Digital Commons Network^™

Unwanted Medical Treatment Harms Patients: Taxonomy Of Healthcare Consent Infractions, Thaddeus Pope

Faculty Scholarship

Patients in the United States are subject to an ever-growing “avalanche” of unwanted medical treatment (UMT).  This is ethically, economically, and legally wrong. First, UMT constitutes a serious violation of patient autonomy and self-determination.  Second, it is waste (and often fraud or abuse) of scarce healthcare resources.  Third, but for rare exceptions, administering UMT contravenes settled legal rules and principles around consent and battery.

This article describe four types of unwanted medical treatment and how the law addresses (or fails to address) them.  The four types of UMT are (1) treatment over patient objections, (2) treatment with zero consent, (3) …

Deep And Continuous Palliative Sedation Without Artificial Nutrition And Hydration: An International Review, Richard Liu, Thaddeus Pope, April Xiaoyi Xu

Faculty Scholarship

Deep and continuous palliative sedation combined with withholding or withdrawal of artificial nutrition and hydration (collectively termed “PSs̄ANH”) is a medical process regularly used in end-of-life care as a means of alleviating suffering. But PSs̄ANH is often not governed by a clear legal framework. To shed light on different approaches to regulating PSs̄ANH, this Article conducts a comparative analysis of the PSs̄ANH legality across twelve jurisdictions.

To facilitate understanding of this broad issue, we subdivided PSs̄ANH into three categories:

(1) PSs̄ANH will not hasten death (“Type 1 PSs̄ANH”),
(2) PSs̄ANH might, but is not certain to, hasten death (“Type 2 …

Feasibility Of A Low-Intensity Intervention To Influence Antibiotic Prescribing Rates Use In Outpatient Settings: A Cluster Randomized Controlled Clinical Trial, Brigid M. Wilson, Sunah Song, Robin L.P. Jump, Federico Perez

Faculty Scholarship

Background. Primary care providers (PCPs) may modify their antibiotic prescription practices if aware of their potentially damaging impact. Methods. We conducted a cluster randomized controlled trial at 12 Veterans Affairs community-based outpatient clinics. PCPs at clinics randomized to the intervention group received quarterly antibiotic use reports with feedback about antibiotics prescribed for acute respiratory infections and adverse event letters alerting about Clostridioides difficile infection or antibiotic-resistant gram-negative bacteria among their patients. The main outcome, antibiotic prescriptions in primary care visits, was compared in the preintervention (April–September 2020), intervention (October 2020 to September 2021), and postintervention periods (September 2021 to September …

Understanding The Utility Of Less Than Six-Month Prognosis Using Administrative Data Among U.S. Nursing Home Residents With Cancer, Long Vu, Siran M. Koroukian, Sara L. Douglas, Hannah L. Fein

Faculty Scholarship

Background: There is a dearth of studies evaluating the utility of reporting prognostication among nursing home (NH) residents with cancer. Objective: To study factors associated with documented less than six-month prognosis, and its relationship with end-of-life (EOL) care quality measures among residents with cancer. Methods: The Surveillance, Epidemiology, and End Results linked with Medicare, and the Minimum Data Set databases was used to identify 20,397 NH residents in the United States with breast, colorectal, lung, pancreatic, or prostate cancer who died between July 2016 and December 2018. Of these, 2205 residents (10.8%) were documented with less than six-month prognosis upon …

Aggressive End-Of-Life Care Across Gradients Of Cognitive Impairment In Nursing Home Patients With Metastatic Cancer, Siran M. Koroukian, Sara L. Douglas, Long Vu, Hannah L. Fein, Nicholas K. Schiltz, Jennifer Cullen, Cynthia Owusu, Martha Sajatovic, Johnie Rose

Faculty Scholarship

Background: Studies examining end-of-life (EOL) care in older cancer patients are scarce, and prior studies have not accounted for gradients of cognitive impairment (COG-I). We examine EOL care patterns across COG-I gradients, hypothesizing that greater COG-I severity is associated with lower odds of receiving aggressive EOL care. Methods: Using data from the linked Surveillance Epidemiology and End Results (SEER) -Medicare -Minimum Data Set (MDS) 3.0, we identified patients with nursing facility stays (NFS) and who died with metastatic cancer from 2013 to 2017. Markers of aggressive EOL care were: cancer-directed treatment, intensive care unit admission, >1 emergency department visit, or …

Dying In Isolation: Public Health Implications Of Transportation And Burial Of Human Remains During A Pandemic A Fifty State Survey, Christopher Ogolla

Faculty Scholarship

No abstract provided.

