Standards and Ethics Issues in the Determination of Death: A Position Paper From the American College of Physicians.

The determination of a patient's death is of considerable medical and ethical significance. Death is a biological concept with social implications. Acting with honesty, transparency, respect, and integrity is critical to trust in the patient-physician relationship, and the profession, in life and in death.

Surgeon Perspectives on Daily Presentation of Ethical Dilemmas: A Qualitative Study.

Background: Surgeons encounter and navigate a unique set of ethical dilemmas. The American College of Surgeons (ACS) previously identified 6 core ethical issues central to the practice of surgery, but there have been no reports of the true range and complexity of ethical dilemmas encountered by surgeons in their daily practice. Qualitative research is well positioned to address this question.

A Standardized Approach to Treatment Over Objection in Patients Lacking Decision-Making Capacity Secondary to Neurologic Disease.

Neurologic diseases, ranging from Alzheimer dementia to mass lesions in the frontal lobe, may impair decision making. When patients with neurologic disease lack decision-making capacity, but refuse treatment, should they be treated over their objection? To address this type of ethical dilemma in medical illness, Rubin and Prager developed a standardized 7-question approach: (1) How imminent is harm without intervention? (2) What is the likely severity of harm without intervention? (3) What are the risks of intervention? (4) What are the logistics of treating over objection? (5) What is the efficacy of the proposed intervention? (6) What is the likely emotional effect of a coerced intervention? (7) What is the patient's reason for refusal? We describe the application of the standardized Rubin/Prager approach as a checklist to the case of a 50-year-old woman with a large frontal lobe meningioma, who lacked capacity as a result of the meningioma, but refused surgery. This approach may be applied to similar ethical dilemmas of treatment over objection in patients lacking capacity as a result of neurologic disease.

In COVID-19 Patients Who Suffer In-Hospital Cardiac Arrest, Cardiopulmonary Resuscitation Outcomes May Be Impacted by Arrest Etiology and Local Pandemic Conditions.

Objectives: The utility and risks to providers of performing cardiopulmonary resuscitation after in-hospital cardiac arrest in COVID-19 patients have been questioned. Additionally, there are discrepancies in reported COVID-19 in-hospital cardiac arrest survival rates. We describe outcomes after cardiopulmonary resuscitation for in-hospital cardiac arrest in two COVID-19 patient cohorts.

Ethical Framework to Guide Decisions of Treatment Over Objection.

Background: Whether to proceed with a medical intervention over the objection of a patient who lacks capacity is a common problem facing practitioners. Despite this, there is a notable gap in the literature describing how to proceed in such situations in an ethically rigorous and consistent fashion. We elaborate on the practical application of the 2018 Rubin and Prager 7-question algorithm for ethics consultations about treatment over objection and we describe the impact of each of the 7 questions.

Electrocerebral Signature of Cardiac Death.

Background: Electroencephalography (EEG) findings following cardiovascular collapse in death are uncertain. We aimed to characterize EEG changes immediately preceding and following cardiac death.

Methods: We retrospectively analyzed EEGs of patients who died from cardiac arrest while undergoing standard EEG monitoring in an intensive care unit.

Ophthalmology and Ethics in the COVID-19 Era.

Purpose: The novel coronavirus, SARS-CoV-2 (COVID-19), has disrupted the practice of ophthalmology and threatens to forever alter how we care for our patients. Physicians across the country encounter unique clinical dilemmas daily. This paper presents a curated set of ethical dilemmas facing ophthalmologists both during and following the pandemic.

The COVID-19 Crisis and Clinical Ethics in New York City.

The COVID-19 pandemic that struck New York City in the spring of 2020 was a natural experiment for the clinical ethics services of NewYork-Presbyterian (NYP). Two distinct teams at NYP's flagship academic medical centers-at NYP/Columbia University Medical Center (Columbia) and NYP/Weill Cornell Medical Center (Weill Cornell)-were faced with the same pandemic and operated under the same institutional rules. Each campus used time as an heuristic to analyze our collective response.

Clinical Ethics Consultations during the COVID-19 Pandemic Surge at a New York City Medical Center.

The COVID-19 pandemic swept through New York City swiftly and with devastating effect. The crisis put enormous pressure on all hospital services, including the clinical ethics consultation team. This report describes the recent experience of the ethics consultants and Columbia University Irving Medical Center during the COVID-19 surge and compares the case load and characteristics to the corresponding period in 2019.

