Current Attitudes of Anesthesiologists towards Medically Futile Care

Purpose: To explore anesthesiologists’ perceptions of the reasons underlying why physicians continue to provide care that they consider futile. Methods: A qualitative study was conducted utilizing a grounded theory approach. Four separate focus groups (2 resident physician groups and 2 attending physician groups) were conducted over a three week span. An interview guide was used consisting of a proposed definition of futility and five open-ended questions. Responses to the five open-ended questions were used to guide follow up questions. Transcribed audio recordings were then analyzed. Results: With data reduction, we were able to separate responses into definitions of futility, stories of cases where futile care was provided, and opinions as to the underlying causes of continuing to provide futile care. A variety of opinions was obtained, suggesting the possibility that different groups (surgeons, anesthesiologists, family members) view questions of futility differently. Conclusions: Complete agreement on a definition of futility does not exist. Even when some agreement exists, there is great difficulty in predicting outcomes in individual cases. Future quantitative studies may provide more evidence of trends in underlying reasons for providing futile care. Focused education efforts may then lead to more agreement between all involved.

Preparation of synthetic rutile via selective sulfation of ilmenite with(NH4)2SO4 followed by targeted removal of impurities

This paper describes a novel, facile chemical pathway for preparing synthetic rutile from ilmenite. The pathway consists of two primary units, i.e., selectively sulfating ilmenite, which was realized via roasting ilmenite with(NH_4)_2SO_4followed by selective thermal decomposition of the sulfated ilmenite, and targeted leaching of the impurities. The effects of the process parameters were systematically investigated. The results showed that the optimum sulfation conditions were a mass ratio of(NH_4)_2SO_4to ilmenite of 14, temperature of 360 °C, and time of 120 min with a sulfation ratio of ~ 95%. The optimum thermal decomposition conditions were480 °C in N_2 atmosphere, and nearly all Ti OSO_4 were decomposed with co-decomposition of Fe SO_4 of 23%. For acid leaching, the optimum conditions were 2.5 wt% HCl, 98 °C and 120 min. Under those conditions, 94.2% iron was removed with a Ti O_2 dissolution loss b 1%. For alkali leaching, 67% Si O_2 was removed in 5 wt% Na OH at102 °C for 1 h. A synthetic rutile with a Ti O_2 content N 92 wt% and total Mg O + Ca O b 1.5 wt% was obtained.Based on these results, a schematic flowsheet was proposed. Additionally, it was found that the decomposition of Fe SO_4 mixed with Ti OSO_4 under N_2was inhibited due to its oxidation to a higher thermal stability Fe_2(SO_4)_3by oxygen emitted from the decomposition of Ti OSO_4. At the same time, Ti OSO_4 decomposition was promoted due to the immediate in situ consumption of oxygen by Fe SO_4. The synergetic effect might be responsible for the enhanced selectivity of sulfated ilmenite thermal decomposition.

Phase Composition Analysis of TiN-AI_2O_3Synthesized from Aluminum-containing Dross and Rutile by Aluminothermic Reductionnitridation Method

TiN- Al2O3 composite powder was prepared by aluminothermic reduction- nitridation method with starting materials of aluminum-containing dross and rutile,and metallic aluminum in the aluminum-containing dross as reducer. The influences of synthesis temperature（600-1 400 ℃） and aluminum-containing dross addition（20% lower than theoretical value,theoretical value,20% higher than theoretical value,and 50% higher than theoretical value） on phase compositions and microstructure of the composites were investigated,and the reaction mechanism was analyzed. The results show that（1） TiN- Al2O3 composite powder can be synthesized under the experimental conditions; the main phases are TiN,α-Al2O3,a little bytownite,and MgAl2O4;（2）enhancing synthesis temperature or increasing aluminumcontaining dross addition favors the reaction of aluminothermic reduction- nitridation;（3） in the synthesized products,α-Al2O3 is platy or columnar; TiN is sub-micron granular,which reinforces and toughens the composite.

