Patient and Family-Centered Care

In addition to excellent imaging and procedural skills, the field of interventional radiology remains committed to the central telos of medicine: healing persons. Often this requires sensitivity to larger, and at times subtle, contexts of patients’ lives. Understanding more of patients’ stories, community and family values, religious views, cultures, and relationships can help interventional radiologists not merely treat their patients but heal them. This page provides tools for exploring a humanistic approach to interventional radiology.

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  • Patient Perspectives

    Prostatic Artery Embolization
    Endovascular Aneurysm Repair (EVAR)
    Liver TACE
    Prostatic Artery Embolization II (Questionnaire)

    Peripheral Vascular Disease

    Liver Cancer
    Prostatic artery embolization
    Pulmonary embolism and deep vein thrombosis

    Arteriovenous malformations

    Uterine artery embolization
  • Medical Values for IR

    What are the most salient medical virtues for interventional radiologists and trainees?

    Informed Consent

    Palliative Care and Ethics
  • Literature and Medicine

    Narrative is a large part of how humans think – try looking at a picture and describing it to someone without the use of narrative. In medicine, diseases are often approached as stories with beginnings (etiology), bodies (pathophysiology, complications), and ends (prognosis). Illnesses can interrupt and break a person’s understanding of how his/her story was supposed to go, giving physicians the opportunity to become co-narrators with their patients and help them write the next chapters of their stories. Reading and thinking about literature can help physicians and trainees appreciate a narrative approach to medicine as well as gaining insight into experiences they may not have encountered first-hand.

    Jean-Dominique Bauby’s The Diving Bell and the Butterfly:

    Jean-Dominique Bauby was a successful editor of the French fashion magazine ELLE. In the mid-1990s he suffered a sudden, massive stroke. He awoke nearly a month later with only the ability to blink his left eye. Despite this, he was able to write the book The Diving Bell and the Butterfly, blinking each time the letter he wanted was read. Unfortunately, Mr. Bauby died two days after his book was published.

    This book provides a window into Mr. Bauby’s experience being locked-in, the terror of an ophthalmologist sewing his right eye shut with no explanation or ability to defend himself, the pain of seeing his wife and children and not being able touch them, the frustration of not being able to interact with many of those around him. However, he is also optimistic and even humorous at times, making light of other patients’ and old acquaintances’ reactions to him. This is a wonderful book for anyone taking care of patients with limited abilities to communicate.

    Leo Tolstoy’s The Death of Ivan Ilych:

    This short book tells of the life of an accomplished man in the field of jurisprudence. The story begins immediately after his death, describing his colleagues’ and wife’s reactions. They are all preoccupied with how his death affects them. We are then told of Ivan’s life, his thrust for power and his relentlessness as he climbed the social latter. He then becomes very ill and yearns for pity, finding it only in a young servant boy who cares for him. In his final moments he begins to think of his family and that he may not have lived life as he should have. He ultimately concludes there is no death.

    This book seems to show how little we think about death until we are confronted with someone else’s or our own mortality. In life, Ivan sought and obtained many material measures of success; yet in death, he seeks what he neglected: human connections and compassion. This is also an important reminder that what someone values at one point in life (and may put on an advance directive) can sharply conflict with what he/she desires later.

    Paul Kalanithi’s When Breath Becomes Air:

    This beautiful piece of prose is an autobiography of a talented young neurosurgery resident faced with terminal cancer. Dr. Kalanithi originally pursued a graduate degree in English after being captivated with literature from a young age. He uses his appreciation and talent for written language to so clearly articulate the complex experience of facing one’s own mortality.

    Leon Kass’ Being Human:

    This is a thoughtful collection of excerpts from literature throughout the world and centuries that explores complex questions such as what is mean to heal, the quest for perfection/immortality, the significance of a body, and what it means to live well. Although there are not simple answers to the questions posed, they are surely worth exploring for anyone in the business of caring for human beings.

  • Religion and Medicine

    Religious /spiritual beliefs are significant aspects of the lives on many people, and many patients want physicians to pay attention to their religious beliefs and practices. Often such beliefs are not discussed unless they conflict with the medical team’s plan, but it can be helpful to discuss such beliefs early in a clinical relationship such as incorporating it into the social history of an H&P.

    Dr. Puchalski’s FICA Tool:

    Faith - Start with broad, open-ended questions. Understand that spirituality is broader for many than religion. “What gives you strength?” “What values are important to you?”

    Importance/Influence - Attempt to under what role the values/beliefs play in the person’s life. Do they impact views of treatments, illness, self, etc?

    Community - Is there a religious community that give the person support? Do certain beliefs or religious leaders hold authority over specific practices?

    Address - “Is there anything we can do in your care to respect your values/beliefs?” “Is there anything else you would like me to know?”