Meeting the Challenge of COVID-19: The Response of Two Ethics Consultation Services in New York City.

From mid-March through May 2020, New York City was the world's epicenter of the COVID-19 pandemic, and its hospitals faced an unparalleled surge of patients who were critically ill with the virus. In addition to putting an enormous strain on medical resources, the pandemic presented many ethical issues to emotionally and physically stressed clinicians and hospital administrators. Analyses of the challenges faced by the ethics consultation services of the two campuses of New York Presbyterian Hospital, and how they assisted their clinician and administrative colleagues, is the subject of the following four articles.

The ethics of neurologically complicated pregnancies.

Bioethical conflicts in pregnancy are distinguished from those in other areas of medicine due to competing interests between mother and fetus because of their shared biology. Historically, prior to the advent of fetal therapy and advances in medical technology, the maternal-fetal complex was considered to be a single entity. With advances in medicine, treatment options can now be directed at both the mother and the fetus, and a duality has evolved in the maternal-fetal unit.

Roles of the Ethics Consultant: A Response to Vaughan and Colleagues and De Renzo.

We respond to commentaries on our article, "The Clinician as Clinical Ethics Consultant: An Empirical Method of Study," that appeared in the summer 2019 issue of The Journal of Clinical Ethics.

Ethical Considerations for Mechanical Support.

Extracorporeal life support can support patients with severe forms of cardiac and respiratory failure. Uncertainty remains about its optimal use owing in large part to its resource-intensive nature and the high acuity illness in supported patients. Specific issues include the identification of patients most likely to benefit, the appropriate duration of support when prognosis is uncertain, and what to do when patients become dependent on extracorporeal life support but no longer have hope for recovery or transplantation.

Practice Patterns and Ethical Considerations in the Management of Venovenous Extracorporeal Membrane Oxygenation Patients: An International Survey.

Objectives: To characterize physicians' practices and attitudes toward the initiation, limitation, and withdrawal of venovenous extracorporeal membrane oxygenation for severe respiratory failure and evaluate factors associated with these attitudes.

Design: Electronic, cross-sectional, scenario-based survey.

Setting: Extracorporeal membrane oxygenation centers affiliated with the Extracorporeal Life Support Organization and the International Extracorporeal Membrane Oxygenation Network.

The Clinician as Clinical Ethics Consultant: An Empirical Method of Study.

Some 30 years ago the role of the clinical ethics consultant (CEC) was formalized. At the time, the perception of the role differed between two groups serving in that capacity, clinicians and nonclinicians. Differences in their roles reflected their training and experience.

Consent for organ donation after circulatory death at U.S. transplant centers.

Background: Despite calls for a controlled organ donation after circulatory death (cDCD) consent process that is more rigorous, consistent, and transparent, little is known about the cDCD consent processes utilized by U.S. hospitals.

Education research: a case-based bioethics curriculum for neurology residents.

Background: In 2012, the American Academy of Neurology (AAN) updated and expanded its ethics curriculum into Practical Ethics in Clinical Neurology, a case-based ethics curriculum for neurologists.

Methods: We piloted a case-based bioethics curriculum for neurology residents using the framework and topics recommended by the AAN, matched to clinical cases drawn from Columbia's neurologic services. Our primary outcome was residents' ability to analyze and manage ethically complex cases as measured on precurriculum and postcurriculum multiple-choice quizzes.

Ethnic disparities in end-of-life care after subarachnoid hemorrhage.

Background: It is common for patients who die from subarachnoid hemorrhage to have a focus on comfort measures at the end of life. The potential role of ethnicity in end-of-life decisions after brain injury has not been extensively studied.

Methods: Patients with subarachnoid hemorrhage were prospectively followed in an observational database.

Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults.

Extracorporeal membrane oxygenation (ECMO) can serve as a bridge to recovery in cases of acute reversible illness, a bridge to transplantation in circumstances of irreversible cardiac or respiratory failure, a bridge to ventricular assist device therapy in select cases of cardiac failure, or a bridge to decision when the prognosis remains uncertain. Recent advances in ECMO technology that allow for prolonged support with decreased complications, the development of mobile ECMO teams, the rapidity of initiation, and the growing body of evidence, much of which remains controversial, have led to a significant increase in the use of ECMO worldwide. This increasing use of a technology that is not a destination device in itself introduces many ethical dilemmas specific to this technology.