Tag Archives: culture

Quality and Safety Measurement

In regards to the incident surrounding the death of Josie King (Josie King Foundation, 2002), there have been many great improvements in the delivery of care at Johns Hopkins (Niedowski, 2003; Zimmerman, 2004). Those aside, and if I was faced with having to develop performance measures of quality and safety in the context of such a tragedy, I would strive to ensure that my measures were accurate and valid to identify areas of grave concern where Johns Hopkins would do good to improve.

First, I would consider measuring the structure of the care delivered. In Josie’s case, a medical response team responded when it was identified that she was in the midst of a medical crisis. The first measurement would serve to identify the availability of such teams and the adequacy of the team’s staffing. The measure would indicate the response time of the team and the licensing and certification level of each team member.

Second, I would consider measuring processes that might have contributed to the death of Josie King. In this instance, Josie was administered a narcotic while suffering acute dehydration. The administration of this medication was contrary to the physician’s orders regarding pain medication for this patient. This measure would indicate the appropriate use of narcotic analgesia in patients faced with contraindications, such as acute dehydration or shock. This measure would be a cross tabulation of recent vital signs and laboratory results.

Third, I would consider measuring outcomes. In cases where pediatric patients are downgraded from the pediatric intensive care unit (PICU) to a general ward, any adverse condition should prompt an upgrade back to the PICU. This measure would identify the number of cases in each reporting period that any recently downgraded patient was upgraded back to the PICU. This measure should account for the time between a crisis and upgrade along with a statement indicating the cause of the crisis and resultant upgrade. This measure should be augmented by a mortality and morbidity subset involving any patients who were downgraded from PICU.

My considerations for these processes are to determine if general ward nurses should be administering any medications on standing order or if there should be a requirement to ensure that any medication administered to a general ward patient is explicitly written in the patient’s chart at the time of administration. Also, nurses should be acutely aware of the contraindications of any medications that they are administering. The process measure will, hopefully, identify misuse of narcotic analgesia and any failure to assess the patient for other possible causes of distress before assuming the distress is in response to pain. Ultimately, a more timely and efficient use of medical response teams should result, which would avail physicians and more experienced nurses to the original patient care team. This should lead to an open discussion of how to better manage the patient post crisis. Also, a greater understanding of medication administration concepts should result, benefiting all patients.


Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

The Patient Perspective: Patient Safety

The Speak Up materials provided by The Joint Commission (2011a, 2011b) do a great service in succinctly illustrating the need to be educated about health care issues. Patients and their families have a unique perspective to understanding their (or, their family member’s) health (Vincent & Coulter, 2002). Although physicians, nurses, and allied health providers are responsible for providing quality care, it remains the domain of the patient to express uncertainty or provide additional information to guide the provider. Ultimately, the patient or surrogate decision-maker must provide consent for treatment and must do so with full understanding. There are times, however, that the scope of treatment is so drastic, emergent, or specialized that the patient may not have the facilities to gain a full understanding of care needing to be rendered (Vincent & Coulter, 2002). This is the exception.

In the case of Josie King (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004), which I elaborated on last week, Sorrel King, Josie’s mother, was educated about her daughter’s condition and spoke up as The Joint Commission recommends. Unfortunately, this case turned into tragedy not because Sorrel King did wrong but because the nurse disregarded her apprehension. This was tantamount to malpractice and no patient or family member could have prevented this, save for using force to physically prevent the administration of medicine. According to MacDonald (2009), there are nurses that believe “[patients] have no say and that medications are the domain of doctors, leaving the nurse and the patient to trust that the doctors would do the right thing” (p. 29).

Perhaps things were slightly different, however. As MacDonald (2009) explains, patient’s who are knowledgeable of their illness and take an active role in their health care decisions add another layer of safety, especially when considering medication action, reaction, and interaction. Medication prescription errors are numerous within health care, and as in the case of Josie King, improved communication between the physicians, nurses, and Sorrel King might have prevented Josie from being administered the narcotic and instead receiving the fluid she so desparately needed (Vincent & Coulter, 2002).

