2013 National Summit on Advanced Illness CareJon Broyles
On January 29 and 30, 2013 the Coalition to Transform Advanced Care (C-TAC) convened over 400 leaders -- from clinicians and policy makers to faith leaders and large employers -- to tackle one of America’s greatest challenges, breaking though the cultural, health system and policy barriers so that seriously ill people receive the right care at the right time and place.
Why screeing cancer patients for distress will increase disparities in psycho...James Coyne
Keynote address
Implementing screening of cancer patients for distress will not improve patient outcomes and may aggravate existing biases in who get psychosocial services.
We will cover the topic of Palliative Care – specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.
Presented by Dr. Jean S. Kutner, MD, MSPH a tenured Professor of Medicine in the Divisions of General Internal Medicine (GIM), Geriatric Medicine, and Health Care Policy and Research at the University of Colorado School of Medicine (UC SOM)
Where’s the evidence that screening for distress benefits cancer patients?James Coyne
“The case against screening for distress.” A presentation delivered as part of an invited debate with Alex Mitchell at the International Psycho Oncology Conference, Rotterdam, November 7, 2013
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
From the event "Specimen Science: Ethics and Policy Implications," held at Harvard Law School on November 16, 2015.
This event is a collaboration between The Center for Child Health and Policy at Case Western Reserve University and University Hospitals Rainbow Babies & Children’s Hospital; the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School; the Multi-Regional Clinical Trials Center of Harvard and Brigham and Women's Hospital; and Harvard Catalyst | The Harvard Clinical and Translational Science Center. It is supported by funding from the National Human Genome Research Institute and the Oswald DeN. Cammann Fund at Harvard University.
For more information, visit our website at http://petrieflom.law.harvard.edu/events/details/specimen-science-ethics-and-policy
How do we deliver on palliative care aspirations at the end of life in the acute setting?
Jean Clark, Karen Sheward, Joy Percy, Celine Collins, Simon Allan
2013 National Summit on Advanced Illness CareJon Broyles
On January 29 and 30, 2013 the Coalition to Transform Advanced Care (C-TAC) convened over 400 leaders -- from clinicians and policy makers to faith leaders and large employers -- to tackle one of America’s greatest challenges, breaking though the cultural, health system and policy barriers so that seriously ill people receive the right care at the right time and place.
Why screeing cancer patients for distress will increase disparities in psycho...James Coyne
Keynote address
Implementing screening of cancer patients for distress will not improve patient outcomes and may aggravate existing biases in who get psychosocial services.
We will cover the topic of Palliative Care – specialized medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.
Presented by Dr. Jean S. Kutner, MD, MSPH a tenured Professor of Medicine in the Divisions of General Internal Medicine (GIM), Geriatric Medicine, and Health Care Policy and Research at the University of Colorado School of Medicine (UC SOM)
Where’s the evidence that screening for distress benefits cancer patients?James Coyne
“The case against screening for distress.” A presentation delivered as part of an invited debate with Alex Mitchell at the International Psycho Oncology Conference, Rotterdam, November 7, 2013
SHARE Presentation: Palliative Care for Womenbkling
Dr. Michael Pearl discusses supportive palliative care for women with cancer, how it differs from hospice care, and the New York Palliative Care Information Act. Dr. Michael Pearl is Professor and Director of the Division of Gynecologic Oncology in the Department of Obstetrics, Gynecology and Reproductive Medicine at Stony Brook University Hospital.
From the event "Specimen Science: Ethics and Policy Implications," held at Harvard Law School on November 16, 2015.
This event is a collaboration between The Center for Child Health and Policy at Case Western Reserve University and University Hospitals Rainbow Babies & Children’s Hospital; the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School; the Multi-Regional Clinical Trials Center of Harvard and Brigham and Women's Hospital; and Harvard Catalyst | The Harvard Clinical and Translational Science Center. It is supported by funding from the National Human Genome Research Institute and the Oswald DeN. Cammann Fund at Harvard University.
For more information, visit our website at http://petrieflom.law.harvard.edu/events/details/specimen-science-ethics-and-policy
How do we deliver on palliative care aspirations at the end of life in the acute setting?
