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Just over a decade ago, http://sunvalleyonline.com/where-can-you-buy-kamagra-over-the-counter/ researchers online pharmacy kamagra announced a first. They had cured a patient of HIV. Known as the Berlin patient, Timothy Ray Brown online pharmacy kamagra had needed a bone marrow transplant to treat his acute myeloid leukemia. Doctors used the opportunity to replace his bone marrow using stem cells from a donor with gene-based HIV immunity.

It worked. Brown’s leukemia was online pharmacy kamagra cured, as was his HIV. More recently, in 2019, a second patient, this time being treated for Hodgkin’s lymphoma, was similarly cured in London. But although these are the most famous stories where patients have been cured from HIV, their treatments represent just one option of many new approaches for tackling the kamagra — and one of the least widely applicable.

It’s too invasive and online pharmacy kamagra too risky to conduct a bone marrow transplant on someone who doesn’t already have cancer that requires the procedure — especially considering most patients with an HIV diagnosis and access to care can effectively control the disease with drugs. In fact, a patient on antiretroviral therapy, or ART, today has the same life expectancy as a person without HIV. Other new approaches show promise for more effectively online pharmacy kamagra treating, and yes, someday curing, HIV. This is especially important since not every patient responds well to ART — including those who suffer brutal side effects like bone loss and weight loss, as well as liver, kidney or heart problems.

€œ[With ART], you’re putting an incredible amount ofresponsibility on the patient to ask them to take these drugs every day for the rest of their lives,” says Ryan McNamara, a virologist at the University of North Carolina at Chapel Hill. The Challenge of HIVThe reason why HIV is so hard to cure in the first place online pharmacy kamagra has to do with the way the kamagra can hide in the body. When the kamagra attacks, it incorporates itself into the DNA of the cell — its genome. From there, it hijacks the cell’s internal workings to replicate itself, making more HIV virions which will go on to attack more cells.

This is where antiretroviral online pharmacy kamagra drugs can step in, blocking certain parts of this process. But sometimes HIV attacks, incorporates itself into the genome, and just … waits. There, latent, it’s safe from the immune system — and from antiretroviral drugs. Recent research suggests this is an adaptation the kamagra has for online pharmacy kamagra thwarting detection.

€œIt goes into hiding, and no amount of drugs we currently use are going to find it,” McNamara says.One new strategy to get around this involves shocking the latent kamagraes out of hiding. In 2020, online pharmacy kamagra researchers effectively achieved latency reversal in both mice and rhesus macaques in the lab. By treating the animals with a small molecule called AZD5582, they could trigger cellular pathways that activate the kamagra, making it visible to antiretrovirals. There are at least three clinical trials now underway to test the effectiveness of latency reversal agents in humans.This is a more elegant approach than the bone marrow transplant that cured the Berlin and London patients, which McNamara likens to the scene in Jurassic Park where the team hopes rebooting the system will solve their problems.

And although a online pharmacy kamagra transplant with HIV-immune cells could, in theory, clear out and rebuild the entire immune system, it still wouldn’t help against any HIV hiding out in what are called immune-privileged sites. €œWhen you’re nuking the immune system, you’re not hitting that latent reservoir,” McNamara says. €œThen you have a real problem on your hands. As soon as the immune system is replenished, the kamagra can wake up and things can go south very quickly.”Another approach — which is perhaps theoretically, but not yet online pharmacy kamagra practically, possible — is to use CRISPR gene editing tools to edit HIV genes out of the genome.

So far studies have only been conducted in mice, but if gene edits that happen in undesired locations (known as off-target effects) could be kept at a safe minimum, the technique could one day be used in humans.Antibodies to the RescuePerhaps the most promising avenue of all in HIV research, McNamara says, is that of broadly neutralizing antibodies. These naturally occur in the immune systems of asmall fraction of HIV online pharmacy kamagra patients whose never progresses to AIDS. Researchers are studying how to harness them to treat other patients. HIV is mutation-prone, which allows it to thwart the immune system — and retroviral drugs — that are made to target specific versions of the kamagra.

For most patients with HIV, this online pharmacy kamagra means their immune system is always in hyperdrive, struggling to ward off a moving target. €œIt’s a nonstop war between the kamagra and the immune system,” McNamara says.But some patients have a special type of antibody that is continually effective. €œWhen it comes to broadly neutralizing antibodies, the kamagra is never able to win,” McNamara says. €œThe antibodies have it check-mated.” Though online pharmacy kamagra latent reservoirs are still an obstacle to them, broadly neutralizing antibodies show a lot of promise when it comes to keeping the kamagra at bay — in particular, ensuring that the never progresses to AIDS and that its transmission risk is low.

Some researchers are examining how they can be used both to treat and prevent HIV, while others are looking at how a combination of neutralizing and non-neutralizing antibodies may even have some effectiveness against latent cells.A Jab for HIV?. €œA lot of people ask me. When are we going to get an online pharmacy kamagra HIV treatment?. And I tell them well we already have them, they’re just not that great,” McNamara explains.

€œI think that we’ve been spoiled rotten with these erectile dysfunction treatments that are 90 to 95 percent effective … they almost raise the bar on immunology as a whole.” Researchers online pharmacy kamagra have been searching for an HIV treatment for decades. The main barrier has been finding one with a high enough effectiveness rate for pharmaceutical companies to want to invest, and the FDA to approve. Right now, a lot of treatment trials turn up with something like 40 percent effectiveness, McNamara says. That just doesn’t cut online pharmacy kamagra it.In addition to antibody therapies, McNamara says he’s most excited about the way the field is progressing now that stigmatization of HIV has gone down.

€œIt seems like trust has been built up between the HIV-AIDS community and the medical community. And this took a long time,” McNamara says. €œIn the early days of the HIV online pharmacy kamagra epidemic in the early 1980s, it was ugly. It was really ugly.

And it took a lot of effort by a lot of people — including Anthony Fauci — to rectify a lot of those wrongs.” He says that new sense of communication and trust is something he looks forward to. €œIf you don’t online pharmacy kamagra have trust, then you can’t do clinical trials. You can’t implement any new drug regimens.”As for how close we are to a cure for HIV?. “If you were to have asked online pharmacy kamagra me that 10 years ago, I might have said never,” says McNamara.

€œBut I’ve changed my view in the last 10 years. I do actually think we’ll see a cure within my lifetime.” How broadly and quickly we can deploy that cure is another question — having a cure, or having a treatment, is different from implementing it worldwide. Edward Jenner discovered the smallpox treatment in 1796, the last smallpox outbreak in the U.S online pharmacy kamagra. Was in 1949, and the disease was declared globally eradicated in 1980.

Jonas Salk developed the polio treatment in 1952, there have been no cases in the U.S. Since 1979, but the disease is not quite online pharmacy kamagra eradicated globally. How fast will HIV disappear once we have a treatment?. €œI don’t online pharmacy kamagra think we’ll eradicate HIV in my lifetime,” says McNamara.

€œBut I would imagine that even by the end of the decade we might have reproducible results where we cure some patients. Doing it on a consistent basis?. Probably another online pharmacy kamagra 10 years. I think the technology is there.”When word came from the Centers for Disease Control and Prevention that fully vaccinated Americans can at last safely go without masks in most places, I felt like one of those holdout Japanese soldiers who spent years hiding in the caves of Guam.

I was blinking in the sunlight, unable to believe that World War II had really ended.“We feel naked,” first lady Jill Biden said after she arrived in West Virginia to promote erectile dysfunction treatment distribution, taking off a mask matching her pink-and-white spring ensemble.I know what she meant.advertisement For more than a year now, we’ve had masks on our faces — or at the ready on our front-hall tables, in our glove compartments, or buttoned to our shirtfronts. I’ve grown online pharmacy kamagra as attached to mine as Linus van Pelt was to his blanket, and the thought of abandoning it is liberating but also unsettling. After all, that modest membrane might just have saved my life.But in recent weeks, the science on masking has become clearer. Real-world studies have shown that fully vaccinated people have next to no chance of contracting the kamagra, even when they’re around unvaccinated people, and — just as importantly — equally little chance of being asymptomatic carriers who can pass it to others unwittingly.advertisement That science, though, is now running up against what have become cultural norms in so many places.

We’ve grown accustomed to our faces missing the bottom two-thirds — indoors and out — and to looking online pharmacy kamagra askance at others whose chins are bare. Suddenly the proper line between safe and unsafe will no longer be as plain as the noses on our faces, and the onus for separating the compliant from the resistant will fall squarely — and surely sometimes angrily — on a range of businesses, institutions, and other private entities, instead of being self-evident.Already, authorities in mostly blue states and localities — like my own in Los Angeles — have announced that they will take their time and review the new CDC guidelines before revising their own mask regulations.That’s fine with me. When we moved online pharmacy kamagra to Southern California from Washington seven years ago — to a neighborhood adjoining L.A.’s thriving Koreatown — I was taken aback, even a bit annoyed, by the number of people walking their dogs in surgical masks. €œWhat on earth are they guarding against?.

€ I thought to myself. Now I know online pharmacy kamagra. This winter’s unusually low number of routine flu cases seems proof enough of the effectiveness of masks in curbing the spread of airborne kamagraes of all kinds.Don’t misunderstand. I don’t love wearing a mask.

I need bifocals, and no matter what I’ve tried — surgical tape, pinching the metal nose-piece, even wearing the mask upside down — even the most form-fitting mask fogs my eyeglasses online pharmacy kamagra. They all play havoc with my facial recognition software. I can’t count the number of times I failed to recognize friends and neighbors by the whites of their eyes alone. I do know many online pharmacy kamagra of those times were in the grocery store, my only regular haunt outside my own home all these past months.

No matter the CDC guidance, I know there’s no way I intend to show disrespect for Judy and Lily, my trusted Gelson’s checkers and their brave colleagues in the United Food and Commercial Workers union. For the time being, I’ll keep a supply of clean masks handy in my car, right along with the reusable grocery bags and my customer rewards number.In this milestone moment, it’s far from clear whether our erectile dysfunction treatment-era masks will become faded relics like the yellowing World War II ration books from my parents’ childhood, or the fallout online pharmacy kamagra shelter instructions from mine. Will they be souvenirs of a forgotten battle won, or seasonal necessities to be hauled out each winter flu season, along with sweaters, galoshes, and gloves?. Too soon to say.For now, perhaps, it’s enough just to be grateful for the privilege that the blinding achievements of science and the bittersweet sacrifices of millions have won us.

As President Biden put online pharmacy kamagra it, “If you’re fully vaccinated and can take your mask off, you’ve earned the right to do something that Americans are known for all around the world. Greet others with a smile.”Eight members of the New York Yankees organization who were fully vaccinated against erectile dysfunction treatment tested positive for the erectile dysfunction this week. And that news has led to a lot of people saying, wait, what?. Below, STAT outlines what we know about the cases and some online pharmacy kamagra of the factors that might have contributed to the cluster.What do we know so far?.

advertisement On Sunday, third base coach Phil Nevin reported feeling some symptoms and tested positive for erectile dysfunction treatment. (He had recovered as of Thursday, General Manager Brian Cashman said.)The team quarantined people who’d had close contact with Nevin and expanded its testing program, which turned up another seven asymptomatic cases by Thursday, when shortstop Gleyber Torres became the eighth person — and first player (the other seven were coaches and support staff) — to test positive.advertisement All eight people had received the Johnson &. Johnson erectile dysfunction treatment and were considered fully vaccinated.What does this mean about online pharmacy kamagra breakthrough s and treatments?. The erectile dysfunction treatments have been shown to be overall highly effective at preventing illness, and even more so at staving off the worst outcomes, like serious disease and death.

But even the best treatments can’t block all s, and those that still occur after immunization are online pharmacy kamagra called breakthroughs. The clinical trials that led to the authorization of the different erectile dysfunction treatments generally measured how effective they were at preventing symptomatic cases, and in its trial, the one-dose J&J shot proved to be 66% efficacious at blocking moderate and severe erectile dysfunction treatment. And while studies have shown the treatments also prevent asymptomatic s in many cases, researchers don’t have firm conclusions at just how effectively they do so. The assumption is that online pharmacy kamagra many asymptomatic cases go unreported in the absence of broad and frequent testing.Which brings us to the Yankees.

Eight breakthrough s seem like a lot, and something odd could be at play here. But it’s notable that only Nevin had some symptoms. It’s possible that at least some, if not all, of the other seven other s would have been missed if they didn’t occur on a team online pharmacy kamagra that’s undergoing regular testing. And while it can’t be known for sure, it’s possible that without treatments, this cluster could have been worse, both in terms of the number of s and how sick certain people got.

