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The following format is advised for the systemaric analysis of rhe cases presenred. This outline can be used whether an individuar case is used ou., on" o. aora sessions. This outline is from taken JC F'ercher, cA Hire, pA r-ombardo, MF Marshail (eds.). Introduction ro Crinicar University Ethtcs, Publishing Group Inc., Frederick, Md. 1995. I. Assessment exist? what is the patient's medical condition and prognosis? what reatmenr oprions 2. Who is rhe appropriate decision maker? 3. What are the parient's preferences? 4. What are the preferences ofher farnily or surrogate decision makers? 5' Are there inreres* .ther than, and porentia,y conflicting with, those ofthe parient which need to be considered? 6. Are rhere insdrurionar, regar or other factors whrch need to be considercd? Identification of rhe Erhicat problem(s) 7. What are the erhical problems in the case? (If appropriate, rank by magnitude.) 8. What ethical considerations are most relevant? 9. fue there analogous cases? 10. What are the rclevant guidelines for clinicians regarding the problem(s)? III. Decision Making and Implementation I I . What arc the ethically acceptable opdons? 12' what justifications can be given for the ethicaly prcfcred rcsorution of the case? r 3' How is a satisfactory rcsolution to the case to be accomprished? Is erhics consultationecessary or desirable? h judicial rcview necessary or desirable?
III. Case Commenb (by Glenn A. Mackin, MD) A. Assessment l. Wat is the patient 's med.ical condition and prognosis?. What treatment options exisl? The patient has a complicated "failed back syndrome" afier 2 lumbar operarions, manifested by severe persistenr lumbar pain and "neuropathic" symptoms in a left S I radicular distribution that evolved into a chronic regional pain syndrome (or CRPS-tr) involving the disral left leg. This condition has been unresponsive to a variery of analgesics, therapy and pain clinic interventions, including sympathetic and regional blocks. He has risk facrors for chronic back pain, including his former occupation as a long-distance truck driver, obesity, and cigarette smoking. He has gained significant panial relief over the past l8 monahs from hydromorphone, a Schedule II "strong" opioid for chronic nonmalignant pain (CNp). Although rhe parient must be considered "physiologically dependent" on opioids, at risk for withdrawal symproms if they are abruprly discontinued, they have evidently rcduced h.is pain and improved his function to enable him to retum to work pan+ime. Aspirin and nonstero.ida.l anti-inflammarory drugs (NSAID) cannot be used because of past gastritis. Given his past hisrory of alcohol abuse and rhe belligerent behavior "psychologic he exhibired in the ER, the possibility of dependence" (addiction) and potential for diversion to nonprescribed uses musr be seriously considered by any physician providing opioid scripts (thus the LR physician,s suggestion thar his name be entered into a local darabase for monitoring purposes, critiqued below). However, there is no evidence of other drug abuse, self-medication umelated to s"u"." pain, hoarding drugs or obtaining opioids from multiple physicians, or ongoing alcohol abuse. His disruprive behavior in rhe ER is best viewed, "pseudoaddictive" as discussed several paragrafhs below, as behavior superfic.ia.lly mimicking--bur not the same as-behaviors of a psychologically dependent addict, reflecting his physical dependence and experience with past muldple failed ana.lgesic auempts. several definitions may be useful. Neuropathic pain should be distinguished from nociceptive pain, which rcfers to pain especially musculoskeletal attriburable to ongoing stimulation of pain-sensitive nerves by inflammadon, compression, and other mechanisms. Trcatment of nociceptive pain rclies upon salicylates and NSAIDs as mainstays. By contrast, neuropathic pain is nerve-based (e.g., diabetic neuropathy, postherpetic neuralgia), "sustaining wherc the mechanism for the pain is infened to involve aberrant somatosensory processing in the peripheral or central nervous system"(l). Trcatment of neuropathic pain commonly involves "adjuvant analgesics,, which arc non_ opioid medications whose principle indications are not pain rclief per se, and whose analgesic range often uses a relatively low dose range. Common examples include tricyclic antidepressants (TCA) including amitriptyline and nonriptyline; seroronin rcuptake inhibiton (SRI) including fluoxetine and paroxetine; some antiepileptic drugs (AED) including carbamazepine, phcnytoin, valproic acid and gabapentin; anriarrhyrhmicsuch as lidocaine and mexilirene; anrispasticiry agents such as baclofen; and sometimes major tranquilizers such as pimozide. True analgesics
Page 1 and 2: AMERJC,{N ACADEMY OF NETJROLOGY ETI
Page 3 and 4: TABLE OF CONTENTS l. Introduction 2
Page 5 and 6: Followrng each case is a proposed o
Page 7 and 8: CODE OF PROFESSIONAL CONDUCT PREFAC
Page 9 and 10: arrange transfer ofthe patient's ca
