Tobacco smoke and occupational these exposures include organic and inorganic dusts and exposures also appear to act additively to increase the chemical agents and fumes impotence from diabetes buy on line eriacta. Studies from developed countries45 erectile dysfunction pump canada buy eriacta 100 mg otc, 46 show that densely populated with people and cars erectile dysfunction bangalore doctor cheap eriacta 100 mg line. Indoor air pollution resulting from women are more susceptible to the effects of tobacco the burning of wood and other biomass fuels is estimated smoke than men44 erectile dysfunction at 65 cheap eriacta 100 mg fast delivery, 47 diabetes obesity and erectile dysfunction purchase eriacta mastercard, 48 erectile dysfunction injection medication purchase eriacta 100mg amex. This is an important question given to kill two million women and children each year36 do erectile dysfunction pumps work buy eriacta 100mg lowest price. Outdoor Air Pollution: High levels of urban air pollution are harmful to individuals with existing heart or lung disease erectile dysfunction drugs injection purchase eriacta amex. However, air pollution from fossil fuel combustion, 51 may also play a significant role in exacerbations. A history primarily from motor vehicle emissions in cities, is associated 37 of severe childhood respiratory infection has been with decrements of respiratory function. The relative associated with reduced lung function and increased effects of short-term, high-peak exposures and long-term, 38, 41, 52 respiratory symptoms in adulthood. There may be an increased diagnosis Lung Growth and Development of severe infections in children who have underlying airway Lung growth is related to processes occurring during hyperresponsiveness, itself considered a risk factor for gestation, birth, and exposures during childhood38-40. It is not clear, Oxidative Stress however, whether this pattern reflects exposures to indoor and outdoor air pollutants, crowding, poor nutrition, or other the lungs are continuously exposed to oxidants generated factors that are related to low socioeconomic status55, 56. In Nutrition addition, intracellular oxidants, such as those derived from mitochondrial electron transport, are involved in many the role of nutrition as an independent risk factor for the cellular signaling pathways. Malnutrition and against this oxidative challenge by well-developed enzymatic weight loss can reduce respiratory muscle strength and and nonenzymatic systems. Oxidative stress not only produces with the development of emphysema has been shown in direct injurious effects in the lungs but also activates experimental studies in animals58. Occupational exposures: evidence for a causal a longitudinal cohort of the Tucson Epidemiological Study association with chronic obstructive pulmonary disease. Am of Airway Obstructive Disease adults with asthma were Rev Respir Dis 1989; 140(3 Pt 2):S85-91. Biological dust exposure in the workplace is a risk factor for chronic obstructive pulmonary disease. Smoking and lung with tobacco smoking and environmental tobacco smoke function of Lung Health Study participants after 11 years. Siblings of patients with severe chronic of chronic obstructive pulmonary disease. Environ Health obstructive pulmonary disease have a significant risk of Perspect 2005; 4:7-15. Transforming growth factor-beta1 genotype and suscepti obstructive respiratory disease in an industrialized urban bility to chronic obstructive pulmonary disease. Effects on lung function during the first 18 months of gene for microsomal epoxide hydrolase and susceptibility to life. Effect of cigarette smoking and Occupational contribution to the burden of airway disease. Smoke the killer in the kitchen: Indoor air weight with adult lung function: findings from the British pollution in developing countries. Indoor air pollution and health in developing imbalance in chronic obstructive pulmonary disease. Shedding new light on Chronic obstructive pulmonary disease surveillance-United wood smoke: a risk factor for respiratory health. Wood smoke exposure and risk of chronic an inhaled anticholinergic bronchodilator on the rate of decline obstructive pulmonary disease. Inaugural article: national burden of disease in Respir Crit Care Med 2000; 162(6):2152-8. Seemungal T, Harper-Owen R, Bhowmik A, Moric I, Sanderson pollutants and lung function in nonsmokers. Relation of birth weight and childhood respiratory infection to adult lung function and death from chronic 52. The relationship between pneumonia in early childhood and impaired lung function in late adult life. Criteria for a recommended standard: occupational exposure to respirable coal mine dust: National Institute of Occupational Safety and Health; 1995. Risk factors associated with the presence of irreversible airflow limitation and reduced transfer coefficient in patients with asthma after 26 years of follow up. These changes include chronic parenchymal tissue destruction (resulting in emphysema), inflammation, and structural changes resulting and disrupt normal repair and defense mechanisms from repeated injury and repair. Structural