Reflections on the papal allocution concerning care for persistent vegetative state patients.

This article critically examines the recent papal allocution on patients in a persistent vegetative state with regard to the appropriate conditions for considering "reformable statements." In the first part of the article, the purpose and meaning of the allocution are assessed. O'Rourke concludes that give consideration of the individual patient's best interest, prolonging artificial nutrition and hydration is not, in every case, the best option. Although he stresses favorability for preservation of the life of the patient through artificial nutrition and hydration, costs and benefits to the patient should be weighed. Ultimately, he argues in favor of leaving the decision to the patient, his caregivers, and others immediately involved in the case.     

Persistent Vegetative State: A Presumption to Treat

The article briefly analyzes the concept of a person, arguing that personhood does not coincide with the actual enjoyment of certain intellectual capacities, but is coextensive with the embodiment of a human individual. Since in PVS patients we can observe a human individual functioning as a whole, we must conclude that these patients are still human persons, even if in a condition of extreme impairment. It is then argued that some forms of minimal treatment may not be futile for these patients; they may constitute a form of respect for their human dignity and benefit these patients, even if they are not aware of that. Moreover, it is important to consider the symbolic significance of care: while many believe that PVS is a kind of imprisonment, for others providing food and fluids is the only way to testify our proximity to these persons. The best policy would be to provide, as a general rule, artificial nutrition and hydration to PVS patients: this treatment could be withdrawn, after a period of observation and reflection by the family and proxies, on the basis of the proxies' objection to the continuation or of the patient's advance directives specifically referring to this situation.     

Stopping nutrition and hydration technologies: a conflict between traditional Catholic ethics and church authority.

This article focuses on the troubling effects of the secular values of individual freedom and autonomy and their impact on laws regarding suicide and euthanasia. The author argues that in an increasingly secularized culture, death and dying are losing their meaning and are not thought of within a moral framework. The debate regarding the provision of artificial nutrition and hydration is critically considered in light of the history of Catholic morality as well as within the modern healthcare context, and finally with new insight from the recent statements made by the late pope. Drane argues that the pope's insistence on providing artificial nutrition and hydration despite irreversible persistent vegetative states in unconvincing.     

Withdrawing life-sustaining medical treatment--a physician's personal reflection

The decision to withhold or withdraw artificially provided hydration and nutrition is one which evolves over time and must be made jointly by the medical team and the patient's family. Although withholding nutrition can be argued to be ethical and appropriate for certain clinical scenarios, it is still a decision which can be difficult to make and, because of different social and legal issues, can be difficult to carry out. This is the story of one physician's journey as he worked with the mother and father of a young child who suffered a severe neurological injury and was left in a persistent vegetative state.     

Religion and United States Physicians’ Opinions and Self-Predicted Practices Concerning Artificial Nutrition and Hydration

This study surveyed 1,156 practicing US physicians to examine the relationship between physicians’ religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.     

Nutrition and hydration: an analysis of the recent papal statement in the light of the Roman Catholic bioethical tradition.

This article discusses the unexpectedly firm stance professed by John Paul II on the provision of artificial nutrition and hydration to patients who are in a persistent vegetative state, and it implications on previously held standards of judging medical treatments. The traditional ordinary/extraordinary care distinction is assessed in light of complexities of the recent allocution as well as its impact on Catholic individuals and in Catholic health care facilities. Shannon concludes that the papal allocution infers that the average Catholic patient is incapable of making proper judgments about their own care. Shannon sees the preservation of life at all costs as at least highly troubling, if not as a radical move against the Catholic medical ethics tradition.     

The burdens-benefits ratio consideration for medical administration of nutrition and hydration to persons in the persistent vegetative state.

In this article, Harvey notes the initial confusion about the statement made by the pope concerning artificial nutrition and hydration on patients suffering persistent vegetative states (PVS) due to misunderstanding through the translation of the pope's words. He clarifies and assesses what was meant by the statement. He also discusses the problems of terminology concerned with the subject of PVS. Harvey concludes that the papal allocution was in line with traditional Catholic bioethics, and that while maintaining the life of a patient is favorable, in particular cases this presumption wanes when it is clear that this treatment modality would be futile or very burdensome.     

Tube feedings and persistent vegetative state patients: ordinary or extraordinary means?

This article looks at the late John Paul II's allocution on artificial nutrition and hydration (ANH) and the implications his statement will have on the ordinary-extraordinary care distinction. The purpose of this article is threefold: first, to examine the medical condition of a persistent vegetative state (PVS); second, to examine and analyze the Catholic Church's tradition on the ordinary-extraordinary means distinction; and third, to analyze the ethics behind the pope's recent allocution in regards to PVS patients as a matter of conscience. Rather than providing clarification, I argue that the papal allocution has raised many difficult questions. People in situations where decisions must be made about withdrawal or continued ANH are in need of guidance. Moreover, additional analysis is needed to determine whether the papal allocution is in conflict with the traditional Catholic medical ethics understanding of the ordinary-extraordinary care distinction.     

Decisions at the end of life: Catholic tradition.

Medical decisions regarding end-of-life care have undergone significant changes in recent decades, driven by changes in both medicine and society. Catholic tradition in medical ethics offers clear guidance in many issues, and a moral framework accessible to those who do not share the same faith as well as to members of its faith community. In some areas, a Catholic perspective can be seen clearly and confidently, such as in teachings on the permissibility of suicide and euthanasia. In others, such as withdrawal of nutrition and hydration, the Church does not yet speak with one voice and has not closed out the discussion. Yet, it is not in the teaching on individual issues that a Catholic moral tradition offers the most help and comfort, but in its account of what it means to lead a life in Christ, and to prepare for a Christian death. As in the problem of pain and suffering, it is the spiritual support more than the ethical guidance that helps both patients and physicians bear the unbearable and fathom the unfathomable.     

冠心病患者对比剂诱发肾病的临床研究

为了比较两种水化方法对对比剂肾病(CIN)的影响,我们选住院行经皮冠状动脉介入治疗(PCI)94例肾功能不全患者,随机分为氯化钠水化组、碳酸氢钠水化组测定术后4天血肌酐水平变化。结果显示,氯化钠水化组6例发生CIN(13.3%),碳酸氢钠水化组3例CIN(6.3%),提示对于慢性肾功能不全患者碳酸氢钠水化方案更优。     

Withholding Hydration and Nutrition in Newborns

In the twenty-first century, decisions to withhold or withdraw life-supporting measures commonly precede death in the neonatal intensive care unit without major ethical controversy. However, caregivers often feel much greater turmoil with regard to stopping medical hydration and nutrition than they do when considering discontinuation of mechanical ventilation or circulatory support. Nevertheless, forgoing medical fluids and food represents a morally acceptable option as part of a carefully developed palliative care plan considering the infant’s prognosis and the burdens of continued treatment. Decisions to stop any form of life support should focus on the clinical circumstances, not the means used to sustain life.     

Simulation Modeling of Policies Directed at Youth Sugar-Sweetened Beverage Consumption

Childhood obesity is a significant public health problem requiring innovative solutions. While recent reviews indicate that some policies show promise, there is a lack of information regarding which policies, and policy combinations, work best. Low-nutrition, energy-dense foods and beverages such as sugar-sweetened beverages (SSBs) have been identified as a major contributor to the problem. The purpose of this paper is to use simulation modeling to show how changes in three categories of SSB policies—school nutrition, school-based education, and taxes—impact SSB and other food consumption. The model shows that policies directed at SSBs, particularly tax hikes, could lead to substantial reductions in the number of calories consumed by youth. The estimates, however, are subject to a high degree of uncertainty. Estimates from school-based nutrition and school-based education policies, while also helping to reduce caloric intake, generally show smaller effects than tax policies and considerable variation around parameter estimates for individual and combined policies. We conclude with a discussion of the limits of the model, and suggest where additional information is needed. Limitations notwithstanding, simulation modeling is a promising methodology that can help advance our understanding of policy effects, thereby helping policymakers to better formulate effective policies to reduce obesity prevalence and the associated social harms.     

INDUCTION AND MAINTENANCE OF SWALLOWING RESPONSES IN INFANTS WITH DYSPHAGIA

A treatment package was used to induce and maintain swallowing with three infants who did not swallow food or liquid. Prior to treatment, they received all nutrition and hydration via gastrostomy tube feedings. The treatment package consisted of least-to-most intrusive physical prompts, an eliciting stimulus, contingent social reinforcement, and repeated trials to induce and maintain swallowing. The design combined elements of reversal and changing criterion designs for all three infants. The package was applied across feeding devices (nipple, cup, spoon), situations (liquid, pureed foods), and persons (trainer, primary nurses, mothers). The number of swallows or ounces per feeding (from 0 to 8 ounces) and the number of feeding sessions per day (from one to five) were progressively increased. In each case, the infant received baseline conditions alternated with the treatment package. Follow-up probes were done at 15 months, 21 months, or 24 months, respectively, after the last phase for the three patients. The package was successful in that the gastrostomy tube was no longer needed for Patients 1 and 3. Patient 2 maintained functional swallowing responses but received supplemental gastrostomy feedings because of unrelated medical problems. Results are discussed in terms of the need to isolate components of the package. The package can be used in cases in which the preexisting treatments (reinforcement with preferred foods, force-feeding) are not feasible because of age, physical fragility, or the lack of a swallowing response following the presentation of food.     

The Making of an Interdisciplinary Partnership: The Case of the Chicago Food System Collaborative

Interdisciplinary partnerships foster innovation to address pressing social problems. This paper describes an interdisciplinary partnership called the Chicago Food System Collaborative (CFSC) composed of a team of partners from four academic institutions and three community-based organizations representing a total of eight disciplines that included: community development and community organizing, community psychology, geography, nursing, nutrition, public health, sociology, and urban planning and policy. Partners came together to address the issue of access to healthy foods and nutrition in a working class African American neighborhood. We analyze and discuss the core principles that guided the partnership and its impact across three dimensions: understanding through interdisciplinary action research, building capacity, and facilitating innovations in practices and policies. Despite the challenges of interdisciplinary partnerships, the potential benefits and impact of such efforts reflect their value as a comprehensive approach to addressing complex social problems.     