Health care should be patient-centric as it remains the responsibility of the patient to be educated about the care they receive and to provide consent for that care and treatment to be rendered. An uneducated patient does add risk, but sometimes this is unavoidable. It is in these instances that special care should be taken until a full medical history can be attained.


The Joint Commission. (2011a, March 7). Speak up: Prevent errors in your care [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up-prevent-errors-in-your-care-/

The Joint Commission. (2011b, April 5). Speak up: Prevent the spread of infection [Video podcast]. Retrieved from http://www.jointcommission.org/multimedia/speak-up–prevent-the-spread-of-infection/

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Macdonald, M. (2009). Pilot study: The role of the hospitalized patient in medication administration safety. Patient Safety & Quality Healthcare, 6(3), 28-31. Retrieved from http://www.psqh.com/

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Vincent, C. A. & Coulter, A. (2002). Patient safety: what about the patient? Quality & Safety in Health Care, 11(1), 76–80. doi:10.1136/qhc.11.1.76

Zimmerman, R. (2004, May 18). Doctors’ new tool to fight lawsuits: Saying ‘I’m sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Medical Error: The Josie King Story

Josie King’s story (Josie King Foundation, 2002; Niedowski, 2003; Zimmerman, 2004) is heartbreaking, but the events told herein empowered Sorrel King, Josie’s mother, to take on a mission responsible for numerous patient care recommendations that have enhanced the safety of pediatric patients throughout the country. Josie King was only 18 months old when she climbed into a hot bath and suffered 1st and 2nd degree burns which led to her being admitted to Johns Hopkins pediatric intensive care unit (PICU). Within 10 days, Josie was released from the PICU and brought to the intermediate floor with all assurances that she was making a remarkable recovery and would be released home in a few days. Josie did not continue her remarkable recovery, however.

According to Sorrel King (Josie King Foundation, 2002), Josie began acting strangely, exhibiting extreme thirst and lethargy, after her central intravenous line had been removed. After much demanding by Sorrel, a medication was administered to Josie to counteract the narcotic analgesia she had been administered. Josie was also allowed to drink, which she did fervently. Josie, again, began recovering quickly. Unfortunately, the next day, a nurse administered methadone, a narcotic, to Josie as Sorrel told her that Josie was not supposed to have any narcotics… that the order had been removed. Josie became limp and the medical team had to rush to her aid. Josie was moved back up to the PICU and placed on life support, but it was fruitless. Josie died two days later and was taken off life support.

The Institute of Medicine (2001) published six dimensions of health care: safety, effectiveness, patient-centered, timeliness, efficiency, and equality. In Josie’s case, the care was not delivered efficiently, effectively, safely, or in a patient- or family-centered fashion. The overuse of narcotics in Josie’s case was certainly not effective or safe. Additionally, withholding fluids and allowing her to become dehydrated was detrimental to her recovery, which was neither safe nor effective. As Josie exhibited extreme thirst, her symptoms were dismissed, which does not follow patient-centeredness. Moreso, when the nurse administered the narcotic to Josie despite the pleadings of her mother, it demonstrated a lack of family-centered care, safety (in that, the order should have been double checked), efficacy (further demonstrating overuse of narcotic analgesia), and efficiency, as medication orders were either unclearly written or removed.

This story is clearly a demonstration that mistakes can happen at even the best of hospitals.


Institute of Medicine. (2001, July). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

Josie King Foundation. (2002). About: What happened. Retrieved from http://www.josieking.org/page.cfm?pageID=10

Niedowski, E. (2003, December 15). From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl’s death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish. The Sun, pp. 1A. Retrieved from http://teacherweb.com/NY/StBarnabas/Quality/JohnsHopkinsErrors.pdf

Zimmerman, R. (2004, May 18). Doctors’ New Tool To Fight Lawsuits: Saying ‘I’m Sorry’. Wall Street Journal, pp. A1. Retrieved from http://www.theoma.org/files/wsj%20-%20medical%20error%20-%2005-18-2004.pdf