Incidence Of Aggressive End-Of-Life Care Among Older Adults With Metastatic Cancer Living In Nursing Homes And Community Settings, Siran M. Koroukian, Sara L. Douglas, Long Vu, Hannah L. Fein, Richa Gairola, Nicholas K. Schiltz, Jennifer Cullen, Cynthia Owusu, Martha Sajatovic, Johnie Rose

Faculty Scholarship

Importance: Nearly 10% of the 1.5 million persons residing in nursing homes (NHs) have received or will receive a diagnosis of cancer. Although aggressive end-of-life (EOL) care is common among community-dwelling patients with cancer, little is known about such patterns of care among NH residents with cancer. Objective: To compare markers of aggressive EOL care between older adults with metastatic cancer who are NH residents and their community-dwelling counterparts. Design, Setting, and Participants: This cohort study used the Surveillance, Epidemiology, and End Results database linked with the Medicare database and the Minimum Data Set (including NH clinical assessment data) for …

Racial Differences In Time To Blood Pressure Control Of Aneurysmal Subarachnoid Hemorrhage Patients: A Single-Institution Study, Xiaofei Zhou, Adam Hwan Bates, Uma V. Mahajan, Ansh Desai, Jeffrey Butke, Yifei Duan, Christopher Burant, Kaylee Sarna, Martha Sajatovic, Dhimant Dani, S. Alan Hoffer

Faculty Scholarship

Background and purpose Aneurysmal subarachnoid hemorrhage occurs in approximately 30,000 patients annually in the United States. Uncontrolled blood pressure is a major risk factor for aneurysmal subarachnoid hemorrhage. Clinical guidelines recommend maintaining blood pressure control until definitive aneurysm securement occurs. It is unknown whether racial differences exist regarding blood pressure control and outcomes (HLOS, discharge disposition) in aneurysmal subarachnoid hemorrhage. Here, we aim to assess whether racial differences exist in 1) presentation, 2) clinical course, and 3) outcomes, including time to blood pressure stabilization, for aSAH patients at a large tertiary care medical center. Methods We conducted a retrospective review …

The Myth Of The "Nationwide Injunction", Portia Pedro

Faculty Scholarship

A growing number of scholars, judges, and Justices are debating the permissibility and propriety of relief that they are calling "national injunctions" or "nationwide injunctions. "An injunction is a court order that prohibits an entity from taking certain actions or that requires an entity to take specified actions. Drawing from scholarly literature and popular discourse, some define a "nationwide injunction" as an injunction with no geographic limitation that benefits nonparties, in addition to named plaintiffs or defined plaintiff classes. Injunctive relief in a number of high-profile cases falls within the crosshairs of "nationwide injunction" opponents. On the chopping block is …

Implementation Of An Antibiotic Stewardship Program In Long-Term Care Facilities Across The Us, Robin L.P. Jump

Faculty Scholarship

Importance: Antibiotic overuse in long-term care (LTC) is common, prompting calls for antibiotic stewardship programs (ASPs) designed for specific use in these settings. The optimal approach to establish robust, sustainable ASPs in LTC facilities is unknown. Objectives: To determine if the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Antibiotic Use, an educational initiative to establish ASPs focusing on patient safety, is associated with reductions in antibiotic use in LTC settings. Design, Setting, and Participants: This quality improvement study including 439 LTC facilities in the US assessed antibiotic therapy data following a pragmatic quality-improvement program, which was …

The House Always Wins: Doctrine And Animus In California’S Covid-19 Prison Litigation, Hadar Aviram

Faculty Scholarship

No abstract provided.

A Pilot Randomized Clinical Trial Of A Teamwork Intervention For Heart Failure Care Dyads, Elliane Irani, Atsadaporn Niyomyart, Mary A. Dolansky, John Paul Stephens, Richard A. Josephson, Ronald L. Hickman Jr.

Faculty Scholarship

Background: Dyadic heart failure (HF) management can improve outcomes for patients and caregivers and can be enhanced through eHealth interventions. Objective: To evaluate the feasibility, acceptability, and preliminary efficacy of an eHealth dyadic teamwork intervention, compared to an attention control condition. Methods: We recruited 29 HF patient-caregiver dyads from inpatient units and randomized dyads to an intervention or a control group. We calculated enrollment and retention rates, described acceptability using interview and questionnaire data, and computed intervention effect sizes. Results: 37% of eligible dyads agreed to participate and 93% of randomized participants completed follow-up questionnaires. Participants found both study conditions …

Caregiving Stress And Self-Rated Health During The Covid-19 Pandemic: The Mediating Role Of Resourcefulness, Elliane Irani, Atsadaporn Niyomyart, Jaclene A. Zauszniewski