The Yankees travel with some 50 people.Overall, the Centers for Disease Control and Prevention has received reports of 9,245 breakthrough cases, a tiny online pharmacy kamagra fraction of which resulted in hospitalization or death. More than 118 million people in the United States have been fully vaccinated. The low number of breakthrough s has been touted as a testament to the power of treatments, which are providing both protection for individuals and helping drive down transmission.But experts also point out two caveats with the number of breakthrough s. For one, some large number of the people who’ve been online pharmacy kamagra fully vaccinated haven’t since been exposed to the erectile dysfunction, so it’s not known how many s there would have been without that treatment coverage.

The tally of breakthroughs is also certainly an undercount because many asymptomatic cases go undetected — unless, of course, they occur in a setting with widespread and frequent testing, like on a professional sports team. Two extra points. Starting Friday, the CDC will only report breakthrough s that lead to hospitalization or death online pharmacy kamagra because those have the “greatest clinical and public health importance.” The Yankees cases, of course, didn’t rise to that level.And Torres, the shortstop, had erectile dysfunction treatment last year, indicating that his case is both a breakthrough and a re. Scientists think res remain rare, though given that second s are generally thought to be mild or asymptomatic (akin to breakthrough s), experts similarly don’t have great estimates for how often they occur.

But considering Torres was asymptomatic, his case fit with what experts expect from most res. How did this online pharmacy kamagra happen?. The team has said it’s conducting contact tracing, and officials from both the New York state health department and CDC are in touch with the team. So far, it’s not clear how this transmission occurred.Two of the most pressing questions we can think of:Where did the spread initiate? online pharmacy kamagra.

Essentially, was this a superspreading event during which someone — likely an unvaccinated person — passed the kamagra to the eight people?. That is one probable explanation. The erectile dysfunction erectile dysfunction is particularly adept at transmitting in crowded, indoor settings, so perhaps someone who was online pharmacy kamagra shedding lots of kamagra came into contact with the team, and that’s how this outbreak occurred. The Yankees have surpassed the threshold of 85% players and personnel vaccinated that allowed them under league and union rules to relax some distancing and masking requirements.It’s also possible that some of the transmission occurred among the eight people who’ve tested positive, though that would seem to be a rarer event.

Even if a vaccinated person contracts the erectile dysfunction, it seems they’re generally less infectious to others than an unvaccinated person with erectile dysfunction treatment — especially if they’re asymptomatic. That might be online pharmacy kamagra because the treatment reduces the amount of kamagra these people can shed, and also shrinks the window during which they’re contagious. Was there a variant involved?. Certain erectile dysfunction variants — most notably B.1.351, which first emerged in South Africa but has circulated at low levels in the United States — cause breakthrough s at higher rates than other forms of the pathogen.

The treatments online pharmacy kamagra still prevent many cases, and retain their overall protection against severe illness and death. But the shots do seem to lose some of their potency in staving off mild or asymptomatic s, and may not be as powerful at preventing people who have breakthrough s from passing on the kamagra.Major League Baseball is working with a Salt Lake City lab for its testing and sequencing efforts, so we could eventually get more information about this question. The sequencing data could also provide insights into whether the eight people were infected during the same event or independently online pharmacy kamagra of each other. Does this mean the CDC was shortsighted in its recommendation Thursday that fully vaccinated people don’t have to wear masks in most settings?.

Depending on the type of mask, face coverings have generally been more about protecting others than yourselves, meaning they’re more of a tool to stop you from spewing kamagra out into the world than blocking kamagra headed your way.There was also some nuance in the CDC’s updated recommendations. The data indicate online pharmacy kamagra that the chances of an asymptomatically infected person who’s been vaccinated spreading the kamagra are extremely low. But CDC Director Rochelle Walensky noted Thursday that if someone starts feeling sick, they should start wearing a mask again and get tested.Still, critics of the CDC decision could point to the Yankees cluster as a sign that prudence is merited. While many experts celebrated the CDC announcement, others argued that the agency was premature or that it should have tied the guidance to hitting thresholds like a further reduction in new cases per capita or reaching a certain level of vaccination coverage.

(Given the variability of and vaccination rates around the country, some places have achieved these milestones.) The concern is that with transmission still at the rate it is, and with vaccination online pharmacy kamagra rates as low as they still are, people who are unvaccinated or who haven’t mounted a strong immune response to treatments (like some people with cancer are experiencing) will be more vulnerable to contracting the erectile dysfunction than if the CDC had just waited a few more weeks. Was this a fluke?. Not every member of the Yankees organization who tested positive this week was vaccinated at the same time, so the outbreak can’t be attributed to one bad batch of treatment or an error in keeping the shots at online pharmacy kamagra the proper temperature. Still, in a kamagra in which hundreds of millions of people have been infected and amid a global treatment campaign, there are going to be some weird outlier situations.

Simply put, perhaps something bizarre happened with the Yankees.It underscores how important it is to avoid drawing conclusions from one case involving fewer than a dozen people. The clinical trials that established the treatments’ efficacy involved tens of thousands of people, and real-world data that have backed up what the online pharmacy kamagra clinical trials concluded. The treatments are immensely powerful against erectile dysfunction treatment.ired someone new and exciting?. Promoted a rising star?.

Finally solved that online pharmacy kamagra hard-to-fill spot?. Share the news with us, and we’ll share it with others. That’s right. Send us your changes, online pharmacy kamagra and we’ll find a home for them.

Don’t be shy. Everyone wants to know who is coming and going.And here is our regular online pharmacy kamagra feature in which we highlight a different person each week. This time around, we note that Capsida Biotherapeutics hired Swati Tole as chief medical officer. Previously, she worked at the Genentech unit at Roche (RHHBY), as vice president of clinical development.

Unlock this article by subscribing to STAT+ and enjoy online pharmacy kamagra your first 30 days free!. GET STARTED Log In | Learn More What is it?. STAT+ is STAT's premium subscription service for in-depth biotech, pharma, policy, and life science coverage and analysis. Our award-winning team covers news on Wall Street, policy developments in Washington, early science breakthroughs and clinical trial results, and health care disruption in Silicon Valley and beyond.

What's included?. Daily reporting and analysis The most comprehensive industry coverage from a powerhouse team of reporters Subscriber-only newsletters Daily newsletters to brief you on the most important industry news of the day STAT+ Conversations Weekly opportunities to engage with our reporters and leading industry experts in live video conversations Exclusive industry events Premium access to subscriber-only networking events around the country The best reporters in the industry The most trusted and well-connected newsroom in the health care industry And much more Exclusive interviews with industry leaders, profiles, and premium tools, like our CRISPR Trackr..

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About Insight Insight provides an in-depth look at health care buy cheap kamagra online issues in and affecting kamagra or viagra California.Have a story suggestion?. Let us know. Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when she kamagra or viagra was growing up.As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland.

She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.“All of those experiences actually made me really dislike physicians,” Asmerom said. €œParticularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”But that changed when kamagra or viagra she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too.

Asmerom came to believe that as a doctor she could help turn things around.Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s kamagra or viagra roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests.

But now, as with countless kamagra or viagra other U.S. Institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action. Don't Miss A Story Subscribe to kamagra or viagra California Healthline’s free Weekly Edition newsletter.

Debunking Race as a Diagnostic ToolFor many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more kamagra or viagra differences among people within each race.

Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.Dr. Brooke Cunningham, a physician and kamagra or viagra sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said.

Some physicians claim it is useful to kamagra or viagra take race into account when treating patients. Others argue it leads to bias and poor care.Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate).

The eGFR can limit Black patients’ access to care because the number used to denote Black kamagra or viagra race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.“It kamagra or viagra was very personal,” Nkinsi said.

€œThat’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”Nkinsi kamagra or viagra helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.Acknowledging Racism’s Adverse Effects on HealthThe Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S.

And Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities.

But little data exists on how many schools teach students how to recognize and fight racism, he said.An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.Recognizing Racism in Medical Education’s Past and PresentActivists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements.

Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. €œIt’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?.

€ she said.While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. €œThere needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.“But I’m not going to hold my breath until I see actual changes,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Related Topics California Public Health Race and Health Disparities Medical EducationAttorneys for GOP-controlled states seeking to kill the Affordable Care Act told the Supreme Court last week that at least some of the 12 million people who newly enrolled in Medicaid signed up only because of the law’s requirement that people have insurance coverage — although a tax penalty no longer exists. The statement drew a rebuke from Justice Sonia Sotomayor, who said it belies reason.

Several health experts also questioned the argument that poor people apply for Medicaid not because they need help getting health care but to meet the ACA’s individual mandate for coverage. The point is vital to the Republicans’ case to overturn the ACA, an effort supported by the Trump administration. The states are trying to prove they were harmed by the 2010 health law — and thus have “legal standing” to challenge its constitutionality.

They argue their Medicaid spending increased because of the mandate, even though Congress eliminated the tax penalty for not having health coverage in 2019. Even when the penalty existed, most poor people were exempt because of their low income. Under the ACA, states can opt to expand Medicaid eligibility to all adults earning less than 138% of the federal poverty level, or about $17,600 for an individual.

States and the federal government share the cost of their care. If the states cannot prove they have standing, the justices can toss their case without ruling on its merits. The case also involves two individuals who purchased private insurance from Texas and are suing to have the law overturned.

The Medicaid costs issue was one of several ways Texas and other GOP-controlled states participating in the lawsuit say they were harmed by the ACA even after the individual mandate penalty was reduced to zero. Several justices, including conservatives Clarence Thomas and Amy Coney Barrett, posed questions about whether the states had standing. The case heard last Tuesday, California v.

Texas, was the third time the high court has taken up a major suit on the ACA. Republican attorneys general in 18 states and the Trump administration want the entire law struck down, a move that would threaten coverage for more than 20 million people, as well as millions of others with preexisting conditions, including erectile dysfunction treatment. Even if the court rules the states have legal standing, the ACA opponents must prove the elimination of a penalty makes the entire law unconstitutional.

The Republican states assert that since the law was upheld under Congress’ taxing powers by the Supreme Court in 2012, once the tax penalty is gone, the entire law must fall, too. A group of Democratic-controlled states led by California and the Democratic House of Representatives are urging the court to keep the law in place. Sotomayor raised serious doubts about the plaintiffs’ Medicaid argument and whether the states had suffered injury.

€œAt some point, common sense seems to me would say. Huh?. € Sotomayor told Kyle Hawkins, Texas’ solicitor general, who is leading the GOP states’ legal fight.

She questioned whether it seemed reasonable that once Medicaid enrollees are told there is no tax penalty for people who don’t have coverage they would “enroll now, when they didn’t enroll when they thought there was a tax?. Does that make any sense to you?. € Hawkins defended his case, saying states need to show that only one person signed up for Medicaid because of the individual mandate.

€œThere’s a substantial likelihood of at least one person signing up for a state Medicaid program, which, of course, would cause at least one dollar in injury and satisfy the standing requirement,” he said. He cited a Congressional Budget Office report issued in 2017, when lawmakers were considering the change in the penalty. It said some people would continue to buy insurance or seek coverage “solely because of a willingness to comply with the law,” even if the individual mandate penalty were eliminated.

Few surveys have asked Medicaid enrollees why they signed up for the program. One of them, by University of Michigan researchers that same year, posed the question to 1,750 adults who had become eligible for Medicaid in the state as a result of the ACA expansion. The most common reasons respondents gave for enrolling were that they had lost other health coverage and had a medical condition that required care.

Just 2% of respondents cited the need to avoid the individual mandate tax penalty. With the tax penalty eliminated, legal and health policy experts said, it’s likely the share of respondents signing up for Medicaid because of the health coverage mandate has dropped closer to zero. Richard Kay, a law professor emeritus at the University of Connecticut, said it’s clear most people don’t seek coverage because of the individual mandate — particularly since there is no longer a financial penalty.

But there could be a few who still do. €œDo you stop at a stop sign if you are in the country and no one is around for miles?. € he said.

€œIt’s not impossible that some people get insurance just because the law requires them.” Kay said there is no precise guidance on how courts decide whether a plaintiff has been penalized enough to prove it has legal standing. €œIt’s a very confused area of the law,” he said. Pratik Shah, a Washington, D.C., attorney who represents America’s Health Insurance Plans, a trade group fighting to preserve the law, said the plaintiffs in the case have not proved standing.