Planning a Terrorist Attack

Planning a clandestine attack using a weapon of mass destruction (WMD) is not simple. First, in order to promote an attack, the target needs to be viewed to have violated some ideology, policy, or other deeply held belief (“Terrorism, definition and history of,” 2002). Usually, a symbol of the offense will be chosen as either a specific target, such as the case of the World Trade Center, or as a vehicle or vector for the attack, as in the case of the U.S. Postal Service anthrax attacks (“Biological terrorism,” 2002; Marshall, 2002; “Weapons of mass destruction,” 2002). The dollar is an international symbol of capitalism and the might of the United States. In the current climate, especially with the declining U.S. economy, I would expect the money supply, itself, to be a viable vector for disseminating some sort of substance capable of causing terror. A dollar bill has a circulating life of 42 months and changes hands, on average, twice a day, and by impregnating paper money with a chosen substance, a single dollar bill could potentially harm more than 2,500 people during its circulation (U.S. Department of the Treasury, Bureau of Engraving, n.d.).

Almost as important as the vehicle is the impregnating substance. Chemical and radiological substances would be too easy to eventually detect, and the amount dispersed on each dollar bill might not be enough to cause harm. A live biological agent suspended in an aqueous nutrient solution could easily coat a dollar bill without detection and easily transfer to hands, surfaces, and other bills. According to Winfield and Groisman (2003), Salmonella enterica might prove to be a hardy pathogen capable of existing in such a solution for months. S. enterica is responsible for typhoid fever in humans. Escherichia coli, though a highly pathenogenic mycobacterium, does not have the same persistance outside of a living host. Both S. enterica and E. coli have detrimental health effects, especially for those with deficient immune systems.

Delivery and dispersion of the weapon would be the next consideration. This would have to be accomplished using a number of distribution points, geographically distant, that transfer small denomination bills easily both in and out, such as gasoline stations, convenience stores, fast food restaurants, and liquor stores. Using a website designed to track dollar bills (http://www.wheresgeorge.com), a single bill has been tracked in about two and a half years, as follows: Florida, Georgia, Florida, Indiana, Arizona, Oregon, New York, Tennessee, and South Carolina. Another has been documented as travelling from Ohio to Michigan via Kentucky, Tennessee, Florida, Texas, Louisiana, Texas, and Utah in a mere 212 days. This is evidence that general dispersion techniques will work well if initially geographically distributed.

Additionally, as the Salmonella bills are being dispersed, I would encourage a technological attack on various credit card networks. If the hacking results in increased network downtime, the American citizenry would be encouraged to use paper money more often, potentiating the transfer of the Salmonella bills. As a final coup de grace, when the American populace finally begin to realize that the money supply, itself, is tainted, I would encourage conventional attacks on banking institutions to include random bombings, shootings, and threats of the same. This would further drive the message against the U.S. money supply and could crash the economy.

This plan was developed in about twenty minutes. The terrorists of the day have had decades to consider such plans, and I for one am glad that they tend to be grandiose. When the terrorists realize the simplicity required of causing terror in the U.S., we need to be very wary.


Biological terrorism. (2002). Encyclopedia of terrorism. Retrieved from http://sage-ereference.com.ezp.waldenulibrary.org/view/terrorism/n76.xml

Marshall, P. (2002, February 22). Policing the borders. CQ Researcher, 12, 145-168. Retrieved from http://library.cqpress.com.ezp.waldenulibrary.org/cqresearcher/

Terrorism, definition and history of. (2002). Encyclopedia of terrorism. Retrieved from http://sage-ereference.com.ezp.waldenulibrary.org/view/terrorism/n415.xml

U.S. Department of the Treasury, Bureau of Engraving. (n.d.). FAQ library. Retrieved from http://www.moneyfactory.gov/faqlibrary.html

Weapons of mass destruction. (2002). Encyclopedia of terrorism. Retrieved from http://sage-ereference.com.ezp.waldenulibrary.org/view/terrorism/n453.xml

Winfield, M. D. & Groisman, E. A. (2003). Role of Nonhost Environments in the Lifestyles of Salmonella and Escherichia coli. Applied Environmental Microbiology, 69(7), 3687-3694. doi:10.1128/AEM.69.7.3687-3694.2003

Ethics and Decision Making During Critical Incidents

As a paramedic, I am faced with ethical decisions fairly frequently. As an example, I am usually the sole responding paramedic to an incident that might involve a number of seriously ill or injured patients (e.g. car accidents, fires, carbon monoxide). These incidents are challenging in that I have to choose which patient(s) will be treated at the higher level of care that I can provide versus the lower level of care that the basic life support units can provide. Typically, I base my decision merely on which patient is more ill or injured; however, many times I am faced with a number of critical patients and must decide based on ethical criteria, such as who would benefit more from my care in the long run, including the fact that adolescent and adult patients tend to fair better than elderly and infant patients (Broos, D’Hoore, Vanderschot, Rommens, & Stappaerts, 1993; Kypri, Chalmers, Langley, & Wrigh, 2000; McGwin, Melton, May, & Rue, 2000).

One of the problems with attempting to remain ethical while decisions during an emergency response is that the situational picture is almost never as clear as you need it. This is especially true as the scope and scale of the incident increases. As the magnitude of an incident grows, the incident command team become inundated with information, and it is common to be overwhelmed. We do, though, try our best to be just and fair in our determinations. We need to make our decisions based on the current information and not dwell on if they were right or wrong (Walsh et al., 2012), only if we could have approached the problem more effectively and efficiently, and this should be done only in the debriefing.


Broos, P. L. O., D’Hoore, A., Vanderschot, P., Rommens, P. M., & Stappaerts, K. H. (1993). Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury, 24(6), 365-368. doi:10.1016/0020-1383(93)90096-O

Kypri, K., Chalmers, D. J., Langley, J. D., & Wrigh, C. S. (2000). Child injury mortality in New Zealand 1986–95. Journal of Paediatrics and Child Health, 36(5), 431–439. doi:10.1046/j.1440-1754.2000.00559.x

McGwin, G., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-term survival in the elderly after trauma. Journal of Trauma, Injury, Infection, & Critical Care, 49(3), 470-476.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.

Determinants of Health – Mental Illness

When attempting to solve many of the issues relevant to public health, it is essential to understand the factors that contribute to disparities across various ethnic, racial, cultural and socioeconomic boundaries (Satcher & Higginbotham, 2008). In northeastern Connecticut, however, health disparities are primarily related to the socioeconomic strata, as much of the population is Caucasian and there are identifiable health disparities within this group (U.S. Census Bureau, 2002, 2008; U.S. Department of Health and Human Services, 2009). The disparity that I will focus on in this paper is mental illness.

According to Adler and Rehkopf (2008), unjust social disparity leads to greater health disparity, but what is unjust about social disparity? Adler and Rehkopf continue to describe efforts of researchers to evaluate how socioeconomic status, both, in conjunction with and independent of race or ethnicity, contribute to health disparities. There exists a significant difference in the manner in which different cultures approach mental health needs (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008). Whites, who are more prone to suffering mental health issues, according to McGuire and Miranda (2008), preferring to seek professional care while Blacks are more likely to opt for self-directed care. Though Wang, Burglund, and Kessler (2001) tell of mental health treatment disparities between Whites and Blacks, in their study, 14 times more Whites responded than Blacks which may suggest that Whites are more apt to discuss mental health issues and Blacks might not unless they are motivated by extrinsic factors, such as poor care or the impression thereof. As long as Blacks are not prevented or discouraged from seeking care, there is no injustice in choosing self-care; however, it may not be the most effective option. Cultural awareness on the part of health care providers who may have an opportunity to provide health education to Blacks may alone increase the utilization of mental health services among the Black demographic.

More importantly, mental illness often exists in the presence of poverty and the lack of education. Much of the literature, such as Schwartz and Meyer (2010), seems to make the implication that low socioeconomic status is a causative risk-factor for mental illness, yet the literature also makes the distinction that one of the lowest groups on the socioeconomic ladder, Blacks, have a lower incidence, overall, of mental illness. This may be true in some instances; however, it is more likely that mental illness may be the proximal cause for an afflicted person’s socioeconomic status, especially if the illness manifested early enough to interfere with the person’s education.

