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Bioethics Grand Rounds

Wed, June 22, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

Timothy Johnson, MD

"Ethical global health engagement: the Michigan Women's Health Model"

Millennial learners are experiencing and want to engage in global issues.  As institutions develop opportunities for their students, ethical issues need to be considered.  Transnational, transcultural, and translational issues as well as issues of equity, bilateral gain, economic transparency, academic values and sustainability must be factored into academic institutional partnerships between Western and low income countries.  The Ghana experience will be used to develop the concept of a “Michigan Model”.

Bioethics Grand Rounds

Wed, July 27, 2016, 12:00pm
Location: 
UH Ford Amphitheater & Lobby

Kunal Bailoor, MD Candidate Class of 2018, Ethics Path of Excellence

"Advance Care Planning: Beyond Durable Power of Attorney (DPOA)"

Abstract: Advance care planning is a crucial part of end of life medical care. It can take many forms, including designation of a surrogate decision maker via a DPOA document. However it can also involve living wills, physicians orders for life sustaining treatment (POLSTs), or even simply clinician patient conversation. The newly revised hospital policy on advance directives reflects this broader approach. The talk will include a brief review of the philosophical and ethical basis of advance care planning before diving into a discussion of the new hospital policy and it's impact on practice.

 

Interim Co-Director Brian Zikmund-Fisher was featured in “Medicine at Michigan.” Brian shared his personal experience with risk and probability in medical decision making.  This experience provided him with the personal career goal of improving patients’ lives by making health information easier to understand.

This is the first featured story in the new section “Gray Matters,” which gives our faculty members the opportunity to write about complex issues in medicine, such as ethics and decision-making.

"A Calculation of Risk"

Bioethics Grand Rounds-Deborah Berman, MD

Wed, January 24, 2018, 12:00pm
Location: 
University Hospital Ford Auditorium

Fetal Therapy: Just Because We can, Should We?

In utero fetal treatment is a complex undertaking that involves Maternal Fetal Medicine as well as a multidisciplinary team that focuses on prenatal diagnosis of specific pregnancy related complications and subsequent fetal therapy with the aim to improve fetal and neonatal outcomes. Several issues, including ethical and legal considerations, are particular to fetal medicine. This talk aims to highlight specific fetal complications in which fetal interventions are an option. In addition, the complex nature of the consultations, interventions, and implications for the patient, family, fetus in the present and future will be discussed.

Bioethics Grand Rounds- Katelyn Bennett- Social Media and the "Medutainment" Phenomenon

Wed, March 28, 2018, 12:00pm
Location: 
Univerisity Hospital Ford Auditorium

Social media is characterized by online spaces of rapid communication, advertising, professional development, and advocacy, and these platforms have revolutionized the way we interact with people and our culture. In surgery, platforms like Facebook, Snapchat, and Instagram are especially attractive for practice promotion and instantaneous connection with potential patients. However, considerable risks and ethical dilemmas lie in wait for the surgeon who attempts to use patient photographs and videos for advertising. It is critical for surgeons to facilitate fully informed consent, consider both context and the patient-physician power differential, and put patients’ interests ahead of their own.

Bioethics Grand Rounds: Naomi Laventhal, MD "Pediatric Care Before Birth: Complex Perinatal Care Coordination and Decision-Making at Michigan Medicine"

Wed, May 23, 2018, 12:30pm
Location: 
University Hospital Ford Auditorium

Expectant parents all hope for an uneventful pregnancy and a healthy baby, but a wide variety of maternal conditions and fetal problems necessitate comprehensive and complex care before birth. This session will offer a review of the nature and outcomes of these conditions, and describe the role of pediatricians in perinatal anticipatory guidance and decision-making, with an exploration of the commonly encountered bioethical issues. The session will include a  review of decision making at the margin of gestational viability, common complex genetic disorders, and technology intense interventions available before, during, and after birth.

Funded by National Institutes of Health

Funding Years: 2014-2016

Nearly half of patients undergoing coronary artery bypass grafting (CABG) nationwide are exposed to red blood cell (RBC) products. While large volumes (3+ units) of transfusions may be delivered to a given patient to preserve life in cases of acute blood loss, evidence suggests that even small amounts (1-2 units) of RBCs often transfused to address poor oxygen delivery are associated with a 16% increase in a patient's risk of mortality and a 27% increase in morbidity, even after case mix adjustment. It is vitally important to allocate RBC products appropriately, given both that cardiac surgery utilizes between 20-25% of the total national blood supply, and the Red Cross reports that 32 of their 36 regions had less than a day's supply available to meet hospital needs. In short, it is important to improve our understanding of how and in what context decisions are made regarding 1-2 units of RBCs, given its association with morbidity, mortality and resource utilization. Growing evidence suggests that some transfusions may be discretionary. In the state of Michigan, nearly 40% of CABG patients are exposed to 1-2 units of RBCs, although the absolute rate varies 32% across institutions. Center-specific variation in transfusion practices is likely attributed to thelack of consensus regarding the indications, setting and hematocrit trigger for transfusions. Given this uncertainty, transfusion rates may be the consequence of differences in organizational (e.g. protocols, types of decision-makers, lack of performance feedback regarding transfusion practice) and provider (e.g. knowledge, beliefs concerning the benefit/harm of transfusions, and inclination to transfuse) factors. Interventions to reduce the rate of unnecessary transfusions first require identifying the set of determinants (at the organizational or provider level) that mot fully explain the observed variation in RBC utilization across regional medical centers. We will use the prospective data and infrastructure of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), a consortium of all 33 cardiac surgical programs in Michigan, to: (1) Develop, pilot, and implement surveys to hospitals and clinical providers within the state of Michigan to describe determinants of 1-2 units of RBC transfusions during cardiac surgery, and (2) Identify the primary organizational and provider characteristics contributing to variability in transfusions. Results from this study will set the sage for a behavioral modification study aimed at reducing the rate of RBC transfusions in the setting of cardiac surgery.

PI(s): Richard Prager, Donald Likosky

Co-I(s): Darin Zahuranec, Min Zhang, Marc Zimmerman, Milo Engoren

Funded by National Institutes of Health; National Institute on Aging

This is competing continuation proposal for Years 23-28 of the Health and Retirement Study (HRS) cooperative agreement, in response to NIA RFA #AG-12-001. We propose to continue core data collection on the steady-state design laid out in the two previous renewal cycles, and collect biomarkers and measures of physical performance in in-person interviews on the rotating half-sample design established in the previous cycle.

PI(s): Sharon Kardia/David Weir

 

How would you adapt? (Nov-05)

Could you cope and find happiness if you were living with paraplegia? Think about what it would be like to have paraplegia and to imagine the impact of this disability on your life. Although some aspects of your life will become more difficult, there are ways to make your daily life a little easier.

List something that would help you to adapt physically if you had paraplegia. (For example, if you lost your eyesight, you could learn Braille, and/or use a cane). Just as there are ways to help you to adapt physically to paraplegia, there are also ways to help handle the immediate and long-term emotional reactions. List a strategy that you would use to emotionally cope with having paraplegia.

Please think about the two most upsetting things about developing paraplegia. Do you think these two things would become more or less upsetting over time?

  • More upsetting over time
  • Less upsetting over time
  • Equally upsetting over time

Please rate paraplegia on a scale from 0 to 100, where 0=quality of life as bad as death and 100=quality of life as good as perfect health.

How do your answers compare?

Those who were given the adaptation exercise rated paraplegia much higher, 62. That means considering adaption tends to have people look more favorably on paraplegia than they otherwise would. For most people, the adaptation exercise resulted in higher ratings. Let's take a closer look at the actual study and explore the importance of considering adaptation.

A discrepancy in perceptions of quality of life

When people first think about a disability, it might seem pretty catastrophic. At first glance, you might think that people living with paraplegia must be miserable. Patients who actually have paraplegia, however, report their quality of life to be significantly better than the public estimates that it would be. It appears, then, that there is a discrepancy between the self-rated quality of life of people with paraplegia, and healthy people's estimates of what their quality of life would be if they had this condition.

Why this discrepancy?

CBDSM director Peter Ubel teamed up with researchers Christopher Jepson and George Loewenstein to conduct a series of studies that aimed to explain why this discrepancy exists. Past research has suggested that patients do not overestimate their good mood, which led the researchers to hypothesize that, in fact, non-patients truly underestimate the quality of life experienced by people with disabilities. The researchers speculated about two explanations that could account for this underestimation. One possibility is that non-patients may be subject to a focusing illusion. That is, they might fail to appreciate that not all life domains or life events will be affected by the disability. Another possibility is that non-patients may be failing to consider adaptation, unable to realize how their feelings and their ability to cope will change over time.

In one study, each subject received one of several defocusing tasks in addition to rating paraplegia. For example, one of these tasks asked subjects to rate how much better or worse their life would be with regards to eight specific life events (e.g., visiting with friends). Another task asked subjects to think of five events that took up the largest amount of their time the preceding day and to rate how much better or worse these events would be if they had paraplegia. In a second study, subjects received one of several adaptation exercise in addition to rating paraplegia. One of these was similar to what you read on the previous page, although more extensive. Another had subjects consider their quality of life both 1 month and 5 years after developing paraplegia. In both studies, sujects rated paraplegia either before and after or only after completing an intervention.

The researchers found that none of the defocusing tasks had any effect on ratings of paraplegia. In fact, these tasks actually caused many participants to give lower ratings than they would have otherwise. All of the adaptation exercises, on the other hand, increased subjects' ratings of paraplegia. Taken together, these results support that the tendency of nonpatients to underestimate the quality of life associated with disabilities is not the result of a focusing illusion, but rather the result of failure to consider adaptation.

Read the article:

Disability and sunshine: Can predictions be improved by drawing attention to focusing illusions or emotional adaptation?
Ubel PA, Jepson C, Loewenstein G. American Journal of Psychiatry 2005;11:111-123.

On Thursday, May 19, at 4:30 pm in the Alumni Center, the Inaugural Bishop Lecture in Bioethics was held.  Established by a generous gift from the estate of Ronald C. and Nancy V. Bishop, both graduates of the University of Michigan Medical School (Class of '44), the inaugural address was given by John D. Lantos, MD, in a talk entitled, "The Complex Ethical Mess Surrounding Genetic Testing in Children." 

Dr. Lantos is the Director of the Children's Mercy Bioethics Center in Kansas City and is a leading voice in bioethics.  He has authored or edited five books and numerous publications, including Do We Still Need Doctors?, The Lazarus Case, Neonatal Bioethics, and The Last Physician: Walter Percy and the Moral Life of Medicine.  Lantos has discussed designer babies on Larry King Live, medical errors on Oprah, and ethics consultations on Nightline.  The Center for Bioethics and Social Sciences in Medicine co-sponsored the event.  Over 75 people attended the lecture, which was followed by a reception.

 

John D. Lantos, MD

 

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