specific in predicting both neonatal mortality and need for ECMO support. We noted 100% mortality with TLV less than 10ml, with non-survivors having a mean TLV of less than 15mL. Fetal echocardiogram results are also incorporated into the perinatal care algorithm and our antenatal counseling of the family.
INTRODUCTION: Mentorship has been recognized as a key element for a successful career in academic surgery. Stakeholders of an effective mentorship program include the mentor, mentee, department, and institution. The objective of this study was to perform an assessment of the presence and structure of mentorship programs in Departments of Surgery in the USA, as this has never been performed.
CONCLUSIONS: When a fetus with CDH is identified as having lethal pulmonary hypoplasia, the family is counseled that neonatal ECMO support will not be provided as it will not provide long term survival. We present this process as a paradigm shift, antenatal imaging is utilized to provide the family palliative supportive care throughout the perinatal period, and ECMO is deferred. We believe this approach is ethically appropriate, and avoid the harms of an invasive intervention that will be futile in achieving its goal of survival.
METHODS: A survey was sent to 155 chairs from Departments of Surgery in the USA regarding the presence and structure of a mentorship program. RESULTS: The survey achieved a 49% response rate. 54% of departments had a mentorship program. 33% of departments described no formal or informal pairing of mentors with mentees. In 80% of departments, no formal training existed for mentors or mentees. In 55% of departments, no formal requirement for the frequency of scheduled meetings between the mentor and mentee existed. In the majority of departments, mentors and mentees were not required to fill out evaluation forms, and when they did, 39% were reviewed only by the Chair. In 92% of departments, no exit strategy existed for failed mentor-mentee relationships. In more than two-thirds of departments, faculty mentoring efforts were not recognized formally by either the department or institution. Only 3% of departments received economic support for the mentoring program from the institution.
Practical wisdom provides ethical justification for the negotiation and enforcement of surgical buy-in Daniel E Hall, MD, MHSc, FACS VA Pittsburgh Healthcare System, Pittsburgh PA; University of Pittsburgh, Pittsburgh, PA INTRODUCTION: Surgeons frequently negotiate informal contracts for the index surgery as well as needed rescue interventions. Although such “buy-in” is prevalent, the literature asserts that surgeons should not enforce the terms of these contracts when patients develop complications and request withdrawal of support.
CONCLUSIONS: These data show that only half of the departments have a mentorship program and that most of these programs are informal and unstructured and do not involve all key stakeholders.
METHODS: I will argue that the philosophical concept of practical wisdom (phronesis) and the legal concept of fiduciary agency provide persuasive justification for the explicit negotiation and enforcement of surgical buy-in whereby patients incur a limited obligation to accept indicated rescue therapy when complications arise in the immediate postoperative period.
Limitations on ECMO in congenital diaphragmatic hernia (CDH): an ethical analysis Aviva L Katz, MD, FACS, Burhan Mahmood, MD Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
RESULTS: Practical wisdom is the capacity to choose the best from among multiple imperfect options. Although informed by scientific knowledge, practical wisdom also requires repeated experience with the decisions common to a particular practice. For example, the need for practical experience explains why investors authorize brokers to trade stocks on their behalf as fiduciary agents. Likewise, patients defer operative conduct to the surgeon’s experience, authorizing them to act as fiduciary agents to achieve the negotiated goal of, for example, pancreatectomy. Because it takes experience to interpret the ramifications of postoperative complications, I conclude that, within negotiated limits, the surgeon’s fiduciary agency should extend into the postoperative period to choose the therapeutic maneuvers most likely to achieve the goals identified by the patient at the beginning of treatment.
INTRODUCTION: Despite significant advances in technology, neonates with CDH still face the risk of significant morbidity and mortality, with associated patient and family suffering. We hope to develop a more precise and compassionate perinatal care algorithm. METHODS: We carried out a retrospective medical record review of antenatal imaging data on consecutive pregnancies presenting with a fetal diagnosis of CDH. Prenatal MRI images were analyzed to measure total and relative fetal lung volume and other indices of
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
e13
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.328 ISSN 1072-7515/15
Lack of structured mentoring programs in modern academic surgery Melina R Kibbe, MD, FACS, FAHA, Carlos A Pellegrini, MD, FACS, Courtney M Townsend, Jr, MD, FACS, Marco G Patti, MD, FACS University of Chicago, Chicago, IL; Northwestern University, Chicago, IL
RESULTS: We have identified fetal imaging parameters that predict lethal pulmonary hypoplasia in neonates with CDH. We found total lung volume (TLV) to be very sensitive and specific in predicting both neonatal mortality and need for ECMO support. We noted 100% mortality with TLV less than 10ml, with non-survivors having a mean TLV of less than 15mL. Fetal echocardiogram results are also incorporated into the perinatal care algorithm and our antenatal counseling of the family.
