Continued from cover Use of Latest Life-saving Technologies Can Raise Critical Ethical Issues “If someone has shoulder pain, for example, we need to figure out where the problem is,” Dr. FitzGerald says. “Ultrasound can help us determine if the swelling is in the rotator cuff joint or in the tendon attached to the joint. The location of the inf lammation suggests one disease over another, but this information would be difficult to find with only a clinical exam.” Because ultrasound provides real-time images, physicians can also use the technology for treatment, such as to guide placement of corticosteroids, which are anti-inflammatory hormones that temporarily relieve pain when injected into affected joints. “We can make the diagnosis and treat the patient right there, with less pain and more accuracy,” Dr. FitzGerald says. “Most patients are very comfortable with ultrasound technology and prefer the convenience of being diagnosed and treated in our office rather than having to go to another place for an MRI or CT scan, and then return for treatment.” Ultrasound has certain limitations. While it works well with skin, soft tissue and tendons, it is less accurate producing images of certain joints and unable to penetrate bone. Overall, however, ultrasound has proven useful in the diagnosis and treatment of arthritic conditions and may continue to be used to inform recommended treatment protocols. “We’re still learning where best to use different types of therapies in arthritis patients,” Dr. FitzGerald says. “If we can eventually use ultrasound to predict whether certain treatments will work long term, we can improve treatment decision making and provide relief to patients much more quickly.” decisions can be made that are consistent with each patient’s clearly stated care goals, says Neil Wenger, MD, director of the UCLA Health Ethics Center. “All of these wonderful advances dramatically increase our responsibility as physicians to ensure that patients and those making decisions for them are fully informed about the pros and cons of using that technology,” Dr. Wenger explains. “To make informed decisions on whether to receive these treatments, patients and their families should understand not only what benefits might come, but also the future outcomes if they don’t benefit in the way that’s anticipated.” Many of these advanced technologies aim at rescue, which means that under normal circumstances, Dr. Wenger explains, without the treatment the patient would die — usually from the failure of an organ. For example, there might be a small-to-moderate chance that with a ventricular-assist device (an artificial heart), a particularly ill patient could be kept alive until an organ became available for transplant. “Under those circumstances, one is shooting for an uncertain or perhaps even improbable benefit, with a high likelihood that the ‘miracle’ won’t happen and decisions will need to be made about future treatments,” Dr. Wenger notes. “Frequently, those decisions need to be made when the patients can’t talk to us. Therefore, the use of advanced technology necessitates an in-depth and detailed discussion with the patient or the people making decisions for the patient about the purpose of the technology, what will happen if the technology doesn’t achieve the intended goal, and how the patient would feel about that.” This makes high-quality conversations between the treating team and the patient and patient’s family particularly important. Dr. Wenger says such discussions should clearly and compassionately identify the spectrum of potential treatments, conveying the likelihood that each approach will be successful and what that success would mean — as well as the potential adverse outcomes and the health states they would produce — to determine the patient’s preferences and goals. “These are difficult conversations,” Dr. Wenger says. “When you’re trying to rescue someone, the last thing that person wants to focus on is what life will be like after a massive stroke. “However, without such conversations beforehand, a patient might end up undergoing unwanted life-sustaining treatment.” Vital Signs Spring 2013 Vol. 58 7