The Impact of Health Care Reform Initiatives on Ethical Conflict and Opportunities for Nurses to Improve Quality of Care While Enhancing Their Work Environments

Background: After more than a decade of the nursing profession contending that healthcare reform based almost exclusively on cost cutting was creating an array of serious ethical issues for nurses, healthcare organizations and other providers are now facing increasing demands primarily from payers to demonstrate improvement in both quality of care and patient experience along with continued cost reduction. Research Question: Have efforts by healthcare organizations to comply with these recently imposed requirements influenced the ethical environment faced by nurses and nurse leaders and if so, how? Materials and Methods: Data for assessing the current ethical environment was gathered with a close-ended survey mailed in October 2012 to a random sample of 3000 members of the American Organization of Nurse Executives. Results and Discussion: Statistical analysis of the data and comparison with the findings of a similar study conducted in 2000 indicated that along with five highly rated issues in the earlier study attributed largely to economic constraints imposed by healthcare organizations, the top-10 key ethical issues today included five issues primarily attributable to interprofessional conflict. Conclusion: Given the success of many ongoing efforts aimed at weakening these key sources of ethical conflict that have blocked many proposals to improve the quality of care, opportunities should arise for the nursing profession to more fully achieve its goals of improving the quality of care, safety and patient satisfaction and enhancing nurses’ work environments essential to that effort.

The Status Quo and Influencing Factors of the Moral Distress in Nurses in Tertiary Grade A Hospitals in Wuhan

Background: As medical technology has advanced, it has also made it possible to maintain end-stage life support for longer periods of time, but it has also been accompanied by a debate about ineffective care, nursing is considered to be an ethically important profession, and nurses aim to achieve ethical goals such as providing the best possible care to patients, achieving high quality outcomes, but it is common when there are insufficient numbers of staff, inadequately trained staff, and organizational policies and procedures that make it difficult, or even impossible, for nurses to meet the needs of patients and their families. This conflict results in moral distress for nurses, yet limited attention has been paid to this phenomenon. Objective: To explore the current phenomenon of moral distress and its triggering factors in nurses in tertiary grade A hospitals in Wuhan, by targeting root causes and understanding the interplay between nurses and settings where moral distress occurs, interventions can be tailored to minimize moral distress with the ultimate goal of enhancing patient care. Method: Totally 384 nurses from clinical departments in 2 tertiary Grade A hospitals in Wuhan were investigated with the Chinese version Moral Distress Scale-Revised (MDS-R). Result: The total score of moral distress was 47.41 ± 27.14, and the mean scores of moral distress frequency and intensity were 1.01 ± 0.53 and 1.19 ± 0.61, which were at a lower level. The main source of moral distress for nurses is related to end-of-life care and medical decision communication;Nurses’ moral distress scores were statistically significant (P Conclusion: Hospital facility leaders and nursing managers need to train nurses to develop competency development such as reflection, empathy, communication, positive thinking, and emotional intelligence to practice ethical dilemma response, and facilitate collaborative communication among healthcare members, so as to alleviate moral distress in nurses.

Construction of Grotesque Elements in The Ballad of the Sad Café

Grotesque is important in expressing the inner mind of the characters and the subject of the novel. Gothic novel originates in 18 th century in England. It spread to America, and has great development. Here, we will introduce the important woman gothic writer Carson McCullers and her famous work-The Ballad of the Sad Café, in this treatise, we have a deep analysis on the grotesque style.

The Futility of Willy's Philosophy of Personal Attractiveness in Death of a Salesman

Arthur Miller's masterpiece Death of a Salesman is a very clear attack on the American success myth.The most dominant theme running throughout the play is Willy Loman's philosophy of personal attractiveness and its doomed futility.This philosophy not only brings failure to Willy's career but also destruction to Willy's family members.

Application of ESR Technique to Distinguish the Phase and Size of TiO_2 Powders

The commercial TiO2 nanopowder and micropowder of anatase phase and rutile phase have been characterized by X-ray diffraction （XRD） and electron spin resonance （ESR） spectroscopy. XRD patterns and ESR spectra of nano-TiO2 in rutile and anatase phases exhibit broad peaks whereas both phases of micro-TiOz demonstrate very sharp peaks. Furthermore, the anatase phase of both particle sizes provide ESR peak at a magnetic field around 3568.25G, On the other hand, this peak is not established in the rutile phase of both particle sizes.

