March 31, 2011

Medical Robots and Medical Robotics

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A medical robot is a robot used in the medical sciences. They include, but are not limited to, surgical robots. These are in most telemanipulators, which use the surgeon's actions on one side to control the "effector" on the other side.

March 22, 2011

The Last Hours of Living: Practical Advice for Clinicians: Summary of Take-Home Lessons

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MedscapeCME - Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD

8. Summary of Take-Home Lessons

Clinical competence, willingness to educate and calm, and empathic reassurance are critical to helping patients and families in the last hours of living. For most dying patients, predictable physiologic changes occur. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations that include ensuring privacy, cultural observances, and communication that may not be customary.

In anticipation of the event, it helps to inform the family and other professionals about what to do and what to expect, including matters such as when rigor mortis sets in, and how to call the funeral home, say goodbye, and move the body. Care does not end until the clinician has helped the family with their grief reactions and helped those with complicated grief to get care. Care at the end of life is an important responsibility for every health professional, and there is a body of knowledge to guide care.[2,65,66]

In summary, keep these key points in mind:
  1. There is only one chance to get management of the last hours right.
  2. Patients in the last hours of life usually need skilled care around the clock. The environment must allow family and friends ready access to their loved one in a setting that is conducive to privacy and intimacy.
  3. Advance preparation and education of professional, family, and volunteer caregivers are essential. They should also be knowledgeable about the potential time course, signs and symptoms of the dying process, and their potential management. The physician or nurse needs to help family members understand that what they see may be very different from what the patient is experiencing.
  4. The physiologic changes of dying are complex. To control each symptom effectively, clinicians need to have an understanding of its cause, underlying pathophysiology, and the appropriate pharmacology to use.
  5. When death is imminent, fatigue is an expected part of the dying process and should not be treated medically in most cases.
  6. Most patients lose their appetite and reduce food intake long before they reach the last hours of their lives. Anorexia may be protective, and the resulting ketosis can lead to a greater sense of well-being and diminish pain.
  7. Most patients also reduce their fluid intake, or stop drinking entirely, long before they die. Dehydration in the last hours of living does not cause distress and may stimulate endorphin release that adds to the patient's sense of well-being.
  8. Moisture should be maintained in mucosal membranes with meticulous oral, lip, nasal, and conjunctival hygiene and lubrication.
  9. Most patients experience increasing drowsiness and sleep much of the time, eventually becoming unarousable. Absence of eyelash reflexes indicates a profound level of coma equivalent to full anesthesia.
  10. It should be assumed that the unconscious patient hears everything.
  11. Moaning, groaning, and grimacing accompanying agitation and restlessness are frequently misinterpreted as pain. Terminal delirium may be occurring. Although a trial of opioids may be beneficial in the unconscious patient who is difficult to assess, benzodiazepines or sedating neuroleptics may be needed to manage terminal delirium. Benzodiazepines may cause paradoxical exciting effects; these patients require neuroleptic medications to control their delirium.
  12. Diminished hepatic function and renal perfusion may change the pharmacology of chronically administered medications.
  13. Secretions from the tracheobronchial tree frequently accumulate. Scopolamine or glycopyrrolate will effectively reduce the production of saliva and other secretions.
  14. Dying in an institution presents particular challenges. Priorities and care plans at the very end of life differ from those priorities and plans focused on life prolongation and cure.
  15. Planning discussions should cover personal, cultural, and religious traditions, rites, and rituals that may dictate how prayers are to be conducted, how a person's body is to be handled after death, and when and how the body can be moved.
  16. When an expected death occurs, the focus of care shifts to the family and those who provided care.
  17. Acute grief reactions should be addressed, especially when the body is moved.
Pearls and Pitfalls

Pearls for quality care include:
  1. Use only essential medications. Stop routine dosing and continue to offer opioids as needed. Accumulating serum concentrations of active drug and metabolites may lead to toxicity and terminal delirium.
  2. Know the signs of the dying process.
  3. Make a partnership with the patient and the family caregiver(s); draw them into the interdisciplinary team and foster their active participation in the care plan.
Common pitfalls include:
  1. Maintaining parenteral fluids. Continuing fluids may have adverse effects that are not commonly considered.
  2. Oropharyngeal suctioning. While suctioning is likely to be ineffective at clearing secretions, it may be very effective at stimulating a gag, cough, or vomiting.
  3. Removing the body insensitively or too soon. This can be more distressing for families than the moment of death.
65. Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ. 2003;326:30-34.
66. Ferris FD, von Gunten CF, Emanuel LL. Competency in end of life care: The last hours of living. J Palliat Med. 2003;6:605-613. Abstract

The EPEC™-O curriculum was initially produced by the EPEC Project™ at Northwestern University’s Feinberg School of Medicine, with major funding provided by the National Cancer Institute and supplemental funding provided by the Lance Armstrong Foundation.