changes: Thickening of intima, endothelial cell dysfunction, smooth muscle pulmonary hypertension. Derived from blood appears to be an amplification of the normal inflammatory monocytes that differentiate within lung tissue. The mechanisms for this amplification are not yet understood but may be genetically determined. Lung inflammation is further amplified by cells, contributing to their destruction. Epithelial cells: May be activated by cigarette smoke to produce inflammatory mediators. Oxidants are generated by cigarette smoke and other inhaled particulates, and released from activated inflammatory cells such as macrophages and neutrophils12. Many of these adverse effects are mediated by Examples of each type of mediator are listed in Figure 4-4. Hyperinflation reduces inspiratory capacity such that functional residual capacity increases, Figure 4-5. It is now Serine proteases thought that hyperinflation develops early in the disease and is the main mechanism for exertional dyspnea15. Neutrophil elastase alpha-1 antitrypsin Cathepsin G alpha-1 antichymotrypsin Bronchodilators acting on peripheral airways reduce air Proteinase 3 Secretory leukoprotease inhibitor trapping, thereby reducing lung volumes and improving Elafin symptoms and exercise capacity. Finally, people with cough, is a feature of chronic bronchitis and is not asthma who smoke develop pathological features similar necessarily associated with airflow limitation. Several mediators and proteases stimulate and may be triggered by infection with bacteria or viruses mucus hypersecretion and many of them exert their or by environmental pollutants. In mild and moderate exacerbations there is an increase in neutrophils and in Pulmonary Hypertension some studies also eosinophils in sputum and the airway wall22. There constriction of small pulmonary arteries, eventually resulting is even less information about severe exacerbations, in structural changes that include intimal hyperplasia and 17 although one study showed a marked increase in later smooth muscle hypertrophy/hyperplasia. There is neutrophils in the airway wall and increased expression an inflammatory response in vessels similar to that seen in 23 of chemokines. During an exacerbation there is the airways and evidence for endothelial cell dysfunction. Pathophysiology of airflow limitation in chronic and comorbid diseases18, 19 (Figure 4-8). Cellular may be a loss of skeletal muscle mass and weakness and structural bases of chronic obstructive pulmonary disease. Oxidative stress in pathogenesis of chronic obstruc tive pulmonary disease: cellular and molecular mechanisms. Dynamic hyperinflation and exercise intolerance in chronic obstructive pulmonary disease. Roles of epidermal growth factor receptor activation in epithelial cell repair and mucin production in air way epithelium. Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis. Further assessing the potential benefit of each approach at deterioration of lung function usually requires the each stage of the illness is a crucial aspect of effective progressive introduction of more treatments, both disease management. Appropriate aimed at the following goals: treatment and measures to prevent further exacerbations should be implemented as quickly as possible. The extent to which these goals can be realized varies with each individual, and some treatments will produce benefits in more than one area. In selecting a treatment plan, the benefits and risks to the individual, and the costs, direct and indirect, to the individual, his or her family, and the community must be considered. These sputum production, and/or a history of exposure indicators are not diagnostic themselves, but the presence to risk factors for the disease. The diagnosis of multiple key indicators increases the probability of a should be confirmed by spirometry. Symptoms and can be present for many years before the development objective measures of airflow limitation should be of airflow limitation and are often ignored or discounted monitored to determine when to modify therapy by patients and attributed to aging or lack of conditioning. The diagnosis should continue, dyspnea worsens, and additional symptoms be confirmed by spirometry. In some cases, significant8 major cause of disability and anxiety associated with the airflow limitation may develop without the presence of a disease. However, the terms used to2 describe dyspnea vary both by individual and by culture3. I walk slower than people of the same age on the Regular production of sputum for 3 or more months in 2 level because of breathlessness, or I have to stop for consecutive years (in the absence of any other conditions breath when walking on my own pace on the level. Sputum production is often difficult to evaluate I am too breathless to leave the house or I am because patients may swallow sputum rather than expectorate breathless when dressing or undressing. The presence of purulent sputum reflects an increase in inflammatory mediators10, and its progressive. Wheezing and chest and may be avoided entirely by appropriate behavioral tightness are nonspecific symptoms that may vary between