More research needs to be undertaken to identify effective programs that aim to mitigate bias of mental health conditions within the community. As mental health disorders lose their stigma, more people who suffer from mental health issues will be able to seek care comfortably and unafraid, leading to increased treatment rates and increased synthesis within the community. This synthesis alone would alleviate much of the socioeconomic burden. Additionally, we need to shift our focus and strive to fix health issues locally, not nationally or globally. The world is comprised of a network of communities of individuals. Impacting the individual is the first step to affecting positive social change. Focusing on individual health will ultimately impact community, national, and global health.

The U.S. Health care system is overtaxed in caring for people with mental illness. According to Insel (2008), we need to refocus our efforts on providing care for mental illness to reduce the enormous indirect costs estimated at $193.2-billion per year. A viable solution in addressing mental illness as a health disparity, I feel, lies in understanding the manner that mental illness causes lower socioeconomic status which, in turn, causes risk of disparate care. Programs designed to aim for situational mitigation instead of mental health recovery will be less costly, more effective and, overall, more ideal. There will still be an obvious and great need for treatment and recovery programs, but with mitigation, I posit that they will be more effective, also.


Adler, N. E. & Rehkopf, D. H. (2008). U.S. disparities in health: descriptions, causes, and mechanisms. Annual Review of Public Health, 29(1), 235-252. doi:10.1146/annurev.publhealth.29.020907.090852

Hatzenbuehler, M. L., Keyes, K. M., Narrow, W. E., Grant, B. F., & Hasin, D. S. (2008). Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population. Journal of Clinical Psychology, 69(7), 1112-1121. doi:10.4088/JCP.v69n0711

Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165, 663-665. doi:10.1176/appi.ajp.2008.08030366

McGuire, T. G. & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs, 27(2), 393-403. doi:10.1377/hlthaff.27.2.393

Newport, F. & Mendes, E. (2009, July 22). About one in six U.S. adults are without health insurance: Highest uninsured rates among Hispanics, the young, and those with low incomes. Gallup-Heathways Well-Being Index. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx

Satcher, D. & Higginbotham, E. J. (2008). The public health approach to eliminating health disparities. American Journal of Public Health, 98(3), 400–403. doi:10.2105/AJPH.2007.123919

Schwartz, S. & Meyer, I. H. (2010). Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses. Social Science and Medicine, 70, 1111-1118. doi:10.1016/j.socscimed.2009.11.032

U.S. Census Bureau. (2002). Census 2000. Retrieved from http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250616

U.S. Census Bureau. (2008). Population estimates: Annual estimates of the resident population by age, sex, race, and Hispanic origin for counties in Connecticut: April 1, 2000 to July 1, 2008 [Data]. Retrieved from http://www.census.gov/popest/counties/asrh/files/cc-est2008-alldata-09.csv

U.S. Department of Health and Human Services. (2009). Community health status indicators report. Retrieved from http://communityhealth.hhs.gov/

Motivation: A Career that I Enjoy

I am lucky to work in a career that I absolutely enjoy. As a paramedic in the emergency medical services (EMS), I am called upon to help those in my community in the worst of circumstances to help them when they feel helpless. There are drawbacks, however. Many people rely on EMS for problems that even they do not view as emergent, and others just plainly abuse the system. Still, I enjoy being the one called upon to help. My primary motivations are my sense of community, my ability to reduce suffering, and my ability to raise the standard of care within the system. Maslow (1943) includes some of the earliest accepted work on motivational theory, and more contemporary work is based on the acceptance, rejection or modification of his theories, so I will focus on Maslow to begin. My needs, according to Maslow, are not as important to motivation. Need fulfillment will not motivate me to perform; however, a lack of fulfillment may prevent me from performing. This is especially true for Maslow’s lower-order needs. Maslow discusses how emergency situations can “obscure the ‘higher’ motivations [and create] a lopsided view of human capacities and human nature” (p. 375), and while my career is focused on responding to emergencies, this may hold true for me. While Maslow’s theory is not wholly accepted motivational schema (Robbins & Judge, 2010), EMS managers, and other public safety managers, would do well to understand this exception to motivational theory.

Many EMS managers, it seems, subscribe to McGregor’s (1957/2000) theory X without understanding the ramifications or the competing theory Y. There is a deep-seated belief that the workforce is lazy and will do anything possible to undermine the operation. This results in micromanagement tactics that seem to promote an unwillingness to promote the goals of the employer. McGregor highlights this and cautions that it a result of poor management technique, not a cause that is easily rectified by the chosen technique.

Other theories, such as goal-setting, equity theory, and expectancy theory, as described in Robbins and Judge (2010), are all lacking in one particular constant: there is no constant in human behavior. There are a number of ways that a single motivational factor might influence a particular person on any particular day. For any theory to always be true in every situation, it would cease to be a theory and become a law. This being said, as managers, we need to measure the importance of certain tasks and focus our efforts on communicating this importance to the workforce. It is the manner of this communication that will tend to fail or succeed, based on both the needs of the manager and the needs of the employee at the moment the message is passed.


Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-396. doi:10.1037/h0054346

McGregor, D. (2000). The Human Side of Enterprise (Reprinted from Adventure in thought and action: Proceedings of the fifth anniversary convocation of the School of Industrial Management, Massachusetts Institute of Technology, Cambridge, 1957, April 9. Cambridge, MA: MIT School of Industrial Management). Reflections, 2(1), 6-14. doi:10.1162/152417300569962

Robbins, S. P. & Judge, T. A. (2010). Motivation concepts. Essentials of organizational behavior (pp. 62-79). Upper Saddle River, NJ: Pearson Prentice Hall.

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.


Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from http://www.cga.ct.gov/2003/olrdata/ph/rpt/2003-R-0515.htm

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from http://www.nationalreview.com

Community Health Centers

Community health centers increase availability of (i.e. access to) health care and is shown by some to improve health outcomes (Taylor, 2009). Improving access to health care is achieved by placing these community health centers geographically proximate to underserved and at-risk populations. Taylor (2009) boasts improvements in health outcomes due to the number and placement of community health centers, but she provides no compelling evidence to say that any improved outcome is not directly caused by the improved access. Forrest and Whelan (2000) discuss a need to improve access to physician offices more than community health centers to improve follow-up care which continues to lack in the community health center model, though the point may be moot if the community health centers can improve the delivery of service to allow for proper follow-up. Forrest and Whelan do, however, acknowledge the value of community health centers in providing increased access to health care to underserved and vulnerable populations.

Dieleman et al. (2004) offers collaboration of health care providers in the primary care setting as a means of improving efficiency and thereby improving health outcomes. The testing instrument used during this study indicates an overall improvement of the attitudes towards role recognition, provider satisfaction, patient satisfaction, and patient health status, as well as the quality of patient care provided. In my experience with many community-based health clinics, they tend to be less than spectacular as far as quality of care, cleanliness, and patient-provider attitudes. By adding other providers into the patient-provider relationship, it would allow others to comment within the team where improvements can be made in relation to each patient-provider relationship and in a more general sense.

A collaborative holistic approach to patient care, whether in primary care, emergency care, or in critical care, will foster a sense of partnership within the team, including the patient and family, that will allow the team to truly care for the patient, will allow the patient to be invested in his or her care, and will promote a complete view of the whole patient both when sick and when well. Collaboration will, hopefully, allow improved efficiency in the provision of care while maintaining a trustworthy and committed relationship with the patient. Forging these relationships will, hopefully, help to overcome any challenges faced within our continually changing health care landscape.


