In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine a... more In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine at the University of Chicago. In my view, CME is an intrinsic part of medicine and is not a branch of bioethics or philosophical ethics or legal ethics. The relationship of patients with medically trained and licensed clinicians is at the very heart of CME. CME must be practiced and applied not by nonclinical bioethicists, but rather by licensed clinicians in their routine, daily encounters with inpatients and outpatients. CME must be practiced and applied by licensed clinicians in their routine, daily encounters with inpatients and outpatients. CME addresses many clinical issues such as truth-telling, informed consent, confidentiality, surrogate decision making, and end-of-life care, while also encouraging personal, humane, and compassionate interactions between experienced clinicians and patients. The goals of CME are to improve patient care and outcomes by helping physicians and other health professionals identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer, and I wrote in the first issue of The Journal of Clinical Ethics, 30 years ago: "The central goal of CME is to improve the quality of patient care by identifying, analyzing, and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine." Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, and the process of consultations is certainly not at the core of cardiology or oncology or CME. In this article, I intend to discuss the origins of the field of CME, its goals and methods, the relationship between the broad field of CME and the much narrower practice of ethics consultation, the contributions of the MacLean Center at the University of Chicago in developing the field of CME, and, finally, how CME has improved the practice of medicine in the United States.
CONTEXT Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac l... more CONTEXT Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac life support but do not provide full resuscitation efforts, is ethically controversial. OBJECTIVES To describe the use of slow codes in practice and their association with clinicians' attitudes and moral distress. METHODS We conducted a cross-sectional survey at Rush University and University of Chicago in January 2020. Participants included physician trainees, attending physicians, nurses and advanced practice providers who care for critically ill patients. RESULTS Of the 237 respondents to the survey (31% response rate, n=237/753), almost half (48%) were internal medicine residents (46% response rate, n=114/246). Over two-thirds of all respondents (69%) reported caring for a patient where a slow code was performed, with a mean of 1.3 slow codes (SD 1.7) occurring in the past year per participant. A narrow majority of respondents (52%) reported slow codes are ethical if the code is medically futile. Other respondents (46%) reported slow codes are not ethical, with 19% believing no code should be performed and 28% believing a full guideline consistent code should be performed. Most respondents reported moral distress when being required to run (75%), do chest compressions for (80%) or witness (78%) a cardiac resuscitation attempt they believe to be medically futile. CONCLUSION Slow codes occur in practice, even though many clinicians ethically disagree with their use. The use of cardiac resuscitation attempts in medically futile situations can cause significant moral distress to medical professionals who agree or are forced to participate in them.
American Journal of Hospice and Palliative Medicine®, 2019
Purpose: Family meetings in the medical intensive care unit can improve outcomes. Little is known... more Purpose: Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality. Methods: We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge. Results: Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting r...
PURPOSE In an attempt to understand some of the complex issues related to the participation of ca... more PURPOSE In an attempt to understand some of the complex issues related to the participation of cancer patients in phase I trials, and the perceptions of patients toward these trials, we conducted a pilot survey study of 30 cancer patients who had given informed consent to participate in a phase I trial at our institution. Concurrently, the oncologists identified by the surveyed patients as responsible for their care were surveyed as well. PATIENTS AND METHODS Twenty-seven of 30 consecutive patients agreed to and completed the survey. Patients were surveyed before they received any investigational agents. Eighteen oncologists participated in this survey study. RESULTS Eighty-five percent of patients decided to participate in a phase I trial for reasons of possible therapeutic benefit, 11% because of advice/trust of physicians, and 4% because of family pressures. Ninety-three percent said that they understood all (33%) or most (60%) of the information provided about the trials in whic...
Patients with localized prostate cancer may be treated with either surgery (radical prostatectomy... more Patients with localized prostate cancer may be treated with either surgery (radical prostatectomy) or radiotherapy. Although controversial, many physicians believe that surgery offers a higher survival rate. However, the surgical treatment may also produce a higher rate of sexual impotency. Our study assessed how men value survival and sexual potency when asked to trade off one for the other. Using the treatment-choice technique, we interviewed 50 men aged 45 to 70 years without known prostate cancer. At hypothetical rates of survival (90% at 5 years for surgery) and impotency (90% for surgery and 40% for radiotherapy) representing published estimates, 32% of respondents were unwilling to trade off any survival, but 68% were willing to trade off a 10% or greater advantage in 5-year survival (by choosing radiotherapy) to maintain sexual potency. The median 5-year survival traded off was 10% (range, 0% to 80%). Willingness to trade off survival for sexual potency was significantly rel...