The impact of homelessness on children.

This article reviews and critiques community-based research on the effects of homelessness on children. Homeless children confront serious threats to their ability to succeed and their future well-being. Of particular concern are health problems, hunger, poor nutrition, developmental delays, anxiety, depression, behavioral problems, and educational underachievement. Factors that may mediate the observed outcomes include inadequate shelter conditions, instability in residences and shelters, inadequate services, and barriers to accessing services that are available. Public policy initiatives are needed to meet the needs of homeless children.     

两种水化疗法对预防对比剂肾病的效果研究

比较两种水化疗法对对比剂肾病(contrast-induced nephropathy,CIN)的预防效果。将150例患者随机分为氯化钠水化组(50例)、碳酸氢钠水化组(50例)和常规治疗组(50例),检测患者造影前3天内及造影后第3天、7天的血肌酐、尿素氮和尿β2微球蛋白。分析三组患者CIN的发病率。结果两水化组CIN的发病率均显著低于常规治疗组(P0.05),两水化组间CIN的发病率无明显差异(P0.05)。结果提示两种水化疗法对CIN的预防效果相仿。     

‘Sticking to a healthy diet is easier for me when I exercise regularly’: Cognitive transfer between physical exercise and healthy nutrition

Objective: Long-term rehabilitation success depends on regular exercise and healthy nutrition. The present study introduces a new framework to explain this association on a psychosocial level. The exercise–nutrition relationship was investigated by exploring the sequential mediation of habit strength and transfer cognitions.

Design: Analyses were performed at two measurement points in time (at 12 and 18?months after rehabilitation), involving 470 medical rehabilitation patients who participated in an exercise intervention.

Main outcome measures: Patients filled in paper-pencil questionnaires assessing exercise (t1) and habit strength, transfer cognitions and healthy nutrition at follow-up (t2).

Results: Habit strength and transfer cognitions mediated the relationship between exercise and nutrition.

Conclusion: Findings suggest that habit strength and transfer cognitions are important factors underlying the relationship between exercise and nutrition.     

临床活体部分小肠移植过程中矛盾现象及处理

从1999年至今、在国内我们率先成功地施行两例临床活体部分小肠移植术,在整个处置过程中出现许多的矛盾现象。如术前为纠正患者严重的营养不良,必须给予肠外营养支持。但是,长期的肠外营养又引起患者肝功能损害,使患者无法耐受手术;对受体来讲,当然是移植的肠管越长越有利,但是在活体移植的情况下供体只能有限地提供肠管,且肠管过长受体也无法接受;手术后患者必须应用有效的免疫抑制剂来防治免疫排斥反应,而机体在免疫抑制下极易发生感染,应用强效而广的抗菌素虽然可防治细菌的感染,但是可引起菌群的失调导致真菌感染;为防止血管内血栓的形成,需应用有效的抗凝剂,但同时可导致出血倾向等等。我们体会：正确地处理这些矛盾现象是我们成功的关键。首先要抓重点,抓主要矛盾,同时应对可能出现的问题有所感知并给与预防,尽可能避免副反应的发生。     

Anticruelty care: commentary

The anticruelty policy is a best-interests test for treatment plans including decisions to forgo life-sustaining therapy for certain incompetent patients. In connection with specific proposed therapy, the policy requires no reference to the patient's unknowable values, subjective experiences, or quality of life. The decision to undertake a treatment plan derives from the caregiver's knowledge of burdens and benefits of that treatment when used in caring for the competent or for those incompetents capable of growth or repair. The caregiver should weigh the potentially cruel effects of treatment against the likelihood of reducing suffering or encumbrance with the treatment. The terms "burden" and "benefit," in fact, are replaced by the terms "cruelty" and "beneficence," as the relevant opposing outcomes that must be weighed. Thus, the anticruelty policy shifts our scrutiny from experiences of the patient that we cannot evaluate to the proposed actions of the competent decision makers and caregivers. Notably, it is a protreatment policy when the goals of medicine are attainable; and it is an anticruelty policy when they are not. The policy does evaluate the world of the patient to the extent that it requires a judgment based upon external appearances about patient pleasure or happiness in living. It presumes to universalize larger societal values about cruelty, beneficence, compassionate concern for the helpless, and certain rights of individuals. And it presumes to universalize on the patient's behalf specific medical values about hopeless injury, timely death, the goals of medicine, and cruelty, which should remain open to societal discussion and revision. The presented definition of hopeless injury does not require brain death, coma, or persistent vegetative state. Specifically, the policy holds that death is timely for a patient with hopeless injury, and that prevention of death for such patients is not a goal of medicine but a cruelty.