Dieleman, S. L., Farris, K. B., Feeny, D., Johnson, J. A., Tsuyuki, R. T., & Brilliant, S. (2004). Primary health care teams: team members’
perceptions of the collaborative process. Journal of Interprofessional Care, 18(1), 75-78. doi:10.1080/13561820410001639370

Forrest, C. B. & Whelan, E. (2000). Primary care safety-net delivery sites in the United States: A comparison of community health centers, hospital outpatient departments, and physicians’ offices. Journal of the American Medical Association, 284(16), 2077-2083. doi:10.1001/jama.284.16.2077

Taylor, T. (2009, October). The role of community-based public health programs in ensuring access to care under universal coverage [Issue brief]. American Public Health Association. Retrieved from http://sylvan.live.ecollege.com/ec/courses/53027/CRS-WUPSYC6205-4570539/CommunityBasedReformupdtd.pdf

Henrietta Lacks

Grady (2010) offers the circumstances of Henrietta Lacks for discussion as it pertains to medical ethics. Henrietta Lacks was a young woman who succumbed to cervical cancer in the early 1950s at Johns Hopkins Hospital (Grady, 2010; Sorrell, 2010). Grady describes Henrietta Lacks and her family as “poor, with little education and no health insurance” (para. 10), yet she was cared for and her cancer was treated with radium, the standard treatment of the day. Despite treatment, Henrietta passed away. During the course of her treatment, however, a small sample of cancer cells were removed from her cervix for testing, and they continue to be tested to this day (Grady, 2010; Sorrell, 2010). Additionally, this line of cells, now known as the HeLa cells, has become commercialized, as they are bought and sold for millions on the biomedical research market (Grady, 2010).

Assuming no consent was given by Henrietta or her family, this raises a few questions. Did the physicians at Johns Hopkins have a right to these cancer cells? Did they have a right to transfer ownership to third parties? Does the estate of Henrietta Lacks require royalties be paid when others profit from what amounts to a donation to the public domain?

No person can own another person (or, a part thereof). This is consistent with the moral society of the United States. However, Henrietta Lacks presented herself to Johns Hopkins hospital with the express desire to rid herself of the cancer cells causing her illness. This alone could mean that the cells are refuse and able to be salvaged, and according to Fost (2010), this is agreed to be the law of the land. Fost describes the circumstances surrounding the HeLa cells as normal course of medical business, and I agree for the most part: “If tissue removed during an operation is about to be thrown out with the garbage and has no identifying information, it should be permissible to use it for research without the patient’s consent” (2010, para. 1). In this case, however, the researchers later approach the Lacks family to obtain DNA samples to discriminate between HeLa cell cultures and non-HeLa cell cultures. This mere fact offers evidence that the tissue is identifiable with Henrietta Lacks and her lineage, and I feel, as does Fost, that this is where the researchers erred, in asking for continued support of the cells by obtaining further comparative specimens for analysis yet not clarifying the misconceptions of the family. The researchers should not have requested further tissue (i.e. blood) donation without obtaining informed consent from the donors. Further, the cell line were given a name representative of Henrietta Lacks, HeLa, and she was named as the donor and widely known as such throughout the biomedical research community. Ergo, there were certainly identifying data linking Henrietta Lacks to the specimen.


Certainly under normal circumstances the cells should be made available for research purposes, but they should not be sold for profit, only for the costs of storage and maintenance. Any tissue freely used for medical science should be in the public domain. Further, if a specimen is found to have financial worth, I feel that the custodial researchers should set aside a royalty account allowing a small percentage of the proceeds to be returned to the donor’s estate. I also feel that if researchers have any special interest in further donation, then those donors should be offered remuneration for their donation which should be commensurate to the gains assumed to be made by their donation.

I find no issue with how the cancer cells were used initially, however, the sample should not have been attached in name to the donor. Though not required, it would have been nice if the researchers provided a royalty to the estate of Ms. Lacks, however, to thank her for her contribution to medicine and science.


Fost, N. (2010). A cell’s life: The immortal life of Henrietta Lacks. Issues in Science and Technology, 26(4), 87+. Retrieved from http://ic.galegroup.com.ezp.waldenulibrary.org

Grady, G. (2010, February 1). Second opinion: A lasting gift to medicine that wasn’t really a gift. The New York Times. Retrieved from http://www.nytimes.com

Sorrell, J. M. (2010). First do no harm: Looking Back to the Future [Editorial]. Journal of Psychosocial Nursing & Mental Health Services, 48(9), 2-3. doi:10.3928/02793695-20100730-07