Who decides in withdrawal of treatment in a critical care setting? A case study on ethical dilemma

Case description:Withdrawal of treatment is a common practice in critical care settings,perticularly when treatment is considered futile.The case study demonstrates an ethical dilemma,in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes.Under such a circumstance,withdrawal of treatment will inevitably be considered,although his family refused to do so.Consequently,acritical question must be answered:Who should make the decision?Ethical dilemma identification:Danny decided to withdraw the use of life-support,whilst his wife and adult children refused to do so.The ethical dilemma is illustrated by the following question:Who decides the withdrawal of treatment in a critical care setting?Analysis:To provide an opotional solution to this case and make the best moral decision,the current study will critically discuss this issue in conjunction with ethical principles,philosophical theories and the values statement of the European and Chinese nurses'codes of ethics.Additionally,the associated literature relative to this case are analysed before the decision-making.Ethical decision-making:The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment.If his family is involved in the discussion,the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.Results:In Danny's case,health professionals opted to respect his decision to withdraw treatment.The medical staff maintained an effective communication with the family involved,and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.

Medical futility in the era of evidence-based medicine

One definition of futility is any treatment that merely preserves permanent unconsciousness or fails to end total dependence of a patient on intensive medical care However, no agreement has ever been reached on what the exact defmition of futility is, as it is not only based on temporary values but also evolves into different subtypes, making it harder to define. The difficulty in dealing with futility problem is how doctors evaluate the futile situation, which is further complicated by lack of standards for specific diseases and experience-based prognosis, leading to subjectivity in evaluation for futility.

Maintenance Chemotherapy in Ovarian Cancer: A Trial-Sequential Analysis

In patients with epithelian ovarian cancer who have achieved remission after initial surgery and induction chemotherapy, the role of maintenance chemotherapy is controversial. We carried out a trial-sequential analysis that included 4 randomised controlled trials. The end-point was progression at 3 years while the boundary for non-inferiority was set at ±20% in risk ratio. The results of our trial-sequential analysis indicated the futility of maintenance chemotherapy, i.e. proof of no effectiveness. Consequently, no further trials of this type should be performed to assess the effectiveness of this intervention in this clinical condition.

Autonomy and authority in medical futility

Medical futility has been proposed for many years to define the procedure that simply prolongs the suffering of patients but heals nothing.To deal with the decision procedure for treatment,two ideas arise：patients＇autonomy and doctors＇authority.Widely recognized in 1960s,patients＇autonomy respected patients＇willingness over treatment,requiring specific consent for treatment and right to choose during medical procedure.Another idea for futility is doctors＇authority,explained from the paternalistic perspective as well.

Factors predicting futility of liver transplant in elderly recipients:A single-center experience

BACKGROUND As the population of the United States ages,there has been an increasing number of elderly patients with cirrhosis listed for transplant.Previous studies have shown variable results in terms of the relative survival benefit for elderly liver transplant(LT)recipients.There may be factors that are associated with a poor post-transplant outcome which may help determine which elderly patients should and should not be listed for LT.AIM To identify factors associated with futility of transplant in elderly patients.METHODS This was a retrospective study of all patients above the age of 45 who underwent liver transplantation at our tertiary care center between January 2010 and March 2020(n=1019).“Elderly”was defined as all patients aged 65 years and older.Futile outcome was defined as death within 90 d of transplant.Logistic regression analysis was performed to determine what variables,if any were associated with futile outcome in elderly patients.Secondary outcomes such as one year mortality and discharge to facility(such as skilled nursing facility or long-term acute care hospital)were analyzed in the entire sample,compared across three age groups(45-54,55-64,and 65+years).RESULTS There was a total of 260 elderly patients who received LT in the designated time period.A total of 20 patients met the definition of“futile”outcome.The mean Model of End-Stage Liver Disease scores in the futile and non-futile group were not significantly different(21.78 in the futile group vs 19.66 in the“non-futile”group).Of the variables tested,only congestive heart failure was found to have a statistically significant association with futile outcome in LT recipients over the age of 65(P=0.001).Of these patients,all had diastolic heart failure with normal ejection fraction and at least grade I diastolic dysfunction as measured on echocardiogram.Patients aged 65 years and older were more likely to have the outcomes of death within 1 year of LT[hazard ratio:1.937,confidence interval(CI):1.24-3.02,P=0.003]and discharge to facility(odds ratio:1.94,CI:1.4-2.8,P<0.001)compared to patients in younger age groups.CONCLUSION Diastolic heart failure in the elderly may be a predictor of futility post liver transplant in elderly patients.Elderly LT recipients may have worse outcomes as compared to younger patients.