change. It is the best detection of technical errors or have an automatic standardized, most reproducible, and most objective prompt to identify an unsatisfactory test and the measurement of airflow limitation available. Spirometry should be performed after the administration of an ade quate dose of a short-acting inhaled bronchodilator. Post bronchodilator reference the presence of airflow limitation that is not fully values in this population are urgently needed to avoid reversible. Much depends on the success of convincing such people, as well as health care workers, that even minor respiratory symptoms are not normal and may be markers of future ill health. Similarly, weight loss tobacco smoking, and abnormal lung function identifies a subgroup of smokers at increased risk for lung cancer. This has been the basis of an argument that screening spirometry should be employed as a global health assessment tool25. Several considerations are important to ensure bronchodilators in the previous six hours, long-acting accurate test results. Changes in arterial blood gas tensions take Spirometry time to occur, especially in severe disease. This could lead to family screening a short-acting bronchodilator is given; 30-45 minutes or appropriate counseling. The best way to detect changes in symptoms Largely irreversible airflow limitation. Suggested Questions for Allergy, rhinitis, and/or eczema also Follow-Up Visits* present. Commonly associated with bacterial Monitor disease progression and development of complications: infection. Monitor pharmacotherapy and other medical treatment: Almost all have chronic sinusitis. What did you do to control seen, and the frequency of visits, will depend on the the symptoms The validity and reliability of these questions Elevation of the jugular venous pressure and the presence have not been assessed. Firm diagnosis of cor pulmonale can be made can be expected to worsen over time, even with the through a number of investigations, including radiography, best available care. Symptoms and objective measures electrocardiography, echocardiography, radionucleotide of airflow limitation should be monitored to determine scintigraphy, and magnetic resonance imaging. However, when to modify therapy and to identify any complications all of these measures involve inherent inaccuracies that may develop. Despite the benefits of being able to delineate pathological anatomy, Pulmonary function. The development function is usually measured by recording the maximum of respiratory failure is indicated by a PaO2 < 8. Screening patients by pulse oximetry and assessing patients when dyspnea or hypercapnia is assessing arterial blood gases in those with an oxygen not readily explained by lung function testing or when saturation (SaO2) < 92% is a useful way of selecting 42 peripheral muscle weakness is suspected. Clinical signs of respiratory failure or right heart failure include central cyanosis, ankle swelling, and an increase Sleep studies. Clinical signs of hyper hypoxemia or right heart failure develops in the presence capnia are extremely nonspecific outside of exacerbations. Several types of tests are available artery pressure 30 mm Hg) is only likely to be important to measure exercise capacity. Monitor Pharmacotherapy and Other Medical Treatment Diagnosis of right heart failure or cor pulmonale. Dosages of various medications, adherence to the regimen, inhaler technique, effectiveness of the current regime at controlling symptoms, and side effects of treatment should be monitored. Monitor Exacerbation History During periodic assessments, health care workers should question the patient and evaluate any records of exacerbations, both self-treated and those treated by other health care providers. Increased sputum volume, acutely worsening dyspnea, and the presence of purulent sputum should be noted. Specific inquiry into unscheduled visits to providers, telephone calls for assistance, and use of urgent or emergency care facilities may be helpful. Severity can be estimated by the increased need for bronchodilator medication or glucocorticosteroids and by the need for antibiotic treatment. Hospitalizations should be documented, including the facility, duration of stay, and any use of critical care or intubation. The clinician then can request summaries of all care received to facilitate continuity of care. Until more integrated guidance about disease management for specific comorbid problems becomes available, the focus should be on identification and management of these individual problems in line with local treatment guidance. Interventions to prevent initiatives should also focus on passive smoking smoking uptake and maximize cessation should be to minimize risks for nonsmokers. Efforts to reduce smoking through public health initiatives should the role of health care providers in smoking cessation. Partners and parents should not smoke in faceted approach, including public policy, information the immediate vicinity of nonsmokers or children, nor in dissemination programs, and health education through the enclosed spaces such as cars and poorly ventilated media and schools59. Involving