Jean Clark, Karen Sheward, Joy Percy, Celine Collins, Simon Allan
Do Not Resuscitate Orders : What They Mean ?SMSRAZA
Most doctors working in Acute areas know when and how to do CPR. However, most get stuck when it comes to ' When not to do CPR' due to cultural, social, ethical and legal issues attached.
A presentation designed to inform health care workers about the components and importance of advance directives, with specific information for Massachusetts residents.
AETCOM (Attitude, Ethics and Communication module)Karun Kumar
Hello friends. In this PPT I am talking about AETCOM (Attitude, Ethics and Communication module) of Pharmacology. If you like it, please do let me know in the comments section. A single word of appreciation from you will encourage me to make more of such videos. Thanks. Enjoy and welcome to the beautiful world of pharmacology where pharmacology comes to life. This video is intended for MBBS, BDS, paramedical and any person who wishes to have a basic understanding of the subject in the simplest way
Similar to Presentation on DNAR Policy (From Acute Hospital Network, June 2014) [AHN 19] (20)
Explores palliative and end of life care. Outlines advance care planning and provides information about planning ahead to include using advance healthcare directives
Reflections on the National Summary of Patient Activity Data for Adult Specia...Irish Hospice Foundation
IHF reflections on MDS data in relation to specialist palliative care services. Reflections offered on SPC beds, access to SPC services. This presentation highlights inequities that exist.
Final Journey’s is a staff development workshop for Acute Hospital Staff which raises awareness regarding quality of care at end of life.
Final Journeys was developed by the Irish Hospice Foundation as part of its Hospice Friendly Hospitals programme in 2010.
The workshop is now eight years old and is due for updating and review to ensure the content of the workshop is relevant and fresh.
Presentation of findings of an audit carried out on the nurses for night care service over a 6 month period that identifies the components of care that support people with dementia to die at home in Ireland
Stephen Toft - Programme Officer Palliative Care, HSE Primary Care Division, specialist palliative care minimum data set acute hospital figures 2016 and 2017 per hospital.
Deirdre Shanagher, IHF: Patient Involvement demonstrates the value and unique voice of people and values patients as the real experts in understanding their unique journey. It also helps empower patients.
Karen Charnley: Patient engagement - encourage and provide service user, carer and community engagement within the context of AIIHPC's work and the work of the wider palliative care community on the island of Ireland. Will inform and influence palliative care education, research, policy and practice, in a collaborative and supportive manner.
Emer Carroll, National Health & Safety Manager, National Health and Safety Function, Workplace Health and Wellbeing Unit, presents on HSE Workplace Stress Management.
The Mater Misericordiae University Hospital and St. James’s Hospital and their academic partners UCD and TCD surveyed bereaved relatives about their experience of end-of-life care in hospital. Results reveal the high standard of care provided in both hospitals and further indicate where improvements could be made to enhance the care experience.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
3. “I knew CPR wouldn’t save our marriage, but I
had to try”
4. DNAR in UCHG
(McNamee & O’Keeffe IJMS 2004)
• Seventeen (3.5%) of 485 patients (= 35.4% of the 48 patients
close to death) were identified as not for resuscitation.
• Written confirmation of the DNR order in the nursing notes for
14 (82%) and in the medical notes for 15 (88%) patients;
• In two cases, it was reported that doctors were reluctant to write
down the agreed decision.
• Discussion with patient (2), family (10) or both (1) was recorded
in 14 cases.
5. CPR in Irish Long-Stay Units
O’Brien & O’Keeffe (Ir J Med Sci 2009)
• 16% of residents die each year
• CPR ever in 40%, advanced CPR in 10%
• Policy in 55%, written in 13%
• Include
– All residents for CPR
– None for CPR unless pt/ family request
– Nobody over 80 years for CPR
– CPR only for staff and visitors
6.
7.
8. General principles
• Presumption in favour of providing CPR
• Need for individual decision making – balance
the benefits and risks
• Involving the individual in discussions
regarding CPR
• Respecting an individual’s refusal of CPR
9.
10. Need to consider CPR and DNAR ?
• Cardiorespiratory arrest is considered unlikely:
– ‘..general presumption in favour of CPR… However, if an
individual indicates that he/she wishes to discuss CPR, then
this should be respected. Also, the wishes of individuals with
an advance care plan refusing CPR under specific
circumstances should be respected if the directive is
considered valid and applicable to the situation that has
arisen’.
• Cardiorespiratory arrest is considered possible or likely:
– ‘Advance care planning, including CPR/DNAR is often
appropriate …and should occur in the context of a general
discussion about the individual’s prognosis and the likelihood
that CPR would be successful, as well as his/her values,
concerns, expectations and goals of care’.
11. • Cardiorespiratory arrest, as a terminal event, is considered
inevitable
– [If] ‘death is considered to be imminent and
unavoidable…cardiorespiratory arrest may represent the
terminal event in their illness and the provision of CPR
would not be clinically indicated…. In many cases, a
sensitive but open discussion of end-of-life care will be
possible in which individuals should be helped to
understand the severity of their condition. However, it
should be emphasised that this does not necessarily
require explicit discussion of CPR or an ‘offer’ of CPR.
Implementing a DNAR order for those close to death does
not equate to “doing nothing”……’
12. Role of family or friends in discussions
regarding CPR
• If the individual wishes to have the support or involvement of
others, such as family or friends, in decision making, this should
be respected. If the individual is unable to participate in
discussions due to illness or incapacity, those with a close, on-
going, personal relationship with the individual may have insight
into his/her preferences, wishes and beliefs. However, their role is
not to make the final decision regarding CPR, but rather to help
the healthcare professional to make the most appropriate decision.
• Where CPR is judged inappropriate, it is good practice to inform
those close to the patient, but there is no need to seek their
‘permission’ not to perform CPR in these circumstance.
13. Why the policy can’t solve it all!
• Applies to all HSE settings (community, long-
stay, hospice, acute hospital)
• Cannot cover all situations that may arise
• Documentation and dissemination issues
• Health care professionals: need for interpretation,
empathy, common sense, knowledge and
communication skills
• Patients, relatives, public: need for better
awareness of limitations of medicine
• Regulators: need for flexibility
14. Communication and Dissemination
of DNAR Decisions
• Service providers should have systems in place to ensure that the
fact that a DNAR decision has been made is readily available to
staff (who may not always be familiar with the individual patient/
service user) to ensure that it is complied with in the event of an
emergency.
• Consider a form to be placed in a prominent position towards the
front of the notes, noting, at a minimum:
– that a DNAR decision has been made (or an advance care plan
or directive is in place),
– whether review is intended or not and
– referring those who require more information, to the date(s)
(and perhaps chart volume) of the relevant medical notes or to
the location of the advance care directive or plan.
15. • Service providers should have systems in place to ensure
that Do-Not-Attempt-Resuscitation decisions do not
become ‘lost’, for example, if an in-patient stay is
prolonged, if a new medical chart volume is opened or due
to staff changes and turnover.
• Approaches that may be helpful include:
– Routine communication of DNAR decisions at
handover or on transfer of care.
– Mechanisms to ensure that the ‘front form’ alerting
staff to the existence of a DNAR decision and a copy of
the primary documentation of DNAR decisions are
photocopied to new medical chart volumes
16. Service providers should have systems in place to ensure that
valid Do-Not-Attempt-Resuscitation decisions made in one
setting are effectively communicated if the patient/ service user
moves to another setting.
• If an indefinite DNAR order is made, it is important that this
is communicated effectively across settings. This requires
that those in settings other than that in which the original
decision was originally made can be confident that it was a
valid decision, that is one made, after appropriate
consultation, by somebody with the requisite expertise or in
the case of an advance directive or plan that it was made in a
valid fashion by the person themselves. This would
…require, at a minimum, information on who had made the
decision, why and whether it was intended to have indefinite
effect.
17. How it can go wrong?
• Spirit vs letter of policy
• Obsession with forms and documentation
– Automatic reviews
– ‘Do they have capacity?’
• Power struggles
– ‘I’m the decider!’
– Who’s the ‘next of kin’
• Mixing ethics and economics
18. • Age Concern (2000) and Ebrahim (BMJ 2000):
– Rampant ageism and disregard of criteria in use of DNR orders
in NHS.
– Legislation required.
• Soper (BMJ 2002): ‘An unmerciful end’ for dying
patients driven by fear of litigation or of complaints by
relatives
– "I knew she was dead, doctor, and I told them that she wouldn't
have wanted them to try and revive her, but they asked ifI had
that in writing."
Britain
19. Futility - ‘an ethical trump card’?
• No obligation to offer or to discuss futile treatment
BUT
• What does futile mean?
• Futile for whom?
Many clinicians view futility the way one
judge viewed pornography.
They may not be able to define it, but
they know it when they see it!
20. • Are we good at predicting outcomes?
– Quantitative thresholds for futility are arbitrary
– Often involves probability: Chance of success rarely zero
– ‘Will he come off the ventilator this time?’
’He’s one tough cookie. I’ve never seen anyone
bounce back from an autopsy before’.
21. • Physicians’ futility judgements rely more on values and
biases than on evidence (Curtis, JAMA 1995)
– Race, age, social class and cause of illness all influence
“Because of your age, I’m going to
recommend doing nothing.”
22. Overestimation of Benefits
• TV major source of public information (Miller, Arch Int Med 1992)
‘’’I’m afraid there is really very little I can do’
23. • CPR on US medical television shows (Diem et al
NEJM 1996)
– 67% survival to discharge
• Prognosis of 24h+ coma in soap operas (Cassaret
BMJ 2005)
– Fifty seven (89%) patients recovered fully
– On the day they regained consciousness, 86% had
no cognitive deficit or residual disability
24. • Very difficult to hold discussion with acutely ill patients
‘To hold vulnerable patients .. in the glare of autonomy, carefully
explaining their bleak prognosis and insisting lawyer-like on a
decision .. seems barbaric to many’ (Finucane JAGS 1999)
• Bad news poorly processed and not remembered well
• Denial—may lead to focus on trivial but controllable matters
• Fear of abandonment “withdrawing care”, “Stopping care.”
• Don’t understand medical situation
Pitfalls in Communication: Patient
25. Pitfalls in Communication: Physician
• Physician’s communication styles can worsen misunderstanding
– Use of medical language when need to discuss values, QOL
– Jargon: “usually” “most of the time” “cannot rule out” “futile”
– Semantics: “everything done” “vegetable”
• Multiple voices of heath care team
• Goals not clarified: what parties believe will be achieved by
treatment or intervention
• Decision-making reduced to power struggle between patient and
clinician
• Failure to ask patient (early enough)!
Goold SD et al. Conflicts regarding decisions to limit treatment. JAMA 2000.
26. • Low agreement between surrogate and patient preferences (e.g.
Ouslander et al, Arch Intern Med 1989)
• Disagreement / ‘Daughter from California syndrome’
• Older people want to be consulted themselves
• Guilt of family members
– Asked to sign patient’s death warrant
– Physicians ask that they take responsibility for medical decisions
• Intrinsic family issues
• Conflict of interest
Pitfalls in Communication: Family
27. Good Ethics makes Good Economics?
• 30% of hospital costs for 5% of
patients who die that year
• 40% of costs of last year of life
in the last month
• Avoid ‘futile care’ and save
‘billions’?
• An illusion (Emanuel & Emanuel, NEJM
1994)
– Humane care not cheap
– Potential savings overstated
• A distraction and contaminant
‘Good news Mrs Jones - I think
we got it all’
28.
29. O’Keeffe et al Eur J Med 1993; Cotter et al Age Ageing 2008
Editor's Notes
Physician/family conflict
Patient capacitated
Competent patients wishes respected more than surrogates, question substituted judgment vs best interests
Slice of larger story
Family attribute higher or lower rate of success
Frame value judgments as medical decisions
Lacking vocabulary for talking about values and uncertainty of legitimacy of quality of life concerns, the physicians in this study couched their recommendations in medical language.