Faculty Scholarship

Family caregivers faced unprecedented circumstances and experienced increased levels of stress during the COVID-19 pandemic. Resourcefulness can minimize the effect of stress on health outcomes. The purpose of this study was to examine the associations between caregiving stress during the pandemic, resourcefulness, and self-rated health and assess the mediating effect of resourcefulness. A convenience sample of 70 family caregivers of adults with chronic and/or disabling conditions was recruited using social media groups and professional networking platforms. Data were collected using an online survey and analyzed using linear regression. Mediation analysis was conducted using the PROCESS macro. Higher levels of caregiving …

Use Of Electronic Pharmacy Transaction Data And Website Development To Assess Antibiotic Use In Nursing Homes, Sunah Song, Brigid M. Wilson, Robin L.P. Jump

Faculty Scholarship

Background: In 2017, the Centers for Medicare and Medicaid Services required all long-term care facilities, including nursing homes, to have an antibiotic stewardship program. Many nursing homes lack the resources, expertise, or infrastructure to track and analyze antibiotic use measures. Here, we demonstrate that pharmacy invoices are a viable source of data to track and report antibiotic use in nursing homes. Methods: The dispensing pharmacy working with several nursing homes in the same healthcare corporation provided pharmacy invoices from 2014 to 2016 as files formatted as comma separated values. We aggregated these files by aligning elements into a consistent set …

Palliative Nursing: The Core Of Covid-19 Care, Polly Mazanec

Faculty Scholarship

No abstract provided.

Technology And Litigation: The 21st Century American Experience, Richard L. Marcus

Faculty Scholarship

No abstract provided.

Is There A "Mulatto Escape Hatch" Out Of Racism?: A Reflection On Multiracial Exceptionalism During A Time Of #Blacklivesmatter, Tanya K. Hernandez

Faculty Scholarship

No abstract provided.

Getting Real: The Maryland Healthcare Ethics Committee Network’S Covid‑19 Working Group Debriefs Lessons Learned, Norton Elson, Howard Gwon, Diane Hoffmann, Adam M. Kelmenson, Ahmed Khan, Joanne F. Kraus, Casmir C. Onyegwara, Gail Povar, Fatima Sheikh, Anita J. Tarzian

Faculty Scholarship

No abstract provided.

Ethical Challenges In The Middle Tier Of Covid-19 Vaccine Allocation: Guidance For Organizational Decision-Making, Nancy Berlinger, Matthew Wynia, Tia Powell, Aimee Milliken, Parinda Khatri, Fatma Marouf, Keisha Ray, Johanna Crane

Faculty Scholarship

This supplement to The Hastings Center’s “Ethical Framework” aims to help structure time-sensitive discussion of significant, foreseeable ethical concerns in responding to Covid-19 and to support collaboration across institutions throughout pandemic response and recovery. It is designed for use by county health systems and by hospitals, community health centers, and other health care organizations responsible for patient care or preventive health, including vaccine education, vaccine distribution, and vaccination. This document aims to support formal and informal convening and policy work within the same geographic region, such as a municipality, county, metropolitan area, state, or multistate area, led by public health …

Characterization Of Community-Wide Transmission Of Sars-Cov-2 In Congregate Living Settings And Local Public Health-Coordinated Response During The Initial Phase Of The Covid-19 Pandemic, Pauline D. Terebuh, Amina J. Egwiekhor, Heidi L. Gullett, Adeola O. Fakolade, Jill E. Miracle, Prakash T. Ganesh, Johnie Rose, Kurt C. Stange, Andrea D. Szabo

Faculty Scholarship

BACKGROUND: Clusters of COVID-19 cases amplify the pandemic and are critical targets for intervention, but comprehensive cluster‐level data are not collected systematically by federal or most state public health entities. This analysis characterizes COVID-19 clusters among vulnerable populations housed in congregate living settings across an entire community and describes early mitigation efforts. METHODS: The Cuyahoga County Board of Health identified and interviewed COVID-19 cases and exposed contacts, assessing possible connections to congregate living facilities within its jurisdiction from March 7, 2020, to May 15, 2020, during the first phase of the pandemic, while state of Ohio stay‐at‐home orders were in …

Distinguishing Moral Hazard From Access For High-Cost Healthcare Under Insurance, Christopher Robertson, Andy Yuan, Wendan Zhang, Keith Joiner

Faculty Scholarship

Health policy has long been preoccupied with the problem that health insurance stimulates spending (“moral hazard”). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States.
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/="/">We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to …

Video Advance Directives: Growth And Benefits Of Audiovisual Recording, Thaddeus Pope

Faculty Scholarship

The key question in Cruzan v. Director, Missouri Department of Health was one of substantiation and evidence: how can the incapacitated patient’s surrogate decision maker prove that the health care decisions she makes on the patient’s behalf are the same health care decisions that the patient would have made for herself? Answering this question, the Court observed that an advance directive would constitute adequate proof because an advance directive constitutes clear and convincing evidence of a patient’s wishes.