as when the fetus is exposed to blood-borne metabolites many of these individuals as possible will help. Education to reduce in utero risks for care workers should encourage all patients who smoke unborn children is also of great importance to prevent the to quit, even those patients who come to the health care effects of maternal smoking in reducing lung growth and provider for unrelated reasons and do not have symptoms causing airways disease in early and later life52, 53. Guidelines for smoking cessation entitled tobacco smoke in the home if a family member smokes. The major conclusions are summarized respiratory infections, and are at a greater risk of in Figure 5. Tobacco dependence is a chronic condition that warrants of airflow limitation, or reduce its progression55, and can repeated treatment until long-term or permanent abstinence is 56 achieved. Brief smoking cessation counseling is effective and every sexes, in all racial and ethnic groups, and in pregnant tobacco user should be offered such advice at every contact with health care providers. Age influences quit rates, with young people less likely to quit, but nevertheless smoking cessation 5.
Jaundice is caused by the buildup of bilirubin impotence grounds for divorce states order generic eriacta canada, a dark yellow-brown substance made in the liver vacuum pump for erectile dysfunction in dubai order eriacta 100mg visa. Bile goes through the common bile duct into the intestines impotence at 46 buy eriacta 100mg line, where it helps break down fats erectile dysfunction at age 17 best buy eriacta. These cancers can press on the duct and cause jaundice while they are still fairly small erectile dysfunction treatment options natural generic eriacta 100 mg with amex, which can sometimes lead to these tumors being found at an early stage erectile dysfunction book order eriacta 100mg with mastercard. There are other signs of jaundice as well as the yellowing of the eyes and skin: q Dark urine: Sometimes erectile dysfunction low libido discount eriacta express, the first sign of jaundice is darker urine erectile dysfunction shot treatment quality 100mg eriacta. Other causes, such as 4 American Cancer Society cancer. Belly or back pain Pain in the abdomen (belly) or back is common in pancreatic cancer. Cancers that start in the body or tail of the pancreas can grow fairly large and start to press on other nearby organs, causing pain. The cancer may also spread to the nerves surrounding the pancreas, which often causes back pain. Pain in the abdomen or back is fairly common and is most often caused by something other than pancreatic cancer. Weight loss and poor appetite Unintended weight loss is very common in people with pancreatic cancer. Nausea and vomiting If the cancer presses on the far end of the stomach it can partly block it, making it hard for food to get through. Gallbladder or liver enlargement If the cancer blocks the bile duct, bile can build up in the gallbladder, making it larger. Sometimes a doctor can feel this (as a large lump under the right side of the ribcage) during a physical exam. Pancreatic cancer can also sometimes enlarge the liver, especially if the cancer has spread there. The doctor might be able to feel the edge of the liver below the right ribcage on an exam, or the large liver might be seen on imaging tests. Blood clots Sometimes, the first clue that someone has pancreatic cancer is a blood clot in a large vein, often in the leg. Sometimes a piece of the clot can break off and travel to the lungs, which might make it hard to breathe or cause chest pain. Last Medical Review: February 11, 2019 Last Revised: February 11, 2019 Tests for Pancreatic Cancer If a person has signs and symptoms that might be caused by pancreatic cancer, certain exams and tests will be done to find the cause. If cancer is found, more tests will be done to help determine the extent (stage) of the cancer. Medical history and physical exam 6 American Cancer Society cancer. The doctor might also ask about possible risk factors, including smoking and your family history. Your doctor will also examine you to look for signs of pancreatic cancer or other health problems. Pancreatic cancers can sometimes cause the liver or gallbladder to swell, which the doctor might be able to feel during the exam. Your skin and the whites of your eyes will also be checked for jaundice (yellowing). If the results of the exam are abnormal, your doctor will probably order tests to help find the problem. You might also be referred to a gastroenterologist (a doctor who treats digestive system diseases) for further tests and treatment. Imaging tests Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body. They can also help show if cancer has spread to organs near the pancreas, as well as to lymph nodes and distant organs. But if a needle biopsy is needed, most doctors prefer to use endoscopic ultrasound (described below) to guide the needle into place. Cholangiopancreatography this is an imaging test that looks at the pancreatic ducts and bile ducts to see if they are blocked, narrowed, or dilated. These tests can help show if someone might have