Arrive, Philadelphia

I arrived in Philadelphia with the sun shining and a refreshing feeling of being on the Eastcoast again after last living in New York City more than thirteen years ago. The cab took me past refineries and industrial stuff that give it its industrial reputation. I'm staying at a place named Club Quarters, a corporate housing hotel that gives me about 300 sq. ft. of living. I can stand in my apartment and make my bed, answer the phone, cook, and iron my shirts from the same spot. As one goes further East the smaller the living space becomes.

Dr. Caplan, Director at Penn Center for Biomedical Ethics, is in Japan so I didn't get to meet with him today. Janice Pringle, his assistant, got me settled into my office without at window near some old chairs and a table. But I have a computer so I work on getting some emails out that let other ethicists at Penn know that I'm around. I am anonymous.

The questions I want to answer while I'm here for the next two months include a nursing issue and a case against "evidence-based" medicine. The trend in critical care medicine seems to be practice by "evidence-based" medicine, but Mark Tonelli, at the University of Washington, has written that a more case-based medicine may be more appropriate, much like lawyers use to try cases. I would like to test the waters at the Penn Center for Biomedical Ethics on this subject.

But I also want to discover a way to help prevent nursing burnout on ICUs. Many nurses that I have worked with seem to voice a conflict like this: they have patients that are frequently admitted to the ICU because the patient doesn't take care of himself, nurses are obligated, and in fact want to take care of, patients the best way they know how. But they are also very concerned about the economy and the cost of medicine, as we all are. They have to spend 8-12 hours a day with people that drink too much, do drugs too much or don't go to dialysis like they should if they have kidney failure. It is this kind of patient that stretchs the cost of health care; not the only group that does, but they are patients who slaps the nurses, and doctors like myself, in the face daily. What do we do? We are obligated to care for the senseless and emotionally challenged but should we have to? What is the nursing obligation, or the doctor obligation, to care for these patients in these troubled economic times. Many in America want to cut the cost of medical care but when it comes to the individual desires to get the most out of the system we all would like "as much as it takes to get us through".

There are some principles of ethics that we all follow in America. The first principle is that of autonomy, the idea that we should be able to make decisions for ourselves that allow us to receive the care that it takes to keep us alive and comfortable. But the fourth principle of ethics(be kind and do no harm are in the middle) includes one that is economically fair to the community. How do these reconcile, the first that allows for giving care to whomever wants it for whatever reason (I just missed my dialysis or I do street drugs...) and the fourth that suggests we should have some resposibility to the community for cost savings. The American College of Chest Physicians has said in the past that we are obligated to care for an individual on the ICU with no cost limitations, within reason, since the money saved by "rationing" care or withholding care would not necessarily end up in the pot for other health care issues like vaccinations for children, hospice care, etc. But is this fair? How can we protect nurses who have to care for those that abuse the system so nurses don't burnout or we don't break the community bank. Who could knowingly withhold care from one individual, knowing he or she would die, staring that patient or family in the face, to save money for the greater good? This is what I would like to discuss at Penn.

Another advantage of being on the East Coast is that the news is more in your face. I read the New York Daily News today that reported that Sara Palin took a job with Fox News for a purported three year contract. It also reported that she is more interested in getting wealth from her new found fame more than she is positioning herself for a run for the president in 2012. "She wants to continue making her views heard"...but, "It doesn't have anything to do with a political strategy in the future." She'll report on "Real American Stories", a series looking at inspirational tales set to launch this year." Whew...

The book Game Change seems to be reporting that Bill and Hillary Clinton didn't get along sometimes on the 2008 campaign tial...Really?! And that Bill suggested a few years ago Barack Obama would have been fetching coffee for Ted Kennedy and Bill Clinton and this didn't make him ready for being President. Ouch.