€œIt does not make logical sense,” he said of the argument that state budgets were harmed by people signing up for Medicaid even after the individual mandate penalty was eliminated. €œIt’s hard to see how the 2017 amendment to the health law would have forced more people into Medicaid,” he said. €œIf they weren’t signed up before, they would be less likely to get it without the penalty.” The court is expected to rule on the case by the end of June.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Phil Galewitz. pgalewitz@kff.org, @philgalewitz Related Topics Contact Us Submit a Story Tip.

About Insight Insight provides an in-depth look at health care issues in and affecting California.Have a online pharmacy kamagra story suggestion?. Let us know. Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when online pharmacy kamagra she was growing up.As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland.

She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.“All of those experiences actually made me really dislike physicians,” Asmerom said. €œParticularly in my community, the online pharmacy kamagra saying is, ‘You only go to the doctor if you’re about to die.’”But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too.

Asmerom came to believe that as a doctor she could help turn things around.Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, online pharmacy kamagra fundamental changes must be made in medical school curriculums.Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests.

But now, as online pharmacy kamagra with countless other U.S. Institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action. Don't Miss A Story Subscribe to California Healthline’s online pharmacy kamagra free Weekly Edition newsletter.

Debunking Race as a Diagnostic ToolFor many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very online pharmacy kamagra little genetic variation among races, and more differences among people within each race.

Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.Dr. Brooke Cunningham, online pharmacy kamagra a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said.

Some physicians claim it is useful to take race into account when online pharmacy kamagra treating patients. Others argue it leads to bias and poor care.Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate).

The eGFR can limit Black patients’ access to care online pharmacy kamagra because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.“It was online pharmacy kamagra very personal,” Nkinsi said.

€œThat’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”Nkinsi helped in a successful campaign to online pharmacy kamagra exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.Acknowledging Racism’s Adverse Effects on HealthThe Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S.

And Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities.

But little data exists on how many schools teach students how to recognize and fight racism, he said.An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.Recognizing Racism in Medical Education’s Past and PresentActivists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements.

Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. €œIt’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?.

€ she said.While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. €œThere needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.“But I’m not going to hold my breath until I see actual changes,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Related Topics California Public Health Race and Health Disparities Medical EducationAttorneys for GOP-controlled states seeking to kill the Affordable Care Act told the Supreme Court last week that at least some of the 12 million people who newly enrolled in Medicaid signed up only because of the law’s requirement that people have insurance coverage — although a tax penalty no longer exists. The statement drew a rebuke from Justice Sonia Sotomayor, who said it belies reason.

Several health experts also questioned the argument that poor people apply for Medicaid not because they need help getting health care but to meet the ACA’s individual mandate for coverage. The point is vital to the Republicans’ case to overturn the ACA, an effort supported by the Trump administration. The states are trying to prove they were harmed by the 2010 health law — and thus have “legal standing” to challenge its constitutionality.

They argue their Medicaid spending increased because of the mandate, even though Congress eliminated the tax penalty for not having health coverage in 2019. Even when the penalty existed, most poor people were exempt because of their low income. Under the ACA, states can opt to expand Medicaid eligibility to all adults earning less than 138% of the federal poverty level, or about $17,600 for an individual.

States and the federal government share the cost of their care. If the states cannot prove they have standing, the justices can toss their case without ruling on its merits. The case also involves two individuals who purchased private insurance from Texas and are suing to have the law overturned.

The Medicaid costs issue was one of several ways Texas and other GOP-controlled states participating in the lawsuit say they were harmed by the ACA even after the individual mandate penalty was reduced to zero. Several justices, including conservatives Clarence Thomas and Amy Coney Barrett, posed questions about whether the states had standing. The case heard last Tuesday, California v.

Texas, was the third time the high court has taken up a major suit on the ACA. Republican attorneys general in 18 states and the Trump administration want the entire law struck down, a move that would threaten coverage for more than 20 million people, as well as millions of others with preexisting conditions, including erectile dysfunction treatment. Even if the court rules the states have legal standing, the ACA opponents must prove the elimination of a penalty makes the entire law unconstitutional.

The Republican states assert that since the law was upheld under Congress’ taxing powers by the Supreme Court in 2012, once the tax penalty is gone, the entire law must fall, too. A group of Democratic-controlled states led by California and the Democratic House of Representatives are urging the court to keep the law in place. Sotomayor raised serious doubts about the plaintiffs’ Medicaid argument and whether the states had suffered injury.

€œAt some point, common sense seems to me would say. Huh?. € Sotomayor told Kyle Hawkins, Texas’ solicitor general, who is leading the GOP states’ legal fight.

She questioned whether it seemed reasonable that once Medicaid enrollees are told there is no tax penalty for people who don’t have coverage they would “enroll now, when they didn’t enroll when they thought there was a tax?. Does that make any sense to you?. € Hawkins defended his case, saying states need to show that only one person signed up for Medicaid because of the individual mandate.

€œThere’s a substantial likelihood of at least one person signing up for a state Medicaid program, which, of course, would cause at least one dollar in injury and satisfy the standing requirement,” he said. He cited a Congressional Budget Office report issued in 2017, when lawmakers were considering the change in the penalty. It said some people would continue to buy insurance or seek coverage “solely because of a willingness to comply with the law,” even if the individual mandate penalty were eliminated.

Few surveys have asked Medicaid enrollees why they signed up for the program. One of them, by University of Michigan researchers that same year, posed the question to 1,750 adults who had become eligible for Medicaid in the state as a result of the ACA expansion. The most common reasons respondents gave for enrolling were that they had lost other health coverage and had a medical condition that required care.

Just 2% of respondents cited the need to avoid the individual mandate tax penalty. With the tax penalty eliminated, legal and health policy experts said, it’s likely the share of respondents signing up for Medicaid because of the health coverage mandate has dropped closer to zero. Richard Kay, a law professor emeritus at the University of Connecticut, said it’s clear most people don’t seek coverage because of the individual mandate — particularly since there is no longer a financial penalty.

But there could be a few who still do. €œDo you stop at a stop sign if you are in the country and no one is around for miles?. € he said.

€œIt’s not impossible that some people get insurance just because the law requires them.” Kay said there is no precise guidance on how courts decide whether a plaintiff has been penalized enough to prove it has legal standing. €œIt’s a very confused area of the law,” he said. Pratik Shah, a Washington, D.C., attorney who represents America’s Health Insurance Plans, a trade group fighting to preserve the law, said the plaintiffs in the case have not proved standing.

€œIt does not make logical sense,” he said of the argument that state budgets were harmed by people signing up for Medicaid even after the individual mandate penalty was eliminated. €œIt’s hard to see how the 2017 amendment to the health law would have forced more people into Medicaid,” he said. €œIf they weren’t signed up before, they would be less likely to get it without the penalty.” The court is expected to rule on the case by the end of June.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Phil Galewitz. pgalewitz@kff.org, @philgalewitz Related Topics Contact Us Submit a Story Tip.

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Latest Healthy Kids News SUNDAY, kamagra oral jelly wholesalers https://www.pferde-recht.com/buy-levitra-online-usa/ Aug. 29, 2021 (HealthDay News) A common bug called respiratory syncytial kamagra (RSV) circulating among American kids during what's normally its off-season may cause concern if parents don't know how to tell it apart from erectile dysfunction treatment, experts say. Getting RSV during the summer is unusual, but the U.S. Centers for Disease Control kamagra oral jelly wholesalers and Prevention recently issued an alert about a rise in RSV cases in Southern states. "We're seeing more winter-like kamagraes this summer than we've ever seen," said Dr.

Steven Abelowitz, medical director of Coastal Kids, a pediatric group in Orange County, Calif. "We are speculating that over the last few months, with society opening up after lockdowns, kamagraes are surging up a kamagra oral jelly wholesalers bit because kids are now exposed more than they were prior." RSV affects the nose, throat and lungs. In most people, it causes cough, runny nose and sometimes a fever. Symptoms usually last seven to 10 days, but some kids develop a cough that takes up to six weeks to clear. RSV can also cause pneumonia or bronchiolitis (an inflammation of small airways in the lungs) in babies, and people older than 50 with heart or lung disease are at risk of complications kamagra oral jelly wholesalers from RSV.

The kamagra is highly contagious. If your child gets it, keep him or her away from anyone who is at high risk of serious illness from the kamagra, experts from the Children's Hospital Los Angeles advised. If your child has RSV symptoms, the first thing to do is to rule out erectile dysfunction treatment by kamagra oral jelly wholesalers getting your child tested. "You don't want to be responsible for more community spread," said Dr. Deborah Liu, associate director of emergency medicine at Children's Hospital Los Angeles.

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For a stuffy nose, use a saline spray and a bulb to suction out the mucus. A humidifier kamagra oral jelly wholesalers may help soothe respiratory passages. If your older child is coughing a lot, prop his or her head with a pillow. "For most kamagraes, the management is the same. Stay home, stay well-hydrated, get lots of sleep and take acetaminophen or ibuprofen for fever," Liu said kamagra oral jelly wholesalers.

More information The American Academy of Pediatrics has more on RSV. SOURCE. Children's Hospital Los Angeles, kamagra oral jelly wholesalers news release, Aug. 24, 2021 Copyright © 2021 HealthDay. All rights reserved..

Latest Healthy Kids News https://www.pferde-recht.com/buy-levitra-online-usa/ SUNDAY, Aug online pharmacy kamagra. 29, 2021 (HealthDay News) A common bug called respiratory syncytial kamagra (RSV) circulating among American kids during what's normally its off-season may cause concern if parents don't know how to tell it apart from erectile dysfunction treatment, experts say. Getting RSV during the summer is unusual, but the U.S. Centers for Disease Control and Prevention recently issued an alert about a rise in RSV cases online pharmacy kamagra in Southern states.

"We're seeing more winter-like kamagraes this summer than we've ever seen," said Dr. Steven Abelowitz, medical director of Coastal Kids, a pediatric group in Orange County, Calif. "We are speculating that over the last few months, with society opening online pharmacy kamagra up after lockdowns, kamagraes are surging up a bit because kids are now exposed more than they were prior." RSV affects the nose, throat and lungs. In most people, it causes cough, runny nose and sometimes a fever.

Symptoms usually last seven to 10 days, but some kids develop a cough that takes up to six weeks to clear. RSV can also cause pneumonia or bronchiolitis (an inflammation of small airways in online pharmacy kamagra the lungs) in babies, and people older than 50 with heart or lung disease are at risk of complications from RSV. The kamagra is highly contagious. If your child gets it, keep him or her away from anyone who is at high risk of serious illness from the kamagra, experts from the Children's Hospital Los Angeles advised.

If your child has RSV symptoms, the first thing to do is to rule out erectile dysfunction treatment by getting online pharmacy kamagra your child tested. "You don't want to be responsible for more community spread," said Dr. Deborah Liu, associate director of emergency medicine at Children's Hospital Los Angeles. She recommends getting a polymerase chain online pharmacy kamagra reaction (PCR) test, which usually provides results in about 24 hours.

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Etchells E, buy kamagra Ho M, Shojania buy kamagra paypal KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual buy kamagra Safe 2016;25:202–6.The article has been corrected since it was published online. The authors want to alert readers to the following error identified in the published version. The error is in the last paragraph of the section “Small samples can make ‘rapid improvement’ Rapid”, wherein the minimum sample size has been considered as six instead of eight.For this first (convenience) sample of 10 volunteer users, 5/10 (50%) completed the form without any buy kamagra input or instructions.

The other five became frustrated and gave up. Table 1 tells you that, with an observed success rate of 50% and a desired target of 90%, any audit with a sample of six or more allows you to confidently reject the null hypothesis that your form is working at a 90% success rate.For decades, those working in hospitals normalised the incessant alarms from medical devices as a necessary, almost comforting, reality of a high tech buy kamagra industry. While nurses drowned in excessive, frequently uninformative alarms, other members of the healthcare team often paid little attention. Fortunately, times are changing and managing alarm fatigue is now a key patient safety priority in acute care environments.1Adverse patient events from alarm fatigue, particularly related to excessive physiological monitor alarms, have received widespread attention over the last decade, including from the news media.2–5 In the buy kamagra USA, hospitals redoubled alarm safety efforts following the 2013 Joint Commission Sentinel Event Alert and subsequent National Patient Safety Goals on alarm safety.1 2 6 We are now beginning to understand how to reduce excessive non-actionable alarms (including invalid alarms as well as those that are valid but not actionable or informative),7 8 better manage alarm notifications and ultimately improve patient safety. Alarm data are readily available and measuring alarm response time during patient care is possible.7 9 Yet we have few high-quality reports describing clear improvement to clinical alarm burden, and most published interventions are of limited scope, duration or both.10 11 To demonstrate value in alarm quality improvement (QI) efforts moving forward, we need more rigorous evidence for interventions and more meaningful outcome measures.In this issue of BMJ Quality and Safety, Pater et al12 report the results of a comprehensive multidisciplinary alarm management QI project executed over 3½ years in a 17-bed paediatric acute care cardiology unit.

