Your patient is hospitalized and in critical condition, unable to make self-determinations for care, to whom do you turn, whose direction do you follow? This situation is problematic when there is no advanced directive or POLST available and the clinical team concludes a particular intervention or set of interventions would constitute futile care.. What are your options as the treating doctor? In the situation where the treating clinical team is interacting with the named or default patient surrogate, there exists the real possibility that conflict will arise. One source of insight on addressing this conflict comes from the ethicists working with the AMA summarized in the linked article.

The above scenario is a common issue, particularly in the ICU. Medical technology has advanced to the point to where it is virtually possible to keep an individual alive (or at least their organ systems functioning) through mechanical and/or chemical intervention almost indefinitely. At some point depending on the medical team and hospitals willingness to persist,  the recommendation not to pursue futile care is made to the surrogate. If the surrogate disagrees, the options open to the treating team seem to be obtaining additional counsel in the form of a palliative care team or ethics consultation AND/OR transfer the patient to the care of another team who is more aligned with the surrogates.

In the scenario where the treating team has run out of transfer options, the ethics committee agrees and recommends not pursuing futile care, and yet the surrogate persists in their directive. Does the treating team have the option of designating an alternative surrogate more closely aligned with their recommendation. The AMA code of ethics provides some guidance on answering this question.

“Though the surrogate’s decision for the incompetent patient should almost always be accepted by the physician, there are four situations that may require either institutional or judicial review and/or intervention in the decision-making process: (1) there is no available family member willing to be the patient’s surrogate decision-maker; (2) there is a dispute among family members and there is no decision maker designated in an advance directive; (3) a health care provider believes that the family’s decision is clearly not what the patient would have decided if competent; and (4) a health care provider believes that the decision is not a decision that could reasonably be judged to be in the patient’s best interests. When there are disputes among family members or between family and health care providers, the use of ethics committees specifically designed to facilitate sound decision making is recommended before resorting to the courts.”

This code indicates that a) surrogates directions are usually required to be adhered to, and b) can be disputed by the physician and ethics consultation and/or legal intervention to change surrogate IF the treating team believes the surrogate is not acting in the patients best interests. This implies some freedom but also a process if the treating team believes what the surrogate is directing is not in the best interest of the patient or represents substituted judgement. A case example might be a transgender individual whose default surrogate was a parent who had been distanced by the patient. In this case, could the patient’s partner be appointed surrogate by the physician. The answer is maybe. However, this would need to follow a process that might include ethics or palliative care consultation, facilitated ‘family’ meetings, and reference to the court to appoint the surrogate. It is important to be aware that the outcome of this process may led to the outcome desired by the clinical team, or may result in recommendation to adhere to the surrogate’s wishes.

OUCH!!! My Toe is Killing Me

4% of Americans at some point in their lives will be diagnosed with gout (over 8 million people). This prevalence is increasing in developed countries over the last decade, exacerbated by increasing rates of co-morbidities that mediate elevated uric acid levels including obesity, metabolic syndrome, alcohol intake, use of diuretics, diets high in proteins such as meat, chronic kidney disease and hypertension.

Acute gout is characterized by joint swelling and pain. In some individuals, these acute attacks increase in frequency and severity leading to chronic gout. Chronic, intermittent gout, affects quality of life, and metabolic function including cardiac function.

Managing Acute Gout

The American College of Physicians released a new guideline on managing acute, recurrent gout[1] which provides recommendations for both non-pharmacologic and pharmacologic strategies for improved management and avoidance of chronic gout. These guidelines released in January 2017 re-examined evidence relating to specific therapeutic interventions, and concluded four major recommendations for the management of acute gouty attacks.

#1: Acute attacks should be managed by NSAIDS, steroids, or colchicine. One placebo controlled trial demonstrated that NSAIDs were superior in managing pain but provided no additional benefit in reducing swelling. There are no placebo controlled trials of oral steroids but six randomized controlled trials demonstrated similar pain outcomes with NSAIDS. There have been five randomized controlled trials of colchicine that have all demonstrated that it reduces pain in acute gout. Moderate quality evidence suggests that low dose colchicine (1.2mg followed by 0.6 mg after 1 hour) are as effective as higher dose regimens with fewer gastrointestinal side effects.

#2: When using colchicine in managing acute gout, the recommendation is to use the low dose regimen as described above.

#3: Urate lowering therapy should not be used following first episode or in patients who have infrequent episodes (<= 2 per year). For patients with more severe episodes, recurrent attacks (>=2 per year), and tophi, chronic renal disease or uric acid renal stones), shared decision making is warranted. Continuation of colchicine or NSAIDs are useful for up to 8 weeks after the acute flare. There is no compelling evidence that monitoring uric acid levels is useful, although levels of 6.8 mg/dl are often used as a trigger for initiating urate lowering therapy.

#4: Shared decision making between clinician and patient should occur to discuss benefits, harms, costs and preferences before initiating urate lowering therapy including concomitant prophylaxis in patients with recurrent gout.

The 2012 American College of Rheumatology guidelines for prophylaxis support the use of colchicine (low dose) or NSAIDS as first line prophylaxis, with low dose steroids as second line. These guidelines recommend starting prophylaxis prior to or at the time of starting urate lowering therapy.  Prophylaxis should be continued for at least 8 weeks though regimens longer than 12 months have not been studied in randomized trials and there is no evidence of optimal duration of urate lowering therapy. It should be noted that in several studies when prophylaxis was discontinued after 8 weeks, rates of acute flares doubled, and that when continued for at least six months resulted in a significant decline in acute flares.


My Baby is Hot

CASE: You are working after hours and a young mother brings her 12 month old infant with fever 104 C

Should you admit this patient and perform an infectious workup or send the patient home with close surveillance?

In any given year, 15% of visits to the ED or urgent care by children under 15 years of age are children with fever. The vast majority of these children have self-limited viral infections. Yet serious illness is also manifested by fever in children and includes meningitis, sepsis, and pneumonia. With increasing rates of vaccination against hemophilus and pneumococcus, invasive infection and meningitis have been declining. The most common serious infections are pneumonia in the less than three month group of infants and urinary tract infection in infants older than 3 months. Red flags indicating serious illness include any of the following:

  • Change in sensorium
  • Changes in crying/moaning patterns
  • Cyanosis
  • Rapid breathing and shortness of breath
  • Hypotension
  • Signs of meningeal irritation
  • Rashes esp petechial
  • seizures

This past year, the American College of Emergency Physicians[1] have released an updated clinical policy on evaluation of the child under two years with fever. Their recommendations are summarized below:

Infants 1-3 months: consider lumbar puncture (LP) to rule out meningitis in infants 29-90 days and admitted to hospital for observation. Antibiotics are appropriate after LP until cultures are returned as negative

Children 2 months – 2 years: perform a chest radiograph in children with fever of at least 100.4F with no clear infection source but have cough, rales or hypoxia. Do not perform CXR in children with fever and wheezing and high probability of bronchiolitis. Consider performing urinalysis and urine culture especially in high risk children including girls under 1 year, uncircumcised boys, fevers lasting longer than 24 hrs. and no clear infection source. If there is a positive urinalysis (leukocyte esterase or nitrates) start antibiotics without waiting on results of urine culture. AAP recommends collecting urine samples through cauterization or suprapubic aspirate.

If the infant or child presents during the influenza season, consider performing rapid influenza testing.

If serious infection is strongly considered, the following age grouped antibiotics are recommended:

Under 1 month                                                 Ampicillin + gentamicin or cefotaxime

Over 1 month with urinary:                         cefotaxime or cefixime

1-3 months possible meningitis                 ceftriaxone

1-3 months (listeria/enterococcus)          add ampicillin

3 months + pneumonia                                 amoxicillin or azithromycin

[1] Annals of Emergency Medicine, May 2016; 67(5): 625-639