Dr John Weeks argued for the ‘con’ side, in that this is actually a big financial challenge for critical care. He accepts that the donation rates will increase, and that this has a clear ethical advantages; saving lives and improving the quality of those lives. However, this needs to be funded. Critical care is already under significant pressure, with scarce beds providing challenges to deliver current care levels. This increase in transplant numbers also won’t result in the transfer of excess funding from dialysis units to the ICU. Indeed, some of these patients in their subsequent care may actually have a higher burden on ICU rather than any other resources (money would be spent managing these patients who are sick with sepsis related to their immunocompromised state). The silo nature of the NHS is unlikely to allow funding reallocation to automatically happen, and this will need active anticipation and intervention. On voting at the end of the debate, it seems that the majority of the ANWICU group have similar worries. If you would like to read more about the concept of presumed consent that was the trigger for this debate, this document provides a detailed analysis.- https://www.ncbi.nlm.nih.gov/books/NBK56888/
The initiative and creativity of the drug producers was once again fascinating to listen to, with small alterations to drug structure initially being used to get around the legislation (creating ‘legal highs’). This was part of the driver for increasing potency, with some of the newer molecules proving to be even stronger than the ones just banned, just through this chemical exploration (for example the simple addition of a fluorine atom). These ‘market forces’ are also contributing to toxicity. Their toxicity is related to a number of factors: the type of SCRA (often a mixture), concentration of SCRA, dosage taken, residual solvents/carriers, method of ingestion (there can be unknown products of pyrolysis from smoking them) and other pharmacy ingestion. The amateur chemistry of these manufacturers results in wide variation in these toxic effects, with great uncertainty around many of these contributing factors. This unpredictability has impacted on drug users in the past, such as the effects in Manchester recently when a change in the dose of the dealt spice lead to an epidemic of severely affected users in the town centre. These patterns are important to be aware of as critical care clinicians, as we are likely to be involved in their care if they require hospital admission, due to the potential severity of the drug effects. The changes in the drug market, such as the introduction of a new molecule, may result is a spate of presentations, and it may be useful to bear this in mind following an isolated presentation - there may be more on the way soon. Again, there are some very helpful resources on the topic, particularly from the Neptune group, which are listed at the end.
The Fallacy of the Last Bed
He discussed some of the challenges of applying similar levels of quality to such studies as are well described in the quantitative world, such as credibility, transferability and confirmability. Similarly, the analysis sounds particularly hard (an approach called grounded theory) but the results sound fascinating. Some themes that emerged included those of negotiation, consensus and the impact of tacitly held practices. These are some of the aspects of our job that I find most interesting, and yet also those which we seem to have fairly little teaching on, or even a very strong understanding of. The efforts to understand these concepts better is definitely very worthwhile, and there are few more useful links listed below if you would like to read a bit more.
The challenge that we have is to make ‘good decisions’. This is a challenging definition, but should include being justifiable, provide satisfaction (for patient, family and clinical team), and reduce fallout and stress. In the biomedical context the application of such a definition is better understood - we use the history, examination and investigations to reach reasoned hypotheses from which we can recommend treatments based on the latest evidence. With ethics there is none of this. Even our curriculum describes only ‘basic applied ethics’, and with a correspondingly smaller proportion of our training directed towards this, despite it probably making up half of the medicine we actually practice. The result is a trend towards heuristics and defaults; at risk of being highly influenced by our biases and preferences (many of which may be unconscious). Dan argues that this domain is essentially no different from the other skills we require. We need to acquire the relevant knowledge, training and practice in them to become appropriately competent. He argues that the use of frameworks can be a starting point here, and he has helped put together one that is a useful starting point for understanding these issues (see here). The classic ethical pillars of Beachamp and Childress are perhaps the best known of such ideas (autonomy, non-maleficence…), but their implementation is unclear. I do find this a particularly fascinating and important topic, although much of my reading is not specifically medically orientated. This is definitely an area I want to understand deeper, especially given the increasing importance of them as we ultimately move to working as consultants. The MORAL balance framework seems like an excellent starting point.
The Robbie McKendrick Prize
The case presentations themselves involved a case of myxoedema coma, a real diagnostic challenge of Guillain-Barre syndrome developing subsequent to a high cervical spine injury, and the winning presentation from Dr April Lu about a case of diffuse TB infection. Similarly, the audit/QI project category was of very high quality and included an audit into end of life planning, an investigation into CVC insertion lengths, a review of the support for managing metabolic disease outside a specialist centre, and the winning presentation from Dr Mercer looking at exactly what a ‘liver panel’ means, and how it can be easily used in a general ITU.
Links & References
- ANWICU. http://www.anwicu.org/
- Rithalia, A. et al. A systematic review of presumed consent for deceased organ donation. 2009. https://www.ncbi.nlm.nih.gov/books/NBK56888/
- NEPTUNE. http://neptune-clinical-guidance.co.uk/
- UNODC. https://www.unodc.org/unodc/index.html?ref=menutop
- European Drug Report. http://www.emcdda.europa.eu/edr2019
- Charlesworth, M. Foex, B. Qualitative research in critical care: has its time finally come? JICS. 2016. 17(2):146-153. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606391/
- Charlesworth, M. An observational study of critical care physicians’ assessment and decision-making practices in response to patient referrals. Anaesthesia. 2017. 72(1):80-92. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.13667
- James, F. et al. Decision-making in intensive care medicine - a review. JICS. 2018. 19(3):247-258. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110024/
- Harvey, D. Gardiner, D. ‘MORAL balance’ decision-making in critical care. BJA Education. 19(3):68-73. https://bjaed.org/article/S2058-5349(18)30145-8/abstract
- GMC. Leadership and management for all doctors. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/leadership-and-management-for-all-doctors
- West, M. et al. Leadership and leadership development in healthcare. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/leadership-leadership-development-health-care-feb-2015.pdf
- FMLM. The state of medical leadership and management training for doctors: FMLM 2017 junior doctor survey. https://www.fmlm.ac.uk/sites/default/files/content/news/attachments/The%20state%20of%20medical%20leadership%20and%20management%20training%20for%20junior%20doctors.pdf