Difficult Conversations and Painful Decisions: When Should Patients with Progressive Cancer Stop Chemotherapy?

Introduction: The decision to stop anti-cancer treatment is fraught with many challenges for the oncologist, the patient, and their caregivers. This review examines the special considerations surrounding the decision to cease chemotherapy in terminally ill cancer patient. Methods: A comprehensive literature search was conducted to find relevant publications on chemotherapy cessation. A total of 2700 records were retrieved and 141 were identified as eligible for inclusion in this review. Results: Palliative chemotherapy does not achieve the goal of tumor-related symptom reduction for patients who have experienced progressive disease with more than two prior lines of chemotherapy. ECOG performance status is a crucial predictor of response to therapy and chemotherapy-related complications. Challenges to stopping chemotherapy at the end of life are multifactorial and are both patient and physician-driven. Racial, ethnic, and income-based disparities are seen in the timing and quality of end-of-life conversations offered by physicians to their patients. Conclusions: The decision to cease chemotherapy is one that should be approached with careful consideration and accurate information. Clear communication, compassion and empathy are important components to the therapeutic relationship. Early involvement of palliative care and clear conversations about prognosis and the expected utility of further chemotherapy is essential to conduct the best possible care for cancer patients at the end of life.

The use of “Objective Correlative” Theory in T.S. Eliot’s The Love Song of J.Alfred Prufrock

“Objective Correlative”theory was first proposed by T.S. Eliot, who holds that people’s emotion can find expression in a series of objective correlative. In his poem The Love Song of J.Alfred Prufrock, the use of objective correlative fully reflects and reveals modern people’s loneliness, futility and alienation.

躯体形式障碍与医疗纠纷

躯体形式障碍（somatoform disorders）是一类以各种躯体症状作为其主要临床表现（躯体形式因此而得名），不能证实有器质性损害或明确的病理生理机制存在，但有证据表明与心理因素或内心；中突密切相关的精神障碍。患者常反复陈述躯体不适，四处求医却未能发现器质性病变；或即使有某种躯体疾病也不能用以解释其主诉症状的严重程度、性质及由此产生的观念和烦恼。

Four Lessons Washington Needs to Learn From Its Trade War With China

Students in many parts of the world are heading back to school for a new semester. In the same vain, it is also time for trade trade hawks in Washington to start learning at least four lessons from their futile trade war with China.

Eight predictive powers with historical and interim data for futility and efficacy analysis

When the historical data of the early phase trial and the interim data of the Phase II trial are avail-able,we should use them to give a more accurate prediction in both futility and efficacy analysis.The predictive power is an important measure of the practical utility of a proposed trial,and it is better than the classical statistical power in giving a good indication of the probability that the trial will demonstrate a positive or statistically significant outcome.In addition to the four predic-tive powers with historical and interim data available in the literature and summarized in Table 1,we discover and calculate another four predictive powers also summarized in Table 1,for one-sided hypotheses.Moreover,we calculate eight predictive powers summarized in Table 2,for the reversed hypotheses.The combination of the two tables gives us a complete picture of the pre-dictive powers with historical and interim data for futility and efficacy analysis.Furthermore,the eight predictive powers with historical and interim data are utilized to guide the futility analysis in the tamoxifen example.Finally,extensive simulations have been conducted to investigate the sensitivity analysis of priors,sample sizes,interim result and interim time on different predictive powers.