  • Ethical/Legal Cases

    Casuistry is a popular ethical theory used heavily in the field of law. In general, landmark cases are applied to the current situation/question at hand to argue that it is similar to or distinct from landmark cases and should be approached similarly or differently, respectively. Below are some ethical/legal cases that seem relevant for those interested in interventional radiology.

    Johnson v. Kokemoor, 1996

    Ms. Johnson was found to have a large posterior circulation aneurysm. Dr. Kokemoor recommended clipping the aneurysm and told Ms. Johnson he had performed many such surgeries, comparing the risks to those of routine operations (~2%). Unfortunately, this operation left Ms. Johnson with quadrapeligia and eye and speech impairment. Since resideny, Dr. Kokemoor had only operated on basilar bifurcations anqurysms twice and never on one as large as Ms. Johnson’s. According to expert witnesses, this operation would have carried a 7-10% risk in the hands of the most experienced surgeons and closer to a 20-30% risk with Dr. Kokemoor’s experience.

    The courts found Dr. Kokemoor guilty based on previous definitions of negligence being present when a reasonable person would have chosen a different action if the withheld information was presented. In other words, the courts felt that Dr. Kokemoor’s inexperience was material information that would have caused a reasonable person to avoid the surgery and resulting damages. This is significant as it is one of the first times characteristics specific to an individual physician has been considered material information for informed consent.

    In re Cook, 2014 & In re Bard, 2015

    Both Cook and Bard have been named in a growing number of class actions over the last few years regarding their IVC filters. Due to this growing number of cases, concerning similar questions of facts the U.S. Judicial Panel on Multidistrict Litigation decided to centralize these lawsuits into two multidistrict litigations (MDLs): 27 suits concerning Cook filters were centralized to the Southern District of Indiana in October 2014 and 15 actions plus 5 potential tag-alongs concerning Bard filters were centralized to the District of Arizona in August 2015.

    The primary legal question concerns whether or not Cook’s and Bard’s filters possess design and/or manufacturing defects making them unreasonably prone to complications. In defense, these companies argue that the FDA’s prior approval of their filters should protect them from such litigation and their filters expose patients to comparable risks to other filters. The first Cook MDL trials should begin in mid to late 2016.

    For more information check out this article.

    In re Quinlan, 1976

    At the age of 21, Karen Quinlan stopped breathing for two 15 min periods after mixing sedatives with alcohol while on a crash diet. She was taken to a nearby hospital and placed on a ventilator by Dr. McGee. She was seen 3 days later by Dr. Moore who found her to be in a persistent vegetative state. She had sleep-wake cycles, made noises, maintained blood pressure, et cetera, but she had no cognitive function and was predicted not to recover. Her father wanted to take her off the ventilator but Dr. Moore and the hospital refused because she was not brain dead.

    The courts ruled in favor of Mr. Quinlan. Patients have a right to refuse life saving interventions and this right can be exercised by a surrogate decision maker. The state’s interest in preserving life declines and patient’s right to privacy increases as the prognosis worsens and invasiveness of the required intervention increases. The ventilation was not curative but instead sustaining and prolonging her eventual decline. Removing Karen’s ventilator was not causing her death but instead allowing her to succumb to her underlying condition.

    McFall v. Shimp, 1978

    Mr. McFall was a middle aged man who developed aplastic anemia and needed a bone marrow transplant to live. His cousin, Mr. Shimp, was the only available donor and he refused to donate his marrow to his cousin.

    The court ruled in favor of Shimp, citing that individuals are generally not required to save others outside of very specific relationships. To intrude upon Shimp’s bodily integrity would undermine our basic freedom. Even with such a relationship, the courts noted that forcing the risks of bone marrow donation on Shimp would likely not be required.

    Vacco v. Quill, 1997

    In 1991, a palliative care physician named Timothy Quill published a New England Journal of Medicine article describing how he assisted in the suicide of a terminally ill patient with leukemia. A number of physicians filed suits challenging New York’s law against physician-assisted suicide (PAS), claiming it violated the Equal Protection Clause of the Fourteenth Amendment.

    An appellate court found the New York law to violate the constitution but this was overturned by the U.S. Supreme Court. They held that PAS is distinct from terminal sedation and withholding treatment, emphasizing the line between commission and omission. Dr. Quill has continued to argue against the principle of double effect in bioethics (derived from the work of Thomas Aquinas), which is used to differentiate terminal sedation from PAS. In short, a morally bad act (e.g. killing) cannot be a means to a good end (relief from pain/suffering) or the end itself. However, if the nature of the act is good and intends to have a good effect (sedation and pain relief), a bad effect may still result (e.g. death) without the act being considered morally wrong. In other words, deliberate administration of potentially unsafe doses of a sedative is justified if the intended end is pain relief, even if there is a possibility of causing death. Other scholars and communities have disagreed, and so PAS is legal in a number of countries and some U.S. states.