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The concept of values-based medicine is relatively new and can be defined as medical practice that aims at maximizing value, specifically desirable or positive value in every step of a patient’s medical management. It is difficult to disagree with such a benevolent practice; however, problems can arise when attempts are made to clarify the concept of value. Traditionally, medical ethics has focused on the four principles of autonomy, beneficence, non-maleficence, and justice. However, these principles can sometimes be difficult to use in everyday clinical practice. Therefore, acknowledgment of additional values can be helpful to guide practice. Values-based medicine aims to identify a set of intrinsic or instrumental values that are important to a particular individual and to use the values to clinical guide care. A thorough working knowledge evidence-based medicine is required in order to enable a critical evaluation of the evidence presented. It is also important the limitations when applying information obtained from large data sets to individual patients because adopting this approach may fail to recognize and acknowledge the diversity of individual values and goals.
For many years, the management of severe TBI has been based on information gained from intracranial pressure (ICP) monitoring. The rationale for its use is based on the three Ps of prognosis, perfusion, and pathology of TBI, with the hope that using ICP to guide therapy would prevent secondary brain injury and ultimately improve neurological outcome.However, one of the fundamental challenges in neurotrauma has been the inability to demonstrate that the fall in ICP achieved by these measures is subsequently translated into an improvement in clinical outcome. For years, patients with severe TBI were routinely hyperventilated, frequently placed in a barbiturate coma, or more recently rendered hypothermic, because these measures consistently reduce intracranial pressure. However, clinical studies have failed to show that lowering intracranial pressure by these techniques provides clinical benefit, and in some instances they may have caused harm. It is this regard that the use of decompressive craniectomy was thought to be promising, and there have now been two large multicentre randomised controlled trials investigating efficacy of the procedure. The results provide good evidence to guide practice but also raise ethical issues regarding the use of a procedure that reduces mortality but increases survival with severe disability.
Acute aneurysmal subarachnoid haemorrhage (aSAH) is associated with significant morbidity and mortality. The worldwide incidence is approximately 9 per 100,000 per year; however, there are regional differences. Accurate, timely diagnosis and treatment is imperative to avoid aneurysmal re-rupture, which has a mortality in the region of 80%. For patients that survive the initial aSAH, the re-rupture rate is approximately 5% in the first 24 hours and thereafter, approximately 1% per day. Patient outcome may be further compromised by complications such as seizures, cerebral vasospasm, cerebral infarction, electrolytes disturbances and hydrocephalus. Definitive treatment of patients admitted with acute aSAH is based on early exclusion of the aneurysm from the circulation in order to prevent rebleeding and for many years, the treatment of choice was an open craniotomy and surgical clipping of the aneurysm. However, over recent years the development of interventional neuroradiological techniques has provided alternative less invasive management options that raise a number of ethical issues that must be considered when faced with a patients with an acute aSAH.
Over the past two hundred years the average global life expectancy has increased from just over thirty years of age to well over seventy years of age. There are many reasons for this ranging from the eradication of certain diseases, life style changes and improvements in public health. As people have lived longer, so they have worked longer, and this is reflected in the changing demographic of the workforce. However, notwithstanding this increase in life expectancy the aging process can takes in toll in terms of cognitive and functional decline which may have an impact on the ability of the older person to perform satisfactorily in the workplace. Where this involves physicians and surgeons there is obvious concern for patient safety.
The use of live televised surgery (LTS) has evolved significantly over recent years. It has usually been organized by a surgical society at a meeting to demonstrate surgical techniques to a large number of members or attendants. This allows examination of surgical techniques, tips, and decisions in a real-time fashion and management of unexpected events such as surgical complications. However, notwithstanding the obvious educational benefits, there has been an increasing awareness that surgery performed under these conditions presents a number of unique ethical considerations. These include patient-centered issues such as privacy, consent, and possible harm, and surgeon-related issues such as impaired performance due to distraction. Finally, there may be participant-related issues regarding the advantages or disadvantages of this type of medical education over and above other types or medical education. Currently there are no specific guidelines for the use of LTS in neurosurgery, and the time may have come for this to be considered.