a pancreatic tumor that is blocking a duct. The doctor can see through the endoscope to find the ampulla of Vater (where the common bile duct empties into the small intestine). X-rays taken at this time can show narrowing or blockage in these ducts that might be due to pancreatic cancer. The doctor doing this test can put a small brush through the 6 tube to remove cells for a biopsy or place a stent (small tube) into a bile or pancreatic duct to keep it open if a nearby tumor is pressing on it. A contrast dye is then injected through the needle, and x-rays are taken as it passes through the bile and pancreatic ducts. A special camera is then used to create a picture of areas of radioactivity in the body. A small amount of contrast dye is 9 American Cancer Society cancer. This test can be useful in finding out if a pancreatic cancer has grown through the walls of certain blood vessels. Mainly, it helps surgeons decide if the cancer can be removed completely without damaging vital blood vessels, and it can also help them plan the operation. X-ray angiography can be uncomfortable because the doctor has to put a small catheter into the artery leading to the pancreas. Usually the catheter is put into an artery in your inner thigh and threaded up to the pancreas. Once the catheter is in place, the dye is injected to outline all the vessels while the x-rays are being taken. These techniques are now used more often because they can give the same information without the need for a catheter in the artery. Blood tests Several types of blood tests can be used to help diagnose pancreatic cancer or to help determine treatment options if it is found. Liver function tests: Jaundice (yellowing of the skin and eyes) is often one of the first signs of pancreatic cancer. Doctors often get blood tests to assess liver function in people with jaundice to help determine its cause. Tumor markers: Tumor markers are substances that can sometimes be found in the blood when a person has cancer. Levels of these tumor markers are not high in all people with 10 American Cancer Society cancer. Still, these tests can sometimes be helpful, along with other tests, in figuring out if someone has cancer. If all of the cancer has been removed, these tests can also be done to look for signs the cancer may be coming back. Percutaneous (through the skin) biopsy: For this test, a doctor inserts a thin, hollow needle through the skin over the abdomen and into the pancreas to remove a small piece of a tumor. The doctor passes an endoscope (a thin, flexible, tube with a small video camera on the end) down the throat and into the small intestine near the pancreas. They can be useful if the surgeon is concerned the cancer has spread beyond the pancreas and wants to look at (and possibly biopsy) other organs in the abdomen. The most common 9 way to do a surgical biopsy is to use laparoscopy (sometimes called keyhole surgery). The surgeon can look at the pancreas and other organs for tumors and take biopsy samples of abnormal areas. Some people might not need a biopsy 11 American Cancer Society cancer. Instead, the doctor will proceed with surgery, at which time the tumor cells can be looked at in the lab to confirm the diagnosis. During surgery, if the doctor finds that the cancer has spread too far to be removed completely, only a sample of the cancer may be removed to confirm the diagnosis, and the rest of the planned operation will be stopped. If treatment (such as chemotherapy or radiation) is planned before surgery, a biopsy is needed first to be sure of the diagnosis. Lab tests of biopsy samples the samples obtained during a biopsy (or during surgery) are sent to a lab, where they are looked at under a microscope to see if they contain cancer cells. This might affect whether certain targeted 10 therapy drugs might be helpful as part of treatment. Testing for these gene mutations can sometimes affect which treatments might be helpful. It might also affect whether other family members should consider genetic counseling and testing as well. DeVita, Hellman, and 13 American Cancer Society cancer. Last Medical Review: February 11, 2019 Last Revised: January 2, 2020 Pancreatic Cancer Stages After someone is diagnosed with pancreatic cancer, doctors will try to figure out if it has spread, and if so, how far. Cancers with similar stages tend to have a similar outlook and are often treated in much the same way. It is based on the results of physical exam, biopsy, and imaging tests (see Tests for Pancreatic Cancer). If you have any questions about your stage, please ask your doctor to explain it to you in a way you understand. Any T the cancer has spread to distant sites such as the liver, peritoneum (the lining of the abdominal cavity), lungs or bones (M1). Tumor grade the grade describes how closely the cancer looks like normal tissue under a microscope. Low-grade cancers (G1) tend to grow and spread more slowly than high-grade (G3) cancers. Most of the time, Grade 3 pancreas cancers tend to have a poor prognosis (outlook) compared to Grade 1 or 2 cancers. But for treatment purposes, doctors use a simpler staging system, which divides cