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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
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