The primary project goal was to reduce alarm buy kamagra notifications from continuous bedside monitoring. Although limited to a single unit, the project is an important contribution to the scant literature on alarm management in paediatric settings for three reasons. First, the initiative lasted longer than most that have been reported, which allowed for tailoring of alarm interventions to the needs of the unit and patient population and measuring the impacts and sustainability over time. Second, the scope of the intervention buy kamagra bundle encompassed a wide variety of changes including adoption of a smartphone notification system. Addition of time delays between when alarm thresholds are violated and when an alarm notification is issued.

Implementation of an alarm notification escalation algorithm after a buy kamagra certain amount of time in alarm threshold violation. Deactivation of numerous technical alarms (such as respiratory lead detachment). Monitoring of electrode lead buy kamagra replacement every 24 hours. And discussion of alarm parameters on daily rounds. Third, the authors introduced a novel strategy for reducing the stress that alarms may cause patients and buy kamagra families by deactivating inroom alarm audio, although no outcomes were reported attributable directly to this component of the intervention.This project constitutes an important contribution to the published literature.

However, Pater et al faced two challenges that are ubiquitous in the field of clinical alarm management. (1) Identification of meaningful buy kamagra outcome measures and (2) Lack of high-quality evidence for most interventions. With regards to the first challenge, the primary outcome measure used in the study comprised ‘initial alarm notifications’, defined as the first notification of a monitor alarm delivered to the nurse’s mobile device. Although initial alarm notifications declined by 68% following the intervention, these notifications accounted for only about half of all alarm recommended you read notifications. The other half included second and third notifications for alarms exceeding specified delay thresholds, which were sent both to the mobile device of the primary nurse and to ‘buddy’ nurses, potentially increasing alarm buy kamagra burden.

On the other hand, eliminating inroom audible alarms may have reduced the perceived alarm burden for nurses compared with having both bedside and mobile device notifications. Determining the true benefit of a reduction in a subset of alarms presents complex challenges.Alarm frequency is the most commonly used outcome measure in alarm research and QI projects, but reduction in alarms does not necessarily indicate improved buy kamagra patient safety or a highly functional alarm management system. Alarm reduction could easily be achieved in an undesirable way by simply turning off alarms. Unfortunately, most studies have not been powered to statistically evaluate buy kamagra improvements in patient safety. (Pater et al did monitor patient safety balancing measures, which remained stable after intervention implementation).

To assess change in buy kamagra nurses’ perceptions of alarm frequency, Pater et al conducted a prepost survey, which despite the small sample size (n=38 preintervention and n=25 postintervention) managed to show improvement, with the percentage of nurses agreeing they could respond to alarms appropriately and quickly increasing from 32% to 76% (p<0.001). That said, this survey was not a validated measure of alarm fatigue. In fact, we currently have no widely accepted, validated tool for assessing alarm fatigue.11As we look towards future evaluations of alarm management strategies, the focus needs to shift buy kamagra away from simply reducing the frequency of alarms to more meaningful outcome metrics. In addition to alarm rates, outcomes such as response time to actual patient alarms7 9 or to simulated alarms injected into real patient care environments13 may be better indicators of whether the entire alarm response system is functioning correctly. Larger, multisite studies are needed to assess patient outcomes.In addition to meaningful outcome measures, the second challenge for alarm QI projects is the lack of good evidence for alarm management interventions.

Most alarm reduction interventions have not been systematically evaluated at all or only in small studies without a control group.10 11 As buy kamagra a result, alarm management projects tend to involve complex and costly bundles of interventions of uncertain benefit. The cost of these interventions is due in part to the growing industry of technology solutions for alarm management. Some institutions have also made massive investments in personnel, such as monitor ‘watchers’ to help nurses identify actionable alarms, for which there is also little evidence.14Future alarm management QI initiatives will benefit from a higher quality evidence base buy kamagra for the growing list of potential alarm management interventions. Pragmatic trials that leverage meaningful outcome measures to assess alarm interventions are warranted. In addition, we need to evaluate interventions that address the full buy kamagra spectrum of the alarm management system.

Most alarm management interventions to date have focused primarily on filtering out non-actionable alarms. Far less emphasis has been placed on ensuring that the nurse receiving the notification is available to respond to the alarm, a prime opportunity for future work.Even if alarms are actionable, we know that buy kamagra nurses may not always respond quickly for a variety of reasons.7 15–17 Factors like insufficient staffing, high severity of illness on the unit and unbalanced nursing skill mix all likely contribute to inadequate alarm response. In critical care, nurses have reported that the nature of their work requires that they function as a team to respond to one another’s alarms.15 Although not ideal, nurses have developed heuristics based on factors like family presence at the bedside to help them prioritise alarm response in hectic work environments.7 16 Emphasising outcomes like faster alarm response time without addressing systems factors risks trading one patient safety problem for another. We do buy kamagra not want to engender more frequent interruptions of high-risk activities, like medication administration,18 19 because nurses feel compelled to respond more quickly to alarms.The robust QI initiative carried out by Pater et al reflects the type of thoughtful approach needed to implement and tailor alarm management interventions for a particular unit, demonstrating a generalisable process for others to emulate. Ultimately, every alarm offers a potential benefit (opportunity to rescue a patient) and comes with a potential cost (eg, increased alarm fatigue, interruptions of other activities).

This trade-off needs to be optimised in the context of the individual unit, accounting for the unit-specific and systems factors that influence the cost of each additional alarm, including non-actionable alarm rates, unit layout, severity of illness and nurse staffing.17 20 With more robust outcome measures and more evidence to support interventions, we can increase the value of alarm QI initiatives and accelerate progress towards optimising alarm management systems.AcknowledgmentsWe thank Charles McCulloch, PhD (University of California, San Francisco) for comments on an early draft..

Etchells E, Ho online pharmacy kamagra M, Shojania KG. Value of small sample sizes in rapid-cycle quality improvement projects. BMJ Qual Safe 2016;25:202–6.The article has been corrected since it was published online pharmacy kamagra online. The authors want to alert readers to the following error identified in the published version. The error is in the last paragraph of the section “Small samples can make ‘rapid improvement’ Rapid”, online pharmacy kamagra wherein the minimum sample size has been considered as six instead of eight.For this first (convenience) sample of 10 volunteer users, 5/10 (50%) completed the form without any input or instructions.

The other five became frustrated and gave up. Table 1 tells you that, with an observed success rate of 50% and a desired target of 90%, any audit with a sample of six or more allows you to confidently reject the null online pharmacy kamagra hypothesis that your form is working at a 90% success rate.For decades, those working in hospitals normalised the incessant alarms from medical devices as a necessary, almost comforting, reality of a high tech industry. While nurses drowned in excessive, frequently uninformative alarms, other members of the healthcare team often paid little attention. Fortunately, times are changing and managing alarm fatigue is now a key patient safety priority in acute care environments.1Adverse patient events from alarm fatigue, particularly related to excessive physiological monitor alarms, have received widespread attention over the last decade, including from the news media.2–5 In the USA, hospitals redoubled alarm safety efforts following the 2013 Joint Commission Sentinel Event Alert and subsequent National Patient Safety Goals on alarm safety.1 2 6 We are now beginning to understand how to reduce excessive non-actionable alarms (including invalid alarms as well as those that are valid but not actionable or informative),7 8 online pharmacy kamagra better manage alarm notifications and ultimately improve patient safety. Alarm data are readily available and measuring alarm response time during patient care is possible.7 9 Yet we have few high-quality reports describing clear improvement to clinical alarm burden, and most published interventions are of limited scope, duration or both.10 11 To demonstrate value in alarm quality improvement (QI) efforts moving forward, we need more rigorous evidence for interventions and more meaningful outcome measures.In this issue of BMJ Quality and Safety, Pater et al12 report the results of a comprehensive multidisciplinary alarm management QI project executed over 3½ years in a 17-bed paediatric acute care cardiology unit.

The primary project goal was online pharmacy kamagra to reduce alarm notifications from continuous bedside monitoring. Although limited to a single unit, the project is an important contribution to the scant literature on alarm management in paediatric settings for three reasons. First, the initiative lasted longer than most that have been reported, which allowed for tailoring of alarm interventions to the needs of the unit and patient population and measuring the impacts and sustainability over time. Second, the scope of the intervention bundle encompassed a online pharmacy kamagra wide variety of changes including adoption of a smartphone notification system. Addition of time delays between when alarm thresholds are violated and when an alarm notification is issued.

Implementation of an alarm notification escalation algorithm after a certain amount online pharmacy kamagra of time in alarm threshold violation. Deactivation of numerous technical alarms (such as respiratory lead detachment). Monitoring of electrode lead replacement every online pharmacy kamagra 24 hours. And discussion of alarm parameters on daily rounds. Third, the authors introduced a novel strategy for reducing the stress that alarms may cause patients online pharmacy kamagra and families by deactivating inroom alarm audio, although no outcomes were reported attributable directly to this component of the intervention.This project constitutes an important contribution to the published literature.

However, Pater et al faced two challenges that are ubiquitous in the field of clinical alarm management. (1) Identification of meaningful outcome measures and (2) Lack online pharmacy kamagra of high-quality evidence for most interventions. With regards to the first challenge, the primary outcome measure used in the study comprised ‘initial alarm notifications’, defined as the first notification of a monitor alarm delivered to the nurse’s mobile device. Although initial alarm notifications declined by 68% following the intervention, these notifications accounted for only about half of all alarm notifications. The other half included second and third online pharmacy kamagra notifications for alarms exceeding specified delay thresholds, which were sent both to the mobile device of the primary nurse and to ‘buddy’ nurses, potentially increasing alarm burden.

On the other hand, eliminating inroom audible alarms may have reduced the perceived alarm burden for nurses compared with having both bedside and mobile device notifications. Determining the true benefit of a reduction in a subset of alarms presents online pharmacy kamagra complex challenges.Alarm frequency is the most commonly used outcome measure in alarm research and QI projects, but reduction in alarms does not necessarily indicate improved patient safety or a highly functional alarm management system. Alarm reduction could easily be achieved in an undesirable way by simply turning off alarms. Unfortunately, most studies have not been powered to statistically evaluate improvements in patient safety online pharmacy kamagra. (Pater et al did monitor patient safety balancing measures, which remained stable after intervention implementation).

To assess change in nurses’ perceptions of alarm online pharmacy kamagra frequency, Pater et al conducted a prepost survey, which despite the small sample size (n=38 preintervention and n=25 postintervention) managed to show improvement, with the percentage of nurses agreeing they could respond to alarms appropriately and quickly increasing from 32% to 76% (p<0.001). That said, this survey was not a validated measure of alarm fatigue. In fact, we currently have no widely accepted, validated tool for assessing alarm fatigue.11As we look towards future evaluations online pharmacy kamagra of alarm management strategies, the focus needs to shift away from simply reducing the frequency of alarms to more meaningful outcome metrics. In addition to alarm rates, outcomes such as response time to actual patient alarms7 9 or to simulated alarms injected into real patient care environments13 may be better indicators of whether the entire alarm response system is functioning correctly. Larger, multisite studies are needed to assess patient outcomes.In addition to meaningful outcome measures, the second challenge for alarm QI projects is the lack of good evidence for alarm management interventions.

Most alarm reduction interventions have not been systematically evaluated at all or only in small studies without a control group.10 11 As a result, alarm management projects tend to involve complex and costly bundles of online pharmacy kamagra interventions of uncertain benefit. The cost of these interventions is due in part to the growing industry of technology solutions for alarm management. Some institutions have also made massive investments in personnel, such as monitor ‘watchers’ to help nurses identify actionable alarms, for which there is also little evidence.14Future alarm management QI initiatives will benefit online pharmacy kamagra from a higher quality evidence base for the growing list of potential alarm management interventions. Pragmatic trials that leverage meaningful outcome measures to assess alarm interventions are warranted. In addition, online pharmacy kamagra we need to evaluate interventions that address the full spectrum of the alarm management system.