A thorough understanding of ethical issues, which are often encountered in the field of paediatric neurosurgery, can help neurosurgeons in decision-making regarding optimal treatment in children. Although ethical dilemmas in paediatric neurosurgical patients frequently share common characteristics with those seen in the management of adult patients, they also differ and are more complex. For example, because child patients do not have the ability to make decisions on their own due to their age, their parents are usually substitute decision makers. Ethical problems in paediatric neurosurgery may arise with prenatal diagnosis and continue to be encountered in various age groups with different characteristics during foetal, neonatal, infancy, playschool age, school age, and adolescence. Moreover, intrauterine foetal life involves the health and wellbeing of the mother, further complicating ethical decision-making. Collaborative communication and the exchange of information between the medical team and the family, which leads to a shared family-centered decision-making, are an increasingly preferred approach to paediatric medical decision-making. In addition, developmental maturation of the child allows for increasing longitudinal inclusion of the child’s opinion in medical decision-making in clinical and research practice. The child should always be informed in a respectful manner and using simple language adjusted to the childs age. Despite the limits of medicine at a specific time, clinicians should always respect a child with an incurable disease and show warm sympathy toward babies born with the fate of a short life.
Consent also serves a third function - the relational function - by providing an environment that fosters relationships of trust between the treating team, the patient and their family. In neurosurgery, where patients are faced with death and have few if any choices open to them beyond surgery, and where surgery is very risky and its’ outcomes difficult to predict, it can be argued that the permissive and risk functions of consent become less important, and the relational function comes to the fore.
In the past decade, there have been considerable advances in the endovascular management of patients with acute ischaemic stroke. However, notwithstanding the clear cut evidence for endovascular therapy there remain major logistical challenges in providing widespread and timely access to this therapy across many healthcare systems. For those patients who either fail endovascular therapy, or who present outside the time dependent therapeutic window, there is a risk that they will go on to develop life threatening cerebral oedema, so-called malignant middle cerebral artery infarction. The prognosis for these patients is poor with a mortality rate in the region of 80%, without specific treatment. In these circumstances, consideration may be given to performing a decompressive hemicraniectomy as a lifesaving intervention. Unfortunately, unlike endovascular therapy that has the potential to reverse a neurological deficit, surgical decompression will only reduce mortality and the concern has always been that many survivors will be left with an unacceptable level of disability. There have now been a number of randomized controlled trials that have demonstrated this outcome, and this presents a number of ethical issues that require consideration when faced with a patient who clinically deteriorates following an ischaemic stroke.
The field of modern-day bioethics is relatively young and continues to constantly evolve in parallel with the ever-increasingly complex nature of contemporary medical practice. These advances present clinicians with an array of therapeutic options that would have not seemed possible only a generation ago. Given these medical advances and the expansion of the academic and medicolegal field of bioethics, one would have thought that clinical decision-making would have become easier. However, paradoxically, this has not proved to be the case.
Neurosurgical interventions have the potential to change a person's concept of self, as well as affect their neurological and cognitive function to an unacceptable level for both patient and family. In an increasingly complex and evolving field, the ethical implications of treatments and their eventual outcomes must be carefully balanced. Ethics in Neurosurgical Practice is a comprehensive and practical guide for managing the treatment of patients with debilitating neurosurgical conditions. Chapters address specific conditions, such as traumatic brain injuries, ischemic stroke and spinal surgery, and the ethical challenges that each of these pose. Detailed case studies present potential scenarios that readers might encounter, and their outcomes. Future developments of this fast-paced field are expanded upon, including televised live surgery and the ethical aspects of innovation in neurosurgery. A broad variety of contributors in different fields, including neurosurgeons, intensivists and bioethicists, ensures comprehensive coverage from a range of views and experiences.
There continues to be considerable interest in the use of decompressive craniectomy following severe traumatic brain injury. The results of trials have confirmed the significant survival advantage; however, evidence that outcome is improved when compared with those patients who survive following medical management is less forthcoming.1,2 This may be for a number of reasons not least of which is the morbidity associated with the initial decompressive craniectomy and the subsequent cranioplasty. If use of the procedure is to continue, ongoing research is required to clarify issues regarding optimal surgical timing and surgical technique, the most appropriate reconstructive materials and minimisation of surgical complications.
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