Today, clinicians and policymakers no longer focus on the constitutional question of how much evidence state law may require from a patient’s …

Shades Of Shakespeare In The Queering Of Hill House, Graley Herren

Faculty Scholarship

In her classic horror novel The Haunting of Hill House, Shirley Jackson appropriates Shakespearean romantic comedies and tragedies for the purposes of lesbian gothic. Shakespeare’s plays provide signposts for leading (as well as misleading) protagonist Eleanor Vance through the fraught terrain of restrictive gender expectations, patriarchal persecution, and queer desire in Fifties America. The present article develops a queer reading of Eleanor’s relationship with Theodora. This essay pays particular attention to the ways Jackson uses Shakespeare to structure and complicate the erotic subtext of The Haunting of Hill House.

A Psychometric Evaluation Of The Family Decision-Making Self-Efficacy Scale Among Surrogate Decision-Makers Of The Critically Ill, Grant A. Pignatiello, Elliane Irani, Sadia Tahir, Emily Tsivitse, Ronald L. Hickman Jr.

Faculty Scholarship

Objectives The purpose of this study was to report the psychometric properties, in terms of validity and reliability, of the Unconscious Version of the Family Decision-Making Self-Efficacy Scale (FDMSE). Methods A convenience sample of 215 surrogate decision-makers for critically ill patients undergoing mechanical ventilation was recruited from four intensive care units at a tertiary hospital. Cross-sectional data were collected from participants between days 3 and 7 of a decisionally impaired patient's exposure to acute mechanical ventilation. Participants completed a self-report demographic form and subjective measures of family decision-making self-efficacy, preparation for decision-making, and decisional fatigue. Exploratory factor analyses, correlation coefficients, …

My Teacher, My Friend, Susan P. Koniak

Faculty Scholarship

In 1977, I think it was, the Yale law faculty considered whether to bar recruiters who discriminated against gays and lesbians-most notably the military-from interviewing students on campus. With the faculty then dominated by liberal giants, one might think the ban would have been a matter of little controversy. But the liberals thought the matter complex, so many interests to consider, nuance, nuance everywhere.

Geoff Hazard was not a liberal giant of that faculty. He was a titan and stood in awe of no giant, liberal or conservative-and there were conservative giants on the faculty then too, albeit fewer in …

How Home Health Nurses Plan Their Work Schedules: A Qualitative Descriptive Study, Elliane Irani

Faculty Scholarship

Aims and objectives: To describe how home health nurses plan their daily work schedules and what challenges they face during the planning process. Background: Home health nurses are viewed as independent providers and value the nature of their work because of the flexibility and autonomy they hold in developing their work schedules. However, there is limited empirical evidence about how home health nurses plan their work schedules, including the factors they consider during the process and the challenges they face within the dynamic home health setting. Design: Qualitative descriptive design. Methods: Semi-structured interviews were conducted with 20 registered nurses who …

Improving Pneumococcal Vaccine Uptake In Veterans With Chronic Lymphocytic Leukemia Through A Virtual Clinic, Brigid M. Wilson, L. Arfons, Federico Perez, Robin L.P. Jump

Faculty Scholarship

Through a “virtual clinic,” we used the electronic medical record to identify and intervene upon patients with chronic lymphocytic leukemia (CLL) who were not current for pneumococcal vaccines. Within 180 days, 100/160 patients (62%) received the recommended pneumococcal vaccine. A virtual clinic may improve vaccination rates among high-risk patient populations.

Influenza Mandates And Religious Accommodation: Avoiding Legal Pitfalls, Dorit Rubinstein Reiss, Veena B. Dubal

Faculty Scholarship

No abstract provided.

Legal History Of Medical Aid In Dying: Physician Assisted Death In U.S. Courts And Legislatures, Thaddeus Pope

Faculty Scholarship

Terminally ill patients in the United States have four medical options for controlling the time and manner of their death. Three of these are legally available to certain clinically qualified patients. First, all patients may withhold or withdraw life-sustaining treatment. Second, all patients may voluntarily stop eating and drinking. Third, patients with intractable suffering may receive palliative sedation to unconsciousness. In contrast, the fourth option is available in only seven U.S. jurisdictions. Only there may patients legally obtain a prescription for a lethal medication that they can later self-ingest.

Medical aid in dying (MAID) is not yet legally available in …

The Dilemma Of The "Doctor In The Family", Joanna K. Weinberg

Faculty Scholarship

No abstract provided.