Most alarm management interventions to date have focused primarily on filtering out non-actionable alarms. Far less emphasis online pharmacy kamagra has been placed on ensuring that the nurse receiving the notification is available to respond to the alarm, a prime opportunity for future work.Even if alarms are actionable, we know that nurses may not always respond quickly for a variety of reasons.7 15–17 Factors like insufficient staffing, high severity of illness on the unit and unbalanced nursing skill mix all likely contribute to inadequate alarm response. In critical care, nurses have reported that the nature of their work requires that they function as a team to respond to one another’s alarms.15 Although not ideal, nurses have developed heuristics based on factors like family presence at the bedside to help them prioritise alarm response in hectic work environments.7 16 Emphasising outcomes like faster alarm response time without addressing systems factors risks trading one patient safety problem for another. We do not want to engender more frequent interruptions online pharmacy kamagra of high-risk activities, like medication administration,18 19 because nurses feel compelled to respond more quickly to alarms.The robust QI initiative carried out by Pater et al reflects the type of thoughtful approach needed to implement and tailor alarm management interventions for a particular unit, demonstrating a generalisable process for others to emulate. Ultimately, every alarm offers a potential benefit (opportunity to rescue a patient) and comes with a potential cost (eg, increased alarm fatigue, interruptions of other activities).

This trade-off needs to be optimised in the context of the individual unit, accounting for the unit-specific and systems factors that influence the cost of each additional alarm, including non-actionable alarm rates, unit layout, severity of illness and nurse staffing.17 20 With more robust outcome measures and more evidence to support interventions, we can increase the value of alarm QI initiatives and accelerate progress towards optimising alarm management systems.AcknowledgmentsWe thank Charles McCulloch, PhD (University of California, San Francisco) for comments on an early draft..

Cheap kamagra next day delivery

While the era following the Bland decision in 19931 might be cheap kamagra next day delivery thought of as the time when concepts such as ‘futility’ were placed under pressure and scrutiny, it’s an idea that has been debated for can you get kamagra over the counter at least forty years. In a 1983 JME commentary Bryan Jennett distinguishes three kinds of reason why Cardiopulmonary Resuscitation (CPR) might be withheld:‘… that CPR would be futile because it is very unlikely to be successful. That quality of life after CPR is likely to be changed to so poor a level as to be a greater burden than the benefit gained from prolongation of life, and that quality of life is already so poor due to chronic or terminal disease that life should not be prolonged by CPR.’ pp-142-1432This crisp definition seems as applicable as it did then, but it was not the final word cheap kamagra next day delivery on the concept. Mitchell, Kerridge and Lovat explore, as others did in the post-Bland and Quinlan eras, how ‘futility’ might apply to those in a persistent vegetative state(PVS).3 They defend withdrawing artificial nutrition and hydration (ANH) when it ‘…offers no reasonable hope of real benefit to the PVS patient’ and note that this ‘would represent a significant shift in the ethical obligation owed by the doctor to the patient.’ p74 The ethical difference between that sense of futility and Jennett’s first sense of a ‘treatment being very unlikely to be successful’ was not lost on those critical of the withdrawal of ANH. Following the Bland decision, Finnis and Keown observed that doctors were now able to determine whether the life of someone in a PVS was worth living and decide that treatment could be withdrawn because treating that patient was deemed futile in the sense of not providing cheap kamagra next day delivery them with an improvement in their quality of life.4 5In addition to worries about the very different kinds of clinical judgement that can be described as futile, some have objected that the clinical use of the term risks being pejorative.

Gillon reaches the view that‘…futility judgments are so fraught with ambiguity, complexity and potential aggravation that they are probably best avoided altogether, at least in cases where the patient or the patient’s proxies are likely to disagree with the judgment.’6 p339Arguing in a similar vein, Ardagh objects both to the complexity in determining before the case that CPR won’t work and to the conceptual implication that futility means a failure of a treatment to benefit.7Futility has continued to be debated in the literature since these and other critical analyses of its utility and coherence were published. This issue of the JME includes papers that re-examine issues that cheap kamagra next day delivery were flagged in earlier debates. Cole et al describe the predicament faced by ambulance clinicians (paramedics) when they decide that CPR is futile and when family members are present who would like everything to be done.8 This brings back into the light the issue of whether the judgement that a treatment is futile is a straightforwardly clinical or physiological assessment. They mention UK guidance that says‘‘‘Where no cheap kamagra next day delivery explicit decision about CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.” Clinicians are however, given discretion to make decisions not to attempt CPR where they think it would be futile.’That, on the face of it, implies that first responders can make a judgement that CPR is futile, but the picture is muddied if we understand futility to be a judgement about the best interests of that patient. That judgement does imply, at the very least, a discussion with family members about what would be in that patient’s interests.

So, clarity about which sense of futility is in play seems as critical as it did when Jennett wrote about it in the 1980s.Vivas and Carpenter grapple with the futility issue that was also at the heart of the Bland decision and the withdrawal of ANH for those in a PVS.9 They say‘How do we define treatment futility when a treatment is often effective in the strict physiological sense (restoring life) cheap kamagra next day delivery while being almost entirely ineffective in the larger, holistic sense—that is, it does not stop dying, merely delays and prolongs it?. €™In the case of CPR they consider the argument that it might be an instance of a death ritual ‘… connected with religious beliefs and broader social values. In our technological society, even ‘physiologically futile’ resuscitation may have significant value as social ritual for the dying and their loved ones.’ They cheap kamagra next day delivery are sensitive to the risks inherent in medicine offering treatments that are highly unlikely to benefit that patient because it helps those around the patient. They suggest that this may be a vital need nonetheless and the issue is therefore whether there are better ways of fulfilling these ‘existential needs’.Ethics statementsPatient consent for publicationNot required.IntroductionInternationally, pre-hospital registered ambulance clinicians (variously called ambulance clinicians, paramedics and emergency services personnel) are often put in the invidious position of having to make a decision about whether or not to attempt cardiopulmonary resuscitation (CPR) when they attend a call and find a patient whose heart has stopped. About 46% of deaths in the England cheap kamagra next day delivery occur in homes or nursing homes1 and ambulances are often called at times of health crisis, even when a death is expected, if caregivers feel unsure what to do.2 The call has been put out, the ambulance clinician has responded to the call.

To do nothing creates certainty around the individual’s death. Where the heart stopping is the final stage of a longer dying process, attempting CPR is likely to be futile, as the heart stopping reflects an overall physiological deterioration which CPR cannot reverse cheap kamagra next day delivery. In other circumstances, particularly in cases where the arrest is unexpected and the primary problem is with the heart, it may result in full recovery for the individual. Or it may give the individual a chance of returned circulation, but with great neurological deficit;3 or it may restart the heart briefly, only for the individual to die again.4The ambulance clinician must therefore make a rapid decision with cheap kamagra next day delivery potentially very significant repercussions. To protect them from the emotional work—and possible litigation—associated with these decisions, their recently updated UK professional guidance5 recommends.

€œWhere no explicit decision about CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.” Clinicians are, however, given the discretion to make decisions not to attempt CPR where they think it would be futile, ‘for example, for cheap kamagra next day delivery a person in the advanced stages of a terminal illness where death is imminent and unavoidable’. However, there is no explicit mention of the importance of listening to family members’ views of what the patient would want, nor reference to the legal obligation of the ambulance clinician to follow the Mental Capacity Act 2005 (MCA 2005) and do what is in the patient’s best interests (which would involve taking into consideration what family members/friends and advocates think the patient would want). In the USA, guidance is cheap kamagra next day delivery not included on how to incorporate relatives’ views with best interests decisions. Ambulance clinicians have reported that they have not been taught to deal with these decisions6 and that it is often easier for them—both emotionally and logistically—to deliver attempted CPR than to consider withholding it. Relatives, who, after all, have been the ones to place the call in the first place, then feel powerless (and sometimes angry) when ambulance clinicians start CPR despite cheap kamagra next day delivery their protestations that this is ‘not what he/she would have wanted’.

In the USA, emergency services personnel have even less discretion than in the UK. In many states, they are bound to start CPR unless a specific Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is in place, even if the patient has another kind of documentation, for example POLST (Physician Order for Life-Sustaining Treatment) until they have spoken to a ‘medical command cheap kamagra next day delivery physician’. They also must continue CPR if it has been started by a bystander even if a DNACPR is in place, until they are told they can stop by a physician.To highlight the moral discomfort experienced and the ethical and legal challenges faced, we present the perspectives of an ambulance clinician and a relative, and then review the legal and ethical framework in which they are operating, before concluding with some suggested changes to policy and guidance which we believe will protect ambulance clinicians, relatives and the patient.Ambulance clinician’s perspective—Rob ColeThe following is a case study to illustrate the grey area faced by ambulance clinicians when they consider they need to make a ‘best interests’ decision on a patient who has arrested. This is a composite case study from my experience of many such calls to protect the anonymity of those involved in any individual case.An emergency call was received by the ambulance emergency operations cheap kamagra next day delivery control room. At this stage, it was important to clarify the justification for this call as this directly influences any further decision making.

If the call was for the purpose of providing resuscitation to a patient in cardiorespiratory arrest then, as early as this stage, we can determine that at the point of call, somebody (accepting unable to qualify cheap kamagra next day delivery exactly whom) believes that the patient is either clinically indicated for resuscitation or someone believes they would desire or benefit from such an intervention. The caller identified that her husband was experiencing a seizure, and this had lasted for 5 min prior to her calling the ambulance. An ambulance was immediately despatched on this information alone (known as pre-alert dispatch). The location was some 4 min from cheap kamagra next day delivery the crew and they therefore arrived on the scene 5 min post call (in fact, on the crew arrival, the caller was still on the phone with the ambulance control centre).The crew were met by a female in her 70s (call with control ended on crew arrival). The crew were, as often is the case, provided with no further details other than that of a male in his 80s with a prolonged seizure.

The ambulance cheap kamagra next day delivery had travelled under emergency conditions to the address. The female greeted the crew (who had approached the property with full life-saving emergency equipment). She stated “I cheap kamagra next day delivery think he has gone” in a calm and clear voice. She allowed the crew into her home and quickly explained (during the journey to the patient, who is on a bed in the dining room downstairs) that the patient was her husband, that he had been generally unwell for some time (increased frailty, heart failure and developing dementia) and while she had not expected him to die at this point in time, she was not particularly surprised that he had. One member of the crew (double crew) prepared the patient for resuscitation, post a period of assessment while the other crew member continued to cheap kamagra next day delivery speak with the patient’s wife to better understand the situation.

The scene looked non-suspicious. The patient cheap kamagra next day delivery was lying peacefully (not breathing and with no heart rate) on a bed downstairs, dressed in pyjamas. The patient presented as frail in appearance but other than that, there was no further information of note.The member of the crew that spoke with the wife of the patient and ascertained that the patient was being treated by a general physician for a simple urinary tract , that there was no DNACPR in place as there was no specific requirement for one to have been put in place. No advance decision to refuse treatment (the female had no idea cheap kamagra next day delivery what this was) nor was there any legal power of attorney (the patient until this point had been broadly of sound mind with occasional episodes of confusion). As the other member of the ambulance crew commenced resuscitation (CPR), the patient’s wife angrily stated that her husband would not wish for this, nor did she or any member of her family.

She reiterated that the 999 call was due to a seizure, and had it been for the purpose of providing resuscitation, she would not have called the emergency services and all agreed that this cheap kamagra next day delivery was not the wish of the patient. Accepting this is not documented anywhere, the patient’s wife explained that these were conversations that had taken place within the family environment, that her husband had a clear view that he would not want to be subjected to any resuscitative efforts should he die, and funeral arrangements had been explored recently by all.To add, the patient’s wife appeared to be of sound mind, no obvious level of confusion and not in any particular state of heightened distress. The son of the patient was 10 min away from cheap kamagra next day delivery the address and on his way. A neighbour had also arrived at the property.To summarise, cardiac arrest of a patient in his 80s, not expected to die look at here but family not surprised (had been quite unwell recently), no DNACPR or other documented evidence of the patient’s thoughts, wishes and beliefs. Call for emergency help was to manage a seizure and NOT provide resuscitation.Family carer perspective—Mike StoneWhen my mother died cheap kamagra next day delivery about 10 years ago,7 I might have found myself as a relative trying to prevent a 999 paramedic from attempting CPR, but in the event, I found myself being ‘confronted by’ 999 personnel who seemed unable to understand why when my mum died at the end of a peaceful 4-day terminal coma, I had NOT felt the need ‘to phone someone immediately’.