Journal of the American College of Cardiology, 2020
BACKGROUND In October 2018, the U.S. heart allocation system expanded the number of priority &quo... more BACKGROUND In October 2018, the U.S. heart allocation system expanded the number of priority "status" tiers from 3 to 6 and added cardiogenic shock requirements for some heart transplant candidates listed with specific types of treatments. OBJECTIVES This study sought to determine the impact of the new policy on the treatment practices of transplant centers. METHODS Initial listing data on all adult heart candidates listed from December 1, 2017 to April 30, 2019 were collected from the Scientific Registry of Transplant Recipients. The status-qualifying treatments (or exception requests) and hemodynamic values at listing of a post-policy cohort (December 2018 to April 2019) were compared with a seasonally matched pre-policy cohort (December 2017 to April 2018). Candidates in the pre-policy cohort were reclassified into the new priority system statuses by using treatment, diagnosis, and hemodynamics. RESULTS Comparing the post-policy cohort (N = 1,567) with the pre-policy cohort (N = 1,606), there were significant increases in listings with extracorporeal membrane oxygenation (+1.2%), intra-aortic balloon pumps (+ 4 %), and exceptions (+ 12%). Listings with low-dose inotropes (-18%) and high-dose inotropes (-3%) significantly decreased. The new priority status distribution had more status 2 (+14%) candidates than expected and fewer status 3 (-5%), status 4 (- 4%) and status 6 (-8%) candidates than expected (p values <0.01 for all comparisons). CONCLUSIONS After implementation of the new heart allocation policy, transplant centers listed more candidates with extracorporeal membrane oxygenation, intra-aortic balloon pumps, and exception requests and fewer candidates with inotrope therapy than expected, thus leading to significantly more high-priority status listings than anticipated. If these early trends persist, the new allocation system may not function as intended.
Clinical pharmacology and therapeutics, Jan 11, 2017
Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively stud... more Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively studied medication changes made by providers representing eight different medicine specialty clinics whose patients had submitted to preemptive pharmacogenomic genotyping. An institutional clinical decision support (CDS) system provided pharmacogenomic results using traffic light alerts: green/genomically favorable, yellow/genomic caution, red/high risk. The influence of pharmacogenomic alerts on prescribing behaviors was the primary endpoint. 2279 outpatient encounters were analyzed. Independent of other potential prescribing mediators, medications with high pharmacogenomic risk were changed significantly more often than prescription drugs lacking pharmacogenomic information (odds ratio [OR]=26.2 [9.0-75.3], p<0.0001). Medications with cautionary pharmacogenomic information were also changed more frequently (OR=2.4 [1.7-3.5], p<0.0001). No pharmacogenomically high-risk medications wer...
In recent years, numerous changes in health care delivery have increased surgeons’ interest in me... more In recent years, numerous changes in health care delivery have increased surgeons’ interest in medical ethics. We report the experience of surgeons who completed a fellowship in clinical medical ethics at a single institution.
In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine a... more In 1972, I created the new field of clinical medical ethics (CME) in the Department of Medicine at the University of Chicago. In my view, CME is an intrinsic part of medicine and is not a branch of bioethics or philosophical ethics or legal ethics. The relationship of patients with medically trained and licensed clinicians is at the very heart of CME. CME must be practiced and applied not by nonclinical bioethicists, but rather by licensed clinicians in their routine, daily encounters with inpatients and outpatients. CME must be practiced and applied by licensed clinicians in their routine, daily encounters with inpatients and outpatients. CME addresses many clinical issues such as truth-telling, informed consent, confidentiality, surrogate decision making, and end-of-life care, while also encouraging personal, humane, and compassionate interactions between experienced clinicians and patients. The goals of CME are to improve patient care and outcomes by helping physicians and other health professionals identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer, and I wrote in the first issue of The Journal of Clinical Ethics, 30 years ago: "The central goal of CME is to improve the quality of patient care by identifying, analyzing, and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine." Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, and the process of consultations is certainly not at the core of cardiology or oncology or CME. In this article, I intend to discuss the origins of the field of CME, its goals and methods, the relationship between the broad field of CME and the much narrower practice of ethics consultation, the contributions of the MacLean Center at the University of Chicago in developing the field of CME, and, finally, how CME has improved the practice of medicine in the United States.
CONTEXT Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac l... more CONTEXT Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac life support but do not provide full resuscitation efforts, is ethically controversial. OBJECTIVES To describe the use of slow codes in practice and their association with clinicians' attitudes and moral distress. METHODS We conducted a cross-sectional survey at Rush University and University of Chicago in January 2020. Participants included physician trainees, attending physicians, nurses and advanced practice providers who care for critically ill patients. RESULTS Of the 237 respondents to the survey (31% response rate, n=237/753), almost half (48%) were internal medicine residents (46% response rate, n=114/246). Over two-thirds of all respondents (69%) reported caring for a patient where a slow code was performed, with a mean of 1.3 slow codes (SD 1.7) occurring in the past year per participant. A narrow majority of respondents (52%) reported slow codes are ethical if the code is medically futile. Other respondents (46%) reported slow codes are not ethical, with 19% believing no code should be performed and 28% believing a full guideline consistent code should be performed. Most respondents reported moral distress when being required to run (75%), do chest compressions for (80%) or witness (78%) a cardiac resuscitation attempt they believe to be medically futile. CONCLUSION Slow codes occur in practice, even though many clinicians ethically disagree with their use. The use of cardiac resuscitation attempts in medically futile situations can cause significant moral distress to medical professionals who agree or are forced to participate in them.