INTRODUCTION: Mentorship has been recognized as a key element for a successful career in academic surgery. Stakeholders of an effective mentorship program include the mentor, mentee, department, and institution. The objective of this study was to perform an assessment of the presence and structure of mentorship programs in Departments of Surgery in the USA, as this has never been performed.
CONCLUSIONS: When a fetus with CDH is identified as having lethal pulmonary hypoplasia, the family is counseled that neonatal ECMO support will not be provided as it will not provide long term survival. We present this process as a paradigm shift, antenatal imaging is utilized to provide the family palliative supportive care throughout the perinatal period, and ECMO is deferred. We believe this approach is ethically appropriate, and avoid the harms of an invasive intervention that will be futile in achieving its goal of survival.
METHODS: A survey was sent to 155 chairs from Departments of Surgery in the USA regarding the presence and structure of a mentorship program. RESULTS: The survey achieved a 49% response rate. 54% of departments had a mentorship program. 33% of departments described no formal or informal pairing of mentors with mentees. In 80% of departments, no formal training existed for mentors or mentees. In 55% of departments, no formal requirement for the frequency of scheduled meetings between the mentor and mentee existed. In the majority of departments, mentors and mentees were not required to fill out evaluation forms, and when they did, 39% were reviewed only by the Chair. In 92% of departments, no exit strategy existed for failed mentor-mentee relationships. In more than two-thirds of departments, faculty mentoring efforts were not recognized formally by either the department or institution. Only 3% of departments received economic support for the mentoring program from the institution.
Practical wisdom provides ethical justification for the negotiation and enforcement of surgical buy-in Daniel E Hall, MD, MHSc, FACS VA Pittsburgh Healthcare System, Pittsburgh PA; University of Pittsburgh, Pittsburgh, PA INTRODUCTION: Surgeons frequently negotiate informal contracts for the index surgery as well as needed rescue interventions. Although such “buy-in” is prevalent, the literature asserts that surgeons should not enforce the terms of these contracts when patients develop complications and request withdrawal of support.
CONCLUSIONS: These data show that only half of the departments have a mentorship program and that most of these programs are informal and unstructured and do not involve all key stakeholders.
METHODS: I will argue that the philosophical concept of practical wisdom (phronesis) and the legal concept of fiduciary agency provide persuasive justification for the explicit negotiation and enforcement of surgical buy-in whereby patients incur a limited obligation to accept indicated rescue therapy when complications arise in the immediate postoperative period.
Limitations on ECMO in congenital diaphragmatic hernia (CDH): an ethical analysis Aviva L Katz, MD, FACS, Burhan Mahmood, MD Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
RESULTS: Practical wisdom is the capacity to choose the best from among multiple imperfect options. Although informed by scientific knowledge, practical wisdom also requires repeated experience with the decisions common to a particular practice. For example, the need for practical experience explains why investors authorize brokers to trade stocks on their behalf as fiduciary agents. Likewise, patients defer operative conduct to the surgeon’s experience, authorizing them to act as fiduciary agents to achieve the negotiated goal of, for example, pancreatectomy. Because it takes experience to interpret the ramifications of postoperative complications, I conclude that, within negotiated limits, the surgeon’s fiduciary agency should extend into the postoperative period to choose the therapeutic maneuvers most likely to achieve the goals identified by the patient at the beginning of treatment.
INTRODUCTION: Despite significant advances in technology, neonates with CDH still face the risk of significant morbidity and mortality, with associated patient and family suffering. We hope to develop a more precise and compassionate perinatal care algorithm. METHODS: We carried out a retrospective medical record review of antenatal imaging data on consecutive pregnancies presenting with a fetal diagnosis of CDH. Prenatal MRI images were analyzed to measure total and relative fetal lung volume and other indices of
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
e13
http://dx.doi.org/10.1016/j.jamcollsurg.2015.08.328 ISSN 1072-7515/15