This prompted me to embark on an investigation into end-of-life (EoL) guidance, protocols, mindsets and laws, which revealed to me a situation I can, at best, describe as urgently requiring improvement, especially but not exclusively for EoL-at-home, and which, in complex and confusing situations, protects professionals at the expense of damaging relatives and, sometimes, even patients.From my family carer perspective, this situation has to change. And, the direction of change must be one which improves the support given to patients, by promoting integration between everyone, lay and professional, cheap kamagra next day delivery involved in supporting patients. This ‘model’ requires ‘us and us’ as opposed to ‘us and them’. It emphasises teamwork between family carers and the clinicians who are in regular and ongoing contact with the patient, and it replaces ‘multidisciplinary team thinking’, with genuine professional-lay integration.Anyone can listen to a patient—provided cheap kamagra next day delivery you are present to listen. If only a relative is present, only the relative can listen.

Often it will require cheap kamagra next day delivery a clinician, such as a 999 paramedic, to confirm that a patient is in cardiopulmonary arrest, but the family carer who called 999, is the person most likely to know if the patient would have wanted CPR. Put simply, the clinicians are the experts in the clinical aspects, and the family and friends are the experts in ‘the patient as an individual’.I believe the current guidance around CPR decision-making is unsatisfactory and incoherent, and must be made more sensible and coherent.8–10 Contemporary protocols for ‘expected death’ are also fundamentally flawed.11 Advance decisions often fail to achieve the patient’s objective, apparently because clinicians are risk-averse.12I have only mentioned a few of the more significant problems, and those I have mentioned could, in theory, be addressed by consensus followed by improved training. Other fundamental problems—notably the fact that relatively few people have personal experience of caring for a loved one all the way to a death at home—are more problematic.To cheap kamagra next day delivery close this brief and personal analysis, I will give two opinions. The first is that the change required is easy to see, and involves things such as more group-based and ‘diffusely achieved’ decision-making instead of identifiable individuals being invariably associated with and responsible for specific decisions. But it is a change which a hierarchical and process/records-based National Health Service (NHS) would really struggle to come to terms with.13The second is my optimism that growing pressure from patients and relatives will make the changes in behaviour inevitable, because, perhaps surprisingly, of social media.14Legal analysis—Alex Ruck KeeneMike’s experiences speak clearly of the practical problems caused by paramedics misunderstanding the law.If there cheap kamagra next day delivery is a situation in which CPR would simply not work to restart the heart or breathing, then the paramedics would be under no duty to attempt it, as there is no duty to seek to carry out a futile procedure.

However, if it appeared that it might work, then the paramedics are, in England and Wales, governed by the MCA 2005. In practice, the realities confronted by paramedics cheap kamagra next day delivery are such that the majority of their decision-making will be governed by the MCA 2005. This Act provides a framework for decision-making in relation to those with impaired decision-making capacity which is (unlike legal frameworks in some other jurisdictions) not predicated on there being an automatic proxy decision-maker, such as a ‘next of kin.’ Rather, the Act provides (in s.5) that any person—such as a paramedic—is able to carry out an act of care and treatment in relation to another (‘P’) with protection from liability if they. (1) take reasonable steps to determine whether cheap kamagra next day delivery P has the capacity to consent to the act. And (2) if P lacks capacity, that they reasonably believe that they are acting in P’s best interests.In all situations, the first step is to consider whether the person has capacity to make their own decision—to consent to or refuse CPR.

In the scenario presented by Rob Cole, as with almost all situations where CPR is required, the patient was unconscious and there were no practicable steps that could be taken to support him within the time available. Reaching the conclusion that the patient did not have capacity could therefore have been effectively instantaneous.The paramedics had taken reasonable steps to ascertain whether the person had made an advance decision to refuse CPR (as a medical treatment), and that he had not made one.This means that they were therefore required to decide whether it was in his best interests for them to attempt it.‘Best interests’ cheap kamagra next day delivery is, deliberately, not defined in the MCA 2005. However, s.4 sets out a series of matters that must be considered whenever a person is determining what is in the person’s best interests to allow them to have a reasonable belief as to they are acting in those best interests. It is extremely important to recognise that the MCA 2005 does not specify what is in the person’s best interests cheap kamagra next day delivery. Rather, it sets down a process by which that conclusion should be reached, which recognises that a lack of decision-making capacity is not an ‘off-switch’ for their rights and freedom (Wye Valley NHS Trust v- Mr B ]2015[ EWCOP 60 in paragraph 11).

The process cheap kamagra next day delivery aims to construct a decision on behalf of the person who cannot make that decision themselves. As the Supreme Court emphasised in Aintree University NHS Hospitals Trust v James [2014] UKSC 67 “[t]he purpose of the best interests test is to consider matters from the patient’s point of view.” It is critically important to understand that the purpose of the decision-making process is to try to arrive at the decision that is the right decision for the person themselves, as an individual human being, and not the decision that best fits with the outcome that the professionals desire. Any information about the patient’s wishes, feelings, beliefs and values will be relevant, including, in particular, preferences and cheap kamagra next day delivery recommendations documented when the person had capacity.Consultation will also be required with those who could shed light on the person’s likely decision, here his wife. The case of Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB) made clear that a failure to consult where it is practicable and appropriate will mean that professionals cannot then rely on the defence in s.5 of MCA to what might otherwise be criminal acts.In making a best interests decision about giving life-sustaining treatment, there is always a strong presumption that it will be in the patient’s best interests to prolong his or her life, and the decision-maker must not be motivated by a desire to bring about the person’s death for whatever reason, even if this is from a sense of compassion. However, the strong presumption in favour of prolonging life can be displaced where:There is clear evidence that the person would not want the treatment in question in the circumstances that have arisen.The treatment itself would be overly burdensome for the patient, in particular by reference to whether the patient accepts invasive and uncomfortable interventions or prefers to be kept comfortable.There is no prospect that the treatment will return the patient to a state of a quality of life that the patient cheap kamagra next day delivery would regard as worthwhile.

The important viewpoint is that of the patient, not of the doctors or healthcare professionals.Case law has made clear that the weight that is to be attached to the reliably ascertainable views of the person should be given very substantial, if not determinative, weight (Re AB (Termination of Pregnancy) [2019) EWCA Civ 1215]. In a case such as that described in the scenario of the ambulance clinician, and given the clarity of the views expressed by the man’s wife in relation to what he would have wanted, the paramedics could properly conclude that attempting CPR was not cheap kamagra next day delivery in his best interests. The Supreme Court has confirmed that they should not then attempt it. NHS Trust v Y [2018] UKSC 22.Drawing the legal threads together, therefore, in a situation such as this:Unless the paramedics have a proper reason to doubt the good faith of the family member present, they should proceed on the basis that they are reliable in relaying what the person would have cheap kamagra next day delivery wanted.The paramedics can then either start or not start CPR accordingly because they have the necessary reasonable belief that they are acting in the person’s best interests.If there is reason to doubt the good faith of the family member present, or the family member does not (or cannot) relay clear views, the paramedics should start CPR. It may be that after they have started, they are able to glean further information which makes the picture clearer and enables them to decide whether continuing is in the patient’s best interests.Ethical overview and proposals for change—Zoë Fritz (and other authors)Law, ethical principles and professional clinical guidelines influence each other.15 In an ideal system, this would ensure just care with recognition of the rights of practitioners and patients.

When it works badly, the ‘letter of the law’ is followed, even when it runs counter to good ethics, with potentially cheap kamagra next day delivery devastating personal consequences. The composite scenario and personal events, described above by an ambulance clinician and a family member, reflect examples of where medical practitioners believed they were following the law, but where their actions could be argued to have been unethical.In contrast, a related example of the law working positively to overturn accepted clinical guidance and practice, is around the need to discuss a decision not to attempt CPR with a patient. The 2007 joint guidance issued by the British cheap kamagra next day delivery Medical Association, Royal College of Nursing and the Resuscitation Council (UK) (2007) stated. €œWhen a clinical decision is made that CPR should not be attempted, because it will not be successful, and the patient has not expressed a wish to discuss CPR, it is not necessary or appropriate to initiate discussion with the patient to explore their wishes regarding CPR.” The case of Janet Tracey challenged this. The judges in the court of appeal cheap kamagra next day delivery found that not discussing a decision to withhold CPR with a patient was in breach of their human rights (Article 8 European Convention on Human Rights) as it deprived them of the right to question the clinical decision or ask for a second opinion, particularly in the context of a potentially life-saving treatment.16 Clinicians rapidly changed their practice.

In fact, the whole nature of CPR conversations was altered to ensure that it was not considered in isolation, but always discussed within overall goals of care. In being forced to discuss CPR with patients, doctors reconsidered the conversation, what it meant and when it could and should occur.17The ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process emerged from this as a way of nudging doctors and cheap kamagra next day delivery patients into having better conversations and documentation of agreed recommendations;18 it is now used in more than 130 trusts.19While, at first glance, there may appear to be ethical and legal tensions in the scenarios described above, it is possible that good training and professional guidance would dispel them. If families were better supported to understand what may happen where a loved one dies at home, they would be better equipped to deal with the crisis when it came. Specific resources cheap kamagra next day delivery are needed. If, for example, there had been a specific number to call for an expected death, other than 999, in the two deaths reported here, then neither of these upsetting scenarios would have occurred.

As mentioned above, social media may be another positive force in both applying pressure for change, and in acting as a leveller in terms of access to information.If the professional guidance and other cheap kamagra next day delivery material—published by Joint Royal Colleges Ambulance Liaison Committee, Royal College of Nursing, Resuscitation Council UK and so on—stated clearly that, where death was expected and CPR appeared to be futile, even in the absence of a DNACPR or ReSPECT form, an ambulance clinician or qualified nurse could decide that attempting CPR was clinically pointless or potentially harmful, then clinicians would not need to choose between what they considered morally right and what they had to do to protect their professional registration.The new JRCALC guidance takes this into account, and it is likely that other guidance will also be explicit about this in the future. They should also be explicit about the role of the MCA and best interests decisions. An honest carer, cheap kamagra next day delivery family member who protests, “… but my husband would definitely not want CPR—don’t do that!. € may be perceived as applying the MCA to her own determination of what is in her husband’s best interests, even if the wife has no awareness of the MCA.If the ambulance clinicians were taught clearly that acting in the patient’s ‘best interests’ in this scenario most often meant doing as the relatives asked, then the (frequently internalised) concern that they were choosing between what was right for the patient and what was right for the patient’s relative would be abolished, and the associated moral discomfort diminished. We recognise that there will, in some cases, be a different tension—where the ambulance clinician considers that the CPR will cheap kamagra next day delivery not be successful but the relatives want it to take place.

But this is where the distinction between the ambulance clinician as the expert in the medical procedure and the relative as the expert in the person comes in—nobody can demand medical treatment which is inappropriate, and CPR is no different.The guidance and the training should emphasise the teawork which Mike Stone mentions above. The default assumption should be that clinicians and relatives have a shared goal of what is best for the patient, and work together as ‘us and us’ as opposed to ‘us and them’.Data availability statementThere are no data in this work.Ethics statementsPatient consent for publicationNot required..

While the era following the Bland decision in 19931 might be thought of as the time when concepts such online pharmacy kamagra as ‘futility’ were placed under pressure and scrutiny, it’s an idea that has been debated for at buy kamagra jelly least forty years. In a 1983 JME commentary Bryan Jennett distinguishes three kinds of reason why Cardiopulmonary Resuscitation (CPR) might be withheld:‘… that CPR would be futile because it is very unlikely to be successful. That quality of life after CPR is likely to be changed to so poor a level as to be a greater burden than the benefit gained from prolongation of life, and that quality of life is already so poor due to chronic or terminal disease that life should not be prolonged by CPR.’ pp-142-1432This crisp definition seems as applicable online pharmacy kamagra as it did then, but it was not the final word on the concept. Mitchell, Kerridge and Lovat explore, as others did in the post-Bland and Quinlan eras, how ‘futility’ might apply to those in a persistent vegetative state(PVS).3 They defend withdrawing artificial nutrition and hydration (ANH) when it ‘…offers no reasonable hope of real benefit to the PVS patient’ and note that this ‘would represent a significant shift in the ethical obligation owed by the doctor to the patient.’ p74 The ethical difference between that sense of futility and Jennett’s first sense of a ‘treatment being very unlikely to be successful’ was not lost on those critical of the withdrawal of ANH.