March 15, 2011

The Last Hours of Living: Practical Advice for Clinicians: Pronouncing Death

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Medscape - Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD

7. Pronouncing Death

In teaching hospitals, medical students and residents are typically called to "pronounce" death.[58] In nonteaching settings, the attending physician or nursing staff may be the professionals to do this task. When a patient dies at home with hospice care, it is usually a nurse who confirms the absence of vital signs. Although local regulations differ, if an expected death occurs at home without hospice care and the patient has a physician or other clinician willing to sign a death certificate, then transportation to a hospital for a physician to confirm death may not be needed.

The telephone call.
The process often begins with a telephone call: "Please come; I think the patient has died." Begin by asking a few key questions:
  • Find out the circumstances of the death -- expected or sudden?
  • Is the family present?
  • What is the patient's age?
Before entering the room.
  • Confirm the details on the circumstances of death with other health professionals or caregivers. Review the chart for important medical (length of illness, cause of death) and family issues. (Who is family? What faith? Is there a clergy contact?)
  • Find out who has been called. Other physicians, nurse practitioner or physician's assistant? The attending physician?
  • Has an autopsy been requested? Do you see a value in requesting an autopsy?
  • Has the subject of organ donation been broached? Has the Organ Donor Network been contacted?
In the room.
  • You may want to ask the nurse, social worker or chaplain to accompany you; he/she can give you support and introduce you to the family.
  • Introduce yourself (including your relationship to the patient) to the family if they are present. Ask each person their name and relationship to the patient. Shake hands with each.
  • Say something empathic: "I'm sorry for your loss..." or "This must be very difficult for you..."
  • Explain what you are there to do. Tell the family they are welcome to stay, if they wish, while you examine their loved one.
  • Ask the family if they have any questions. If you cannot answer, contact someone who can.
The pronouncement of death.
  • Identify the patient. Use the hospital ID tag if available. Note the general appearance of the body.
  • Test for response to verbal or tactile stimuli. Overtly painful stimuli are not required. Nipple or testicle twisting, or deep sternal pressure, are inappropriate and unnecessary.
  • Listen for the absence of heart sounds; feel for the absence of carotid pulse.
  • Look and listen for the absence of spontaneous respirations.
  • Record the position of the pupils and the absence of pupillary light reflex.
  • Record the time at which your assessment was completed.
Documentation in the medical record.
  • Note that you were called to pronounce the death of (name); chart findings of physical examination.
  • Note date and time of death; distinguish the time family or others noted death from the time you confirmed the absence of vital signs. Note whether family and attending physician were notified.
  • Document whether family declines or accepts autopsy; document whether the coroner was notified.
Telephone Notification

There will be situations in which the people who need to know about the death are not present.[59-63] In some cases, you may choose to tell someone by telephone that the patient's condition has "changed," and wait for them to come to the bedside in order to tell the news. Factors to consider in weighing whether to break the news over the telephone include: whether death was expected, what the anticipated emotional reaction of the person may be, whether the person is alone, whether the person is able to understand, how far away the person is, the availability of transportation for the person, and the time of day (or night). Inevitably, there are times when notification of death by telephone is unavoidable. If this is anticipated, prepare for it. Determine who should be called and in what fashion. Some families will prefer not to be awakened at night if there is an expected death.

Get the setting right. Determine the facts before you call. Find a quiet or private area with a telephone. Identify yourself and ask the identity of the person to whom you are talking and their relationship to the patient. Ask to speak to the person closest to the patient (ideally, the healthcare proxy or the contact person indicated in the chart). Avoid responding to direct questions until you have verified the identity of the person to whom you are speaking. Ask whether the contact person is alone. Do not give death notification to minor children.

Ask what the person understands. Ask what the person understands about the patient's condition with a phrase like, "What have you been told about M's condition?"

Provide a "warning shot." One approach may be to begin with a sentence such as "I'm afraid I have some bad news."

Tell the news. Use clear, direct language without jargon. For example, you could say, "I'm sorry to have to give you this news, but M just died." Avoid words like "expired," "passed away," and "passed on." They are easily misinterpreted.

Respond to emotions with empathy Most importantly, listen quietly to the person and allow enough time for the information to sink in. Elicit questions with a phrase like, "What questions do you have?" Ascertain what support the person has. Ask if you can contact anyone for them. Consider other support through the person's church, Red Cross, local police, or other service agencies if it is needed.

Conclude with a plan. If the family chooses to come to see the body, arrange to meet them personally. Provide contact information for the physician, nurse, or other professional who can meet with them and/or make arrangements.