Page 11 and 12: items as long as this practice prov
Page 13 and 14: 2 AmericanAssociationofNeurological
Page 15 and 16: II. Case Ms. JA is a 24 year old wo
Page 17 and 18: III. Case Comments (bv Roben F. Nel
Page 19 and 20: 8. What ethical considerations are
Page 21 and 22: HUNTINGTON'S DISEASE - PRESYMPTOMAT
Page 23 and 24: PROPOSED OUTLINE FOR ETHICAL ANALYS
Page 25 and 26: 6. Are there institutional, legal,
Page 27 and 28: AMENCAN ACADEMYOF NEUROLOGY Page I
Page 29 and 30: CARE OFAN HIV.INFECTED PATIENT IN A
Page 31 and 32: The following format is advised for
Page 33 and 34: B. Idenrification ofthe Ethical Pro
Page 35 and 36: 9. t0. Are there analogous cases? W
Page 37 and 38: Ethical Role of Ncurologisrs io AID
Page 39 and 40: OPIOID TREATMENT OF CHRONIC NONMALI
Page 41: and mexilitene. Finally, Mr. Jones
Page 45 and 46: Ponenoy has extensively reviewed ex
Page 47 and 48: defined "rescue" doses or hospitali
Page 49 and 50: 8. What ethical considerations are
Page 51 and 52: 16. Rodwin MA. Srrains in rhe fiduc
Page 53 and 54: II. Case A 25 year-old woman sustai
Page 55 and 56: III. Case Comments (by Michael P. M
Page 57 and 58: some guidance, if they are consiste
Page 59 and 60: On the basis of this analytic appro
Page 61 and 62: 80 years ago by Justice Benjamin Ca
Page 63 and 64: Although physicianshould always act
Page 65 and 66: t(, ;-)- AMERICAN ACADEMY OF NEUROL
Page 67 and 68: @ Persistent VeSetativeSlate Paticn
Page 69 and 70: 1r= ) AMERICAN ACADEMY OF NEUROLOCY
Page 71 and 72: PRSISTE\TT }TGETATTVE STAIE ard chi
Page 73 and 74: PRSISTE{T VEGETATryE STATE PAGE 5 T
Page 75 and 76: PNSISTEYT ITGETATTVE STATE PAGE 7 5
Page 77 and 78: PNSISTF{T VEGETATTVE STATE PAGE 9 O
Page 79 and 80: II. Case Because of progressive dys
Page 81 and 82: III. Case Comments (by James Bernat
Page 83 and 84: mother's wishes, some of her guilt
Page 85 and 86: Special Article n"r.oro*r*,ffi* Eth
Page 87 and 88: injur5r from improper application o
Page 89 and 90: ,R,, '.=--' AMERICAN ACADEMY OF NEU
Page 91 and 92: DIAGNOSIS AND EVALUAIION OF D&TBI"I
Page 93 and 94:
DLTGNOSIS AND EVALUAIION OF DE\,I6|
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II. Case The patient (Mrs. M) was a
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III. Case Comments (by Alison Wichm
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usually be identified as her surrog
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with the surrogate and other family
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RAIN DEATH IN ADULTS PAGE 2 3. with
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BRAIN DEATH IN ADIJLTS PAGE 4 E. So
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PHYSICIAN-ASSISTED DYING I. Learnin
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The neurologist writes the prescrip
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Continuation Version Two when the g
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Continuation Version Four The pills
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III. Case Comments (by David Goldbl
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might have benefitted from professi
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from engaging in any acr thar direc
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II. Case @ Neurologi consultation w
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III. Case Comments (by Russell D. S
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C. Dcci.sion Mnkinp and Intplernent
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UNCOOPERATIVE PARENTS @ I. Learning
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The following format is advised for
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even though rhese needs appear to t
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CLINICAL TRIALS I. Learning Objecti
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III, Case Comments (by David Goldbl
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@ ro identify a her to enroll in th
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II. Case A 46-year-old white ntale
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III. Case Comments (by Russell Snyd
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4. The medical community needs to c
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GIFTS FROM INDUSTRY t. Learning Obj
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II. Case Dr. Daniel Barker was rece
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@ B. Identifcation of the Ethical P
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@ specialty medical associations. U
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PROFESSIONAL MISCONDUCT OF A SEXUAL
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The following format is advised for
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one class of nonsexual touching is
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