The Ether Way

Its not continuous quality improvement, its CQD

Or…..we have to eat too!

 

 I herewith recite some of the teachings of my erstwhile teacher and career-long colleague, Mike Rie, now of the University  of  Kentucky  and paraphrase an abstract we presented at ASA in 2003 called:

 

“Pareto Economics: Research Ethics And Law Violations In Interventional Continuous Quality Improvement (CQI) Reports”

Recent reports offer examples of efficiency driven non therapeutic CQI projects in Anesthesia and Critical Care (1,2,3). These reports describe innovations in process designed to conserve resources but with no intent to improve the outcomes of the patients involved in the reports.  I expect those health care providers  involved in implementing these processes did not conceptualize that they were involved in the involuntary taking of quality from the involved patients…. kind of like eminent domain when they take your house for the new highway (or shopping center). This is actually a medical form of Pareto economics.

This conservation and reallocation of resources assumes that the Pareto Improvements (4,5,6) in an economic system depicted in the figure  are both ethical and legal in health care process innovation notwithstanding the constitutional protections when it comes to eminent domain.

Pareto Economics. In an economic system a Pareto improvement occurs if a person made better off can compensate a person potentially worse off such that resources remain after such compensation. This is used to lawfully justify public policy of building roads. If a property must be taken by eminent domain to promote the public good, the American Constitution provides that just compensation must be provided. As everyone knows this taking of property certainly involves awareness of the “takee” with a due process recourse. Too bad the  patients suffering involuntary taking of quality are seldom aware and have little recourse for appeal or for compensation. This leads to the notion that not CQI but CQD is the process of our time… a time wherein health care costs are predicted to double. That will never happen. After all as a society, we have to eat, provide for the common defense, and make sure our CEOs are well fed.

 Continuous Quality Decrement (CQD) Activities. Industrial CQI methods have been widely incorporated into health care and assume, for the overall good, that a small decrease of costly health care at point B (figure) can be permissibly redistributed to point A. This application of Pareto economics, usually implicit, underlies the managed care assertion that enhancing preventive services safely permits and justifies decreased budgetary allocations to expensive services like anesthesia and critical care. This assumes that a small (even if difficult to measure) decrement in quality at B is universally acceptable to those patients at B (or that they would voluntarily accept economic recompense) so as to enhance preventive benefits to patient populations situated at point A. However, this Pareto trade off in health care has been ethically rejected in theory and by two prominent medical consensus task forces (4,5,6). The a priori prediction that a small diminution in quality to some patients at point B is acceptable represents an untested population-based research hypothesis and imposition of an operational moral value to patient care

 Recent American case law suggests that the Nuremberg Code of Ethics may now be legally applicable, requiring changes in patient populations disclosure of interventional CQI with accountability to IRBs (7,8,9) or perhaps others sorts of ethical oversight. Given that these patients who suffered involuntary CQD with no prospect of improved outcome and clear risk of injury, one must wonder when this will be used as a legal theory buttressing successful litigation that will change our style of treating patients like widgets.
Conclusion. The creation of undisclosed Pareto trade offs in health care clash with individual rights to previously agreed upon contractual services in medical care and may constitute unethical and illegal human experimentation. For maintenance of professional integrity and public confidence in the medical profession, medical organizations should begin public disclosure of the CQD decisions that are undertaken in our clinical practices. In addition, editorial boards of peer-reviewed journals should review their policies concerning ethical review of CQI/CQD type interventional reports

 

References.

1. Anesthesiology 91:83947,1999

2. Anesth Analg 96:1104-8,2003

3. J Trauma 46:6259, 1999

4. J Health Econ16:131,1997

5. JAMA 276:11727,1996

6. Am J Respir Crit Care Med 165:54050,2002

7. Grimes v Kennedy Krieger Institute: Md Ct
of Appeals 366 MD.29, 782 A.2d 807;

8. Crit Care Med 31(suppl):S143-52,2003

9. Curr Opin Crit Care 3:329-33,1997

 

Donation after Cardiac Death: Is mostly dead slightly alive?

"There's a big difference between mostly dead and all dead. Now, mostly dead ... is slightly alive."

-Miracle Max, The Princess Bride.(1)

In Jainism, a gentle devout sect of Hinduism, the sanctity of life is taken to an extreme. Jains are vegetarians. The most devout Jains will not eat fruits and vegetables that are harvested; they prefer to eat produce that has fallen naturally from the vine or tree.

Which brings us to the euphemistic "Donation after Cardiac Death," or DCD. For those of you who have wandered into this blog, a little history. In 1968 a Harvard committee headed by Henry Knowles Beecher (Harvard Professor of anesthesiology) defined Brain Death. This led naturally to the notion that with proper consent, the organs from such unfortunate ex-individuals (individuality being lost once the person died) could be of utility to society and potential organ recipients. These potential donors are the poor folks who have fallen off the vine of life, but for whom some organs still possess vitality. But, there were problems, the main one being that as the industry advanced, there just weren't enough organs to meet the burgeoning demand.

So, the transplant industry, with transplant surgeons and organ procurement organizations (OPOs) in the lead, set aside decades of careful philosophical and ethical reasoning behind brain death in favor of a utilitarian formulation; they lowered the bar for donation...