Immediately after the death, those who survive will need time to recover. A bereavement card from the physician, nurse, or healthcare professional and attendance at the patient's funeral may be appropriate.[64] Many members of the professional team consider it a part of their professional duty of care to encourage follow-up visits from bereaved family members in order to assess the severity of their grief reactions and the effectiveness of their coping strategies, and to provide emotional support. Professional members of the interdisciplinary team can also offer to assist family members in dealing with outstanding practical matters, such as helping to secure documents necessary to redeem insurance, find legal counsel to execute the will and close the estate, find resources to meet financial obligations, etc. Bereavement care for the family is a standard part of hospice care in the United States.

58. Weissman DE, Heidenreich CA. Fast Facts and Concepts #4: Death Pronouncement in the Hospital. Milwaukee, Wi: End of Life Physician Education Resource Center. Available at: Accessed August 1, 2006.
59. Osias RR, Pomerantz DH, Brensilver JM. Fast Facts and Concepts #76 and Telephone Notification of Death. Milwaukee, Wi: End of Life Physician Education Resource Center. Available at: Accessed August 1, 2006.
60. Marchand LR, Kushner KP. Death pronouncement: survival tips for residents. Am Fam Physician. 1998;58:284-285. Abstract
61. Magrane BP, Gilliland MG, King DE. Certification of death by family physicians. Am Fam Physician. 1997;56:1433-1438. Abstract
62. Iserson KV. The gravest words: sudden death notification and emergency care. Ann Emerg Med. 2000;36:75-77. Abstract
63. Iserson KV. The gravest words: notifying survivors about sudden unexpected deaths. Resident Staff Physician. 2001;47:66-72.
64. Irvine P. The attending at the funeral. N Engl J Med. 1985;312:1704-1705. Abstract

March 10, 2011

9/11 Call For Papers: how did one day change health?

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The Lancet logo

One day changed the world.
We invite you to tell us how it changed health.

Call for papers

Deadline announcement - please submit your research before 31st March 2011.

The Lancet will dedicate a special issue in 2011 to September 11 - a decade on. We invite submissions (research articles, reviews, health policy papers, and viewpoints) that address the short-term and long-term physical, mental, and public health consequences of the events that took place (and continue to take place) in New York, Iraq, Afghanistan, or any other part of the world touched by September 11.

We are also interested in how the war on terrorism has affected the services, outcomes, policies, and regulations made in the fight against chronic and acute diseases, domestically and worldwide.
"2011 marks the tenth anniversary of this unprecedented domestic event with global implications...It will be a moment to reflect on how the world would have been different without September 11, 2001. It will be a time to think about what our nations have done right for human security and where they have made mistakes. It will be an opportunity to look forward, learning the lessons of the past decade."
- Richard Horton (Editor, The Lancet)
To respond to our call for papers, please submit your original research article or opinion piece via our online submission system, stating in your cover letter that the submission is in response to this call. The deadline for submissions is March 31, 2011.

To submit your research paper to us, please click here

Copyright © 2010 Elsevier Limited. All rights reserved. THE LANCET ® is a registered trademark of Elsevier Properties SA.

March 08, 2011

The Last Hours of Living: Practical Advice for Clinicians: Notifying Others of the Death

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MedscapeCME - Linda Emanuel, MD, PhD; Frank D. Ferris, MD; Charles F. von Gunten, MD, PhD; Jamie H. von Roenn, MD

6. Notifying Others of the Death

Spiritual advisors or other interdisciplinary team members may be instrumental in orchestrating events to facilitate the experiences of those present for a death. Those who have not been present may benefit from listening to a recounting of how things went leading up to the death and afterward. Grief reactions beyond cultural norms may suggest a risk for significant ongoing or delayed grief reactions.

When letting people know about the death, follow the guidelines for communicating bad news. Try to avoid breaking unexpected news by telephone, as communicating in person provides much greater opportunity for assessment and support. If additional visitors arrive, spend a few moments to prepare them for what they are likely to see.

Once family members have had the time they need to deal with their acute grief reactions and observe their customs and traditions, then preparations for burial or cremation and a funeral or memorial service(s) can begin. Some family members may find it therapeutic to help bathe and prepare the person's body for transfer to the funeral home or the hospital morgue. For many, such rituals will be their final act of direct caring.

Depending on local regulations and arrangements, some funeral directors will insist on the completed death certificate being present before they pick up the body. All will require a completed death certificate to proceed with any body preparation and registration of the death. To avoid delaying the process, ensure that the clinician who will complete the certificate has ample warning that one will be required.

For many, moving the body is a major confrontation with the reality of the death. Some family members will wish to witness the removal. Others will find it very difficult and will prefer to be elsewhere. Once the body has been removed and family members are settled, professional caregivers can offer to assist them with some of their immediate tasks. They may notify other clinicians and caregivers that the death has occurred so that services can be stopped and equipment removed. Local regulations governing the handling of medications and waste disposal after a death vary. When family members are ready, professional caregivers can let the family know how to reach them, and then leave them to have some privacy together.