Following the Bland decision, Finnis and Keown observed that doctors were now able to determine whether the life of someone in a PVS was worth living online pharmacy kamagra and decide that treatment could be withdrawn because treating that patient was deemed futile in the sense of not providing them with an improvement in their quality of life.4 5In addition to worries about the very different kinds of clinical judgement that can be described as futile, some have objected that the clinical use of the term risks being pejorative. Gillon reaches the view that‘…futility judgments are so fraught with ambiguity, complexity and potential aggravation that they are probably best avoided altogether, at least in cases where the patient or the patient’s proxies are likely to disagree with the judgment.’6 p339Arguing in a similar vein, Ardagh objects both to the complexity in determining before the case that CPR won’t work and to the conceptual implication that futility means a failure of a treatment to benefit.7Futility has continued to be debated in the literature since these and other critical analyses of its utility and coherence were published. This issue of the JME includes papers that re-examine online pharmacy kamagra issues that were flagged in earlier debates. Cole et al describe the predicament faced by ambulance clinicians (paramedics) when they decide that CPR is futile and when family members are present who would like everything to be done.8 This brings back into the light the issue of whether the judgement that a treatment is futile is a straightforwardly clinical or physiological assessment.

They mention UK guidance that says‘‘‘Where no explicit decision about CPR has been online pharmacy kamagra considered and recorded in advance, there should be an initial presumption in favour of CPR.” Clinicians are however, given discretion to make decisions not to attempt CPR where they think it would be futile.’That, on the face of it, implies that first responders can make a judgement that CPR is futile, but the picture is muddied if we understand futility to be a judgement about the best interests of that patient. That judgement does imply, at the very least, a discussion with family members about what would be in that patient’s interests. So, clarity about which sense of futility is in play seems as critical as it did when Jennett wrote about it in the 1980s.Vivas and Carpenter grapple with the futility issue that was also at the heart of the Bland decision and the withdrawal of ANH for those in a PVS.9 They say‘How do we define treatment futility when a treatment is often effective in the strict physiological sense (restoring online pharmacy kamagra life) while being almost entirely ineffective in the larger, holistic sense—that is, it does not stop dying, merely delays and prolongs it?. €™In the case of CPR they consider the argument that it might be an instance of a death ritual ‘… connected with religious beliefs and broader social values.

In our technological society, even ‘physiologically futile’ resuscitation may have significant value as social ritual for the dying and their loved ones.’ They are sensitive to the risks inherent in online pharmacy kamagra medicine offering treatments that are highly unlikely to benefit that patient because it helps those around the patient. They suggest that this may be a vital need nonetheless and the issue is therefore whether there are better ways of fulfilling these ‘existential needs’.Ethics statementsPatient consent for publicationNot required.IntroductionInternationally, pre-hospital registered ambulance clinicians (variously called ambulance clinicians, paramedics and emergency services personnel) are often put in the invidious position of having to make a decision about whether or not to attempt cardiopulmonary resuscitation (CPR) when they attend a call and find a patient whose heart has stopped. About 46% of deaths in the England occur in homes or nursing homes1 and ambulances are often called at times of health crisis, even when a death is expected, if caregivers feel unsure online pharmacy kamagra what to do.2 The call has been put out, the ambulance clinician has responded to the call. To do nothing creates certainty around the individual’s death.

Where the heart stopping is the final stage of a longer dying process, attempting CPR is likely to be futile, as the online pharmacy kamagra heart stopping reflects an overall physiological deterioration which CPR cannot reverse. In other circumstances, particularly in cases where the arrest is unexpected and the primary problem is with the heart, it may result in full recovery for the individual. Or it may give the individual a chance of returned circulation, but with great online pharmacy kamagra neurological deficit;3 or it may restart the heart briefly, only for the individual to die again.4The ambulance clinician must therefore make a rapid decision with potentially very significant repercussions. To protect them from the emotional work—and possible litigation—associated with these decisions, their recently updated UK professional guidance5 recommends.

€œWhere no online pharmacy kamagra explicit decision about CPR has been considered and recorded in advance, there should be an initial presumption in favour of CPR.” Clinicians are, however, given the discretion to make decisions not to attempt CPR where they think it would be futile, ‘for example, for a person in the advanced stages of a terminal illness where death is imminent and unavoidable’. However, there is no explicit mention of the importance of listening to family members’ views of what the patient would want, nor reference to the legal obligation of the ambulance clinician to follow the Mental Capacity Act 2005 (MCA 2005) and do what is in the patient’s best interests (which would involve taking into consideration what family members/friends and advocates think the patient would want). In the USA, guidance is not included on how to online pharmacy kamagra incorporate relatives’ views with best interests decisions. Ambulance clinicians have reported that they have not been taught to deal with these decisions6 and that it is often easier for them—both emotionally and logistically—to deliver attempted CPR than to consider withholding it.

Relatives, who, after all, have been the ones to place the call in the first place, then feel powerless (and online pharmacy kamagra sometimes angry) when ambulance clinicians start CPR despite their protestations that this is ‘not what he/she would have wanted’. In the USA, emergency services personnel have even less discretion than in the UK. In many states, they are bound to start CPR unless a specific Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) is in place, even if the patient has another kind of documentation, for example POLST (Physician Order for Life-Sustaining Treatment) until they have online pharmacy kamagra spoken to a ‘medical command physician’. They also must continue CPR if it has been started by a bystander even if a DNACPR is in place, until they are told they can stop by a physician.To highlight the moral discomfort experienced and the ethical and legal challenges faced, we present the perspectives of an ambulance clinician and a relative, and then review the legal and ethical framework in which they are operating, before concluding with some suggested changes to policy and guidance which we believe will protect ambulance clinicians, relatives and the patient.Ambulance clinician’s perspective—Rob ColeThe following is a case study to illustrate the grey area faced by ambulance clinicians when they consider they need to make a ‘best interests’ decision on a patient who has arrested.

This is a composite online pharmacy kamagra case study from my experience of many such calls to protect the anonymity of those involved in any individual case.An emergency call was received by the ambulance emergency operations control room. At this stage, it was important to clarify the justification for this call as this directly influences any further decision making. If the call was for the purpose of providing resuscitation to a patient in cardiorespiratory arrest then, as early as this stage, we can determine online pharmacy kamagra that at the point of call, somebody (accepting unable to qualify exactly whom) believes that the patient is either clinically indicated for resuscitation or someone believes they would desire or benefit from such an intervention. The caller identified that her husband was experiencing a seizure, and this had lasted for 5 min prior to her calling the ambulance.

An ambulance was immediately despatched on this information alone (known as pre-alert dispatch). The location was some 4 min from the crew and they therefore arrived on the scene 5 min post call (in fact, on the crew arrival, the caller was still on the phone with the ambulance control centre).The crew were met by a female in her 70s (call with control online pharmacy kamagra ended on crew arrival). The crew were, as often is the case, provided with no further details other than that of a male in his 80s with a prolonged seizure. The ambulance online pharmacy kamagra had travelled under emergency conditions to the address.

The female greeted the crew (who had approached the property with full life-saving emergency equipment). She stated “I think online pharmacy kamagra he has gone” in a calm and clear voice. She allowed the crew into her home and quickly explained (during the journey to the patient, who is on a bed in the dining room downstairs) that the patient was her husband, that he had been generally unwell for some time (increased frailty, heart failure and developing dementia) and while she had not expected him to die at this point in time, she was not particularly surprised that he had. One member of the crew (double crew) prepared the patient online pharmacy kamagra for resuscitation, post a period of assessment while the other crew member continued to speak with the patient’s wife to better understand the situation.

The scene looked non-suspicious. The patient was lying peacefully online pharmacy kamagra (not breathing and with no heart rate) on a bed downstairs, dressed in pyjamas. The patient presented as frail in appearance but other than that, there was no further information of note.The member of the crew that spoke with the wife of the patient and ascertained that the patient was being treated by a general physician for a simple urinary tract , that there was no DNACPR in place as there was no specific requirement for one to have been put in place. No advance decision to refuse treatment (the female had no idea what this was) nor was there any legal power of attorney (the patient until this point had been online pharmacy kamagra broadly of sound mind with occasional episodes of confusion).

As the other member of the ambulance crew commenced resuscitation (CPR), the patient’s wife angrily stated that her husband would not wish for this, nor did she or any member of her family. She reiterated that the 999 call was due to a seizure, and had it been for the purpose of providing resuscitation, she would not have called the emergency services and all agreed online pharmacy kamagra that this was not the wish of the patient. Accepting this is not documented anywhere, the patient’s wife explained that these were conversations that had taken place within the family environment, that her husband had a clear view that he would not want to be subjected to any resuscitative efforts should he die, and funeral arrangements had been explored recently by all.To add, the patient’s wife appeared to be of sound mind, no obvious level of confusion and not in any particular state of heightened distress. The son of the patient was 10 min away from the address and on online pharmacy kamagra his way.

A neighbour had also arrived at the property.To summarise, cardiac arrest of a patient in his 80s, not expected to die but family not surprised (had been quite unwell recently), no DNACPR or other documented evidence of the patient’s thoughts, wishes and beliefs. Call for emergency help was to manage a seizure and NOT provide resuscitation.Family carer perspective—Mike StoneWhen my mother died about online pharmacy kamagra 10 years ago,7 I might have found myself as a relative trying to prevent a 999 paramedic from attempting CPR, but in the event, I found myself being ‘confronted by’ 999 personnel who seemed unable to understand why when my mum died at the end of a peaceful 4-day terminal coma, I had NOT felt the need ‘to phone someone immediately’. This prompted me to embark on an investigation into end-of-life (EoL) guidance, protocols, mindsets and laws, which revealed to me a situation I can, at best, describe as urgently requiring improvement, especially but not exclusively for EoL-at-home, and which, in complex and confusing situations, protects professionals at the expense of damaging relatives and, sometimes, even patients.From my family carer perspective, this situation has to change. And, the direction online pharmacy kamagra of change must be one which improves the support given to patients, by promoting integration between everyone, lay and professional, involved in supporting patients.

This ‘model’ requires ‘us and us’ as opposed to ‘us and them’. It emphasises teamwork between family carers and the clinicians who are in regular and online pharmacy kamagra ongoing contact with the patient, and it replaces ‘multidisciplinary team thinking’, with genuine professional-lay integration.Anyone can listen to a patient—provided you are present to listen. If only a relative is present, only the relative can listen. Often it will require a clinician, such as a 999 paramedic, to confirm that a patient is in cardiopulmonary arrest, but the family carer who called 999, is the person most likely to know if online pharmacy kamagra the patient would have wanted CPR.

Put simply, the clinicians are the experts in the clinical aspects, and the family and friends are the experts in ‘the patient as an individual’.I believe the current guidance around CPR decision-making is unsatisfactory and incoherent, and must be made more sensible and coherent.8–10 Contemporary protocols for ‘expected death’ are also fundamentally flawed.11 Advance decisions often fail to achieve the patient’s objective, apparently because clinicians are risk-averse.12I have only mentioned a few of the more significant problems, and those I have mentioned could, in theory, be addressed by consensus followed by improved training. Other fundamental problems—notably the fact that relatively few people have personal experience of caring for a loved one all the way online pharmacy kamagra to a death at home—are more problematic.To close this brief and personal analysis, I will give two opinions. The first is that the change required is easy to see, and involves things such as more group-based and ‘diffusely achieved’ decision-making instead of identifiable individuals being invariably associated with and responsible for specific decisions. But it is a change which a hierarchical and process/records-based National Health Service (NHS) would really struggle to come to terms with.13The second is my optimism that growing pressure from patients and relatives will make the changes in behaviour inevitable, because, perhaps surprisingly, of social media.14Legal analysis—Alex Ruck KeeneMike’s experiences speak clearly of the practical problems caused by paramedics misunderstanding the law.If there is a situation in which CPR would simply not work to restart the heart or breathing, then the paramedics would be under no duty to online pharmacy kamagra attempt it, as there is no duty to seek to carry out a futile procedure.

However, if it appeared that it might work, then the paramedics are, in England and Wales, governed by the MCA 2005. In practice, the realities confronted by paramedics are such that the majority of their decision-making will be online pharmacy kamagra governed by the MCA 2005. This Act provides a framework for decision-making in relation to those with impaired decision-making capacity which is (unlike legal frameworks in some other jurisdictions) not predicated on there being an automatic proxy decision-maker, such as a ‘next of kin.’ Rather, the Act provides (in s.5) that any person—such as a paramedic—is able to carry out an act of care and treatment in relation to another (‘P’) with protection from liability if they. (1) take reasonable steps to determine whether P has the capacity to online pharmacy kamagra consent to the act.

And (2) if P lacks capacity, that they reasonably believe that they are acting in P’s best interests.In all situations, the first step is to consider whether the person has capacity to make their own decision—to consent to or refuse CPR. In the scenario presented by Rob Cole, as with almost all situations where CPR is required, the patient was unconscious and there were no practicable steps that could be taken to support him within the time available. Reaching the conclusion that the patient did not have capacity could therefore have been effectively instantaneous.The paramedics had taken reasonable steps to ascertain whether the person had made an advance decision to refuse CPR (as a medical treatment), and that he had not made one.This means that they were therefore required to decide online pharmacy kamagra whether it was in his best interests for them to attempt it.‘Best interests’ is, deliberately, not defined in the MCA 2005. However, s.4 sets out a series of matters that must be considered whenever a person is determining what is in the person’s best interests to allow them to have a reasonable belief as to they are acting in those best interests.

It is extremely important to recognise that the MCA 2005 does not specify what is in online pharmacy kamagra the person’s best interests. Rather, it sets down a process by which that conclusion should be reached, which recognises that a lack of decision-making capacity is not an ‘off-switch’ for their rights and freedom (Wye Valley NHS Trust v- Mr B ]2015[ EWCOP 60 in paragraph 11). The process aims to construct a decision on behalf online pharmacy kamagra of the person who cannot make that decision themselves. As the Supreme Court emphasised in Aintree University NHS Hospitals Trust v James [2014] UKSC 67 “[t]he purpose of the best interests test is to consider matters from the patient’s point of view.” It is critically important to understand that the purpose of the decision-making process is to try to arrive at the decision that is the right decision for the person themselves, as an individual human being, and not the decision that best fits with the outcome that the professionals desire.

Any information about the patient’s wishes, feelings, beliefs and values will be relevant, including, in particular, preferences and recommendations documented when the person had capacity.Consultation will also be required with those who could shed light online pharmacy kamagra on the person’s likely decision, here his wife. The case of Winspear v City Hospitals Sunderland NHS Foundation Trust [2015] EWHC 3250 (QB) made clear that a failure to consult where it is practicable and appropriate will mean that professionals cannot then rely on the defence in s.5 of MCA to what might otherwise be criminal acts.In making a best interests decision about giving life-sustaining treatment, there is always a strong presumption that it will be in the patient’s best interests to prolong his or her life, and the decision-maker must not be motivated by a desire to bring about the person’s death for whatever reason, even if this is from a sense of compassion. However, the strong presumption in favour of prolonging life can be displaced where:There is online pharmacy kamagra clear evidence that the person would not want the treatment in question in the circumstances that have arisen.The treatment itself would be overly burdensome for the patient, in particular by reference to whether the patient accepts invasive and uncomfortable interventions or prefers to be kept comfortable.There is no prospect that the treatment will return the patient to a state of a quality of life that the patient would regard as worthwhile. The important viewpoint is that of the patient, not of the doctors or healthcare professionals.Case law has made clear that the weight that is to be attached to the reliably ascertainable views of the person should be given very substantial, if not determinative, weight (Re AB (Termination of Pregnancy) [2019) EWCA Civ 1215].

In a case such as that described in the scenario of the ambulance clinician, and given the clarity of the views expressed by the man’s wife in relation to what he would have wanted, the paramedics could properly conclude that attempting CPR was not in his best online pharmacy kamagra interests. The Supreme Court has confirmed that they should not then attempt it. NHS Trust v Y [2018] UKSC 22.Drawing the legal threads together, therefore, in a situation such as this:Unless the paramedics have a proper online pharmacy kamagra reason to doubt the good faith of the family member present, they should proceed on the basis that they are reliable in relaying what the person would have wanted.The paramedics can then either start or not start CPR accordingly because they have the necessary reasonable belief that they are acting in the person’s best interests.If there is reason to doubt the good faith of the family member present, or the family member does not (or cannot) relay clear views, the paramedics should start CPR. It may be that after they have started, they are able to glean further information which makes the picture clearer and enables them to decide whether continuing is in the patient’s best interests.Ethical overview and proposals for change—Zoë Fritz (and other authors)Law, ethical principles and professional clinical guidelines influence each other.15 In an ideal system, this would ensure just care with recognition of the rights of practitioners and patients.

When it online pharmacy kamagra works badly, the ‘letter of the law’ is followed, even when it runs counter to good ethics, with potentially devastating personal consequences. The composite scenario and personal events, described above by an ambulance clinician and a family member, reflect examples of where medical practitioners believed they were following the law, but where their actions could be argued to have been unethical.In contrast, a related example of the law working positively to overturn accepted clinical guidance and practice, is around the need to discuss a decision not to attempt CPR with a patient. The 2007 joint guidance issued online pharmacy kamagra by the British Medical Association, Royal College of Nursing and the Resuscitation Council (UK) (2007) stated. €œWhen a clinical decision is made that CPR should not be attempted, because it will not be successful, and the patient has not expressed a wish to discuss CPR, it is not necessary or appropriate to initiate discussion with the patient to explore their wishes regarding CPR.” The case of Janet Tracey challenged this.

The judges in the court of appeal found that online pharmacy kamagra not discussing a decision to withhold CPR with a patient was in breach of their human rights (Article 8 European Convention on Human Rights) as it deprived them of the right to question the clinical decision or ask for a second opinion, particularly in the context of a potentially life-saving treatment.16 Clinicians rapidly changed their practice. In fact, the whole nature of CPR conversations was altered to ensure that it was not considered in isolation, but always discussed within overall goals of care. In being forced to discuss CPR with patients, doctors reconsidered the conversation, what online pharmacy kamagra it meant and when it could and should occur.17The ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process emerged from this as a way of nudging doctors and patients into having better conversations and documentation of agreed recommendations;18 it is now used in more than 130 trusts.19While, at first glance, there may appear to be ethical and legal tensions in the scenarios described above, it is possible that good training and professional guidance would dispel them. If families were better supported to understand what may happen where a loved one dies at home, they would be better equipped to deal with the crisis when it came.

Specific resources online pharmacy kamagra are needed. If, for example, there had been a specific number to call for an expected death, other than 999, in the two deaths reported here, then neither of these upsetting scenarios would have occurred. As mentioned above, social media may be another positive force in both applying pressure for change, and in acting as a leveller in terms of access to online pharmacy kamagra information.If the professional guidance and other material—published by Joint Royal Colleges Ambulance Liaison Committee, Royal College of Nursing, Resuscitation Council UK and so on—stated clearly that, where death was expected and CPR appeared to be futile, even in the absence of a DNACPR or ReSPECT form, an ambulance clinician or qualified nurse could decide that attempting CPR was clinically pointless or potentially harmful, then clinicians would not need to choose between what they considered morally right and what they had to do to protect their professional registration.The new JRCALC guidance takes this into account, and it is likely that other guidance will also be explicit about this in the future. They should also be explicit about the role of the MCA and best interests decisions.

An honest carer, family member who protests, “… but my husband would definitely not want CPR—don’t do that! online pharmacy kamagra. € may be perceived as applying the MCA to her own determination of what is in her husband’s best interests, even if the wife has no awareness of the MCA.If the ambulance clinicians were taught clearly that acting in the patient’s ‘best interests’ in this scenario most often meant doing as the relatives asked, then the (frequently internalised) concern that they were choosing between what was right for the patient and what was right for the patient’s relative would be abolished, and the associated moral discomfort diminished. We recognise that there will, in some cases, be a different tension—where the ambulance clinician considers that the CPR will not be successful but online pharmacy kamagra the relatives want it to take place. But this is where the distinction between the ambulance clinician as the expert in the medical procedure and the relative as the expert in the person comes in—nobody can demand medical treatment which is inappropriate, and CPR is no different.The guidance and the training should emphasise the teawork which Mike Stone mentions above.

The default assumption should be that clinicians and relatives have a shared goal of what is best for the patient, and work together as ‘us and us’ as opposed to ‘us and them’.Data availability statementThere are no data in this work.Ethics statementsPatient consent for publicationNot required..

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Sung II Park, assistant professor in the Department of Electrical kamagra liquid jelly and Computer Engineering. "Our device has the potential to do both of these things in the harsh gastric conditions, which, in the future, can be hugely beneficial to people needing dramatic weight-loss surgeries."Further details about their device are published in the January issue of Nature Communications.Obesity is a global epidemic. Furthermore, its associated health problems have kamagra liquid jelly a significant economic impact on the U.S. Health care system, costing $147 billion a year.

Additionally, obesity puts people at risk for chronic diseases such as diabetes, heart disease and even some kamagra liquid jelly cancers. For those with a body mass index greater than 35 or who have at least two obesity-related conditions, surgery offers a path for patients to not only lose the excess weight but maintain their weight over the long term.In recent years, the vagus nerve has received much attention as a target for treating obesity since it provides sensory information about fullness from the stomach lining to the brain. Although there are medical devices that can stimulate the vagus nerve endings and consequently help in curbing hunger, these devices are similar in design to a pacemaker, that is, wires connected to a current kamagra liquid jelly source provide electrical jolts to activate the tips of the nerve. advertisement However, Park said wireless technology, as well as the application of advanced genetic and optical tools, have the potential to make nerve stimulation devices less cumbersome and more comfortable for the patient."Despite the clinical benefit of having a wireless system, no device, as of yet, has the capability to do chronic and durable cell-type specific manipulation of neuron activity inside of any other organ other than the brain," he said.To address this gap, Park and his team first used genetic tools to express genes that respond to light into specific vagus nerve endings in vivo.

Then, they designed kamagra liquid jelly a tiny, paddle-shaped device and inserted micro LEDs near the tip of its flexible shaft, which was fastened to the stomach. In the head of the device, called the harvester, they housed microchips needed for the device to wirelessly communicate with an external radio frequency source. The harvester was also equipped to produce tiny currents to power the kamagra liquid jelly LEDs. When the radio frequency source was switched on, the researchers showed that the light from the LEDs was effective at suppressing hunger.The researchers said they were surprised to uncover that the biological machinery coordinating hunger suppression in their experiments was different from conventional wisdom.

In other words, it is widely accepted that when the stomach is full, it expands and the information about stretch is conveyed to the brain by mechanoreceptors on the vagus nerve."Our findings suggest that stimulating the non-stretch receptors, the ones that respond to chemicals in the food, could also give the feeling of satiety even when the stomach was not distended," said Park.Looking ahead, he said that the current device could also be used to manipulate nerve endings throughout the kamagra liquid jelly gastrointestinal tract and other organs, like the intestine, with little or no modifications."Wireless optogenetics and identifying peripheral neural pathways that control appetite and other behaviors are all of great interest to researchers in both the applied and basic fields of study in electronics, material science and neuroscience," said Park. "Our novel tool now enables interrogation of neuronal function in the peripheral nervous systems in a way that was impossible with existing approaches." Story Source. Materials provided by kamagra liquid jelly Texas A&M University. Original written by Rachel Rose.

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Gastric bypass surgery is sometimes the last resort for those who struggle with obesity or have serious health-related issues http://susanmorning.com/?p=1 due online pharmacy kamagra to their weight. Since this procedure involves making a small stomach pouch and rerouting the digestive tract, it is very invasive and prolongs the recovery period for patients. In a new study, researchers at Texas A&M University have described a online pharmacy kamagra medical device that might help with weight loss and requires a simpler operative procedure for implantation.Researchers said their centimeter-sized device provides the feeling of fullness by stimulating the endings of the vagus nerve with light.

Unlike other devices that require a power cord, their device is wireless and can be controlled externally from a remote radio frequency source."We wanted to create a device that not only requires minimal surgery for implantation but also allows us to stimulate specific nerve endings in the stomach," said Dr. Sung II Park, assistant professor online pharmacy kamagra in the Department of Electrical and Computer Engineering. "Our device has the potential to do both of these things in the harsh gastric conditions, which, in the future, can be hugely beneficial to people needing dramatic weight-loss surgeries."Further details about their device are published in the January issue of Nature Communications.Obesity is a global epidemic.

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Then, they designed a tiny, paddle-shaped device and inserted micro online pharmacy kamagra LEDs near the tip of its flexible shaft, which was fastened to the stomach. In the head of the device, called the harvester, they housed microchips needed for the device to wirelessly communicate with an external radio frequency source. The harvester was online pharmacy kamagra also equipped to produce tiny currents to power the LEDs.

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