American Journal of Hospice and Palliative Medicine®, 2019
Purpose: Family meetings in the medical intensive care unit can improve outcomes. Little is known... more Purpose: Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality. Methods: We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge. Results: Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting r...
PURPOSE In an attempt to understand some of the complex issues related to the participation of ca... more PURPOSE In an attempt to understand some of the complex issues related to the participation of cancer patients in phase I trials, and the perceptions of patients toward these trials, we conducted a pilot survey study of 30 cancer patients who had given informed consent to participate in a phase I trial at our institution. Concurrently, the oncologists identified by the surveyed patients as responsible for their care were surveyed as well. PATIENTS AND METHODS Twenty-seven of 30 consecutive patients agreed to and completed the survey. Patients were surveyed before they received any investigational agents. Eighteen oncologists participated in this survey study. RESULTS Eighty-five percent of patients decided to participate in a phase I trial for reasons of possible therapeutic benefit, 11% because of advice/trust of physicians, and 4% because of family pressures. Ninety-three percent said that they understood all (33%) or most (60%) of the information provided about the trials in whic...
Patients with localized prostate cancer may be treated with either surgery (radical prostatectomy... more Patients with localized prostate cancer may be treated with either surgery (radical prostatectomy) or radiotherapy. Although controversial, many physicians believe that surgery offers a higher survival rate. However, the surgical treatment may also produce a higher rate of sexual impotency. Our study assessed how men value survival and sexual potency when asked to trade off one for the other. Using the treatment-choice technique, we interviewed 50 men aged 45 to 70 years without known prostate cancer. At hypothetical rates of survival (90% at 5 years for surgery) and impotency (90% for surgery and 40% for radiotherapy) representing published estimates, 32% of respondents were unwilling to trade off any survival, but 68% were willing to trade off a 10% or greater advantage in 5-year survival (by choosing radiotherapy) to maintain sexual potency. The median 5-year survival traded off was 10% (range, 0% to 80%). Willingness to trade off survival for sexual potency was significantly rel...
Journal of the American College of Cardiology, 2020
BACKGROUND In October 2018, the U.S. heart allocation system expanded the number of priority &quo... more BACKGROUND In October 2018, the U.S. heart allocation system expanded the number of priority "status" tiers from 3 to 6 and added cardiogenic shock requirements for some heart transplant candidates listed with specific types of treatments. OBJECTIVES This study sought to determine the impact of the new policy on the treatment practices of transplant centers. METHODS Initial listing data on all adult heart candidates listed from December 1, 2017 to April 30, 2019 were collected from the Scientific Registry of Transplant Recipients. The status-qualifying treatments (or exception requests) and hemodynamic values at listing of a post-policy cohort (December 2018 to April 2019) were compared with a seasonally matched pre-policy cohort (December 2017 to April 2018). Candidates in the pre-policy cohort were reclassified into the new priority system statuses by using treatment, diagnosis, and hemodynamics. RESULTS Comparing the post-policy cohort (N = 1,567) with the pre-policy cohort (N = 1,606), there were significant increases in listings with extracorporeal membrane oxygenation (+1.2%), intra-aortic balloon pumps (+ 4 %), and exceptions (+ 12%). Listings with low-dose inotropes (-18%) and high-dose inotropes (-3%) significantly decreased. The new priority status distribution had more status 2 (+14%) candidates than expected and fewer status 3 (-5%), status 4 (- 4%) and status 6 (-8%) candidates than expected (p values <0.01 for all comparisons). CONCLUSIONS After implementation of the new heart allocation policy, transplant centers listed more candidates with extracorporeal membrane oxygenation, intra-aortic balloon pumps, and exception requests and fewer candidates with inotrope therapy than expected, thus leading to significantly more high-priority status listings than anticipated. If these early trends persist, the new allocation system may not function as intended.
Clinical pharmacology and therapeutics, Jan 11, 2017
Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively stud... more Changes in behavior are necessary to apply genomic discoveries to practice. We prospectively studied medication changes made by providers representing eight different medicine specialty clinics whose patients had submitted to preemptive pharmacogenomic genotyping. An institutional clinical decision support (CDS) system provided pharmacogenomic results using traffic light alerts: green/genomically favorable, yellow/genomic caution, red/high risk. The influence of pharmacogenomic alerts on prescribing behaviors was the primary endpoint. 2279 outpatient encounters were analyzed. Independent of other potential prescribing mediators, medications with high pharmacogenomic risk were changed significantly more often than prescription drugs lacking pharmacogenomic information (odds ratio [OR]=26.2 [9.0-75.3], p<0.0001). Medications with cautionary pharmacogenomic information were also changed more frequently (OR=2.4 [1.7-3.5], p<0.0001). No pharmacogenomically high-risk medications wer...
In recent years, numerous changes in health care delivery have increased surgeons’ interest in me... more In recent years, numerous changes in health care delivery have increased surgeons’ interest in medical ethics. We report the experience of surgeons who completed a fellowship in clinical medical ethics at a single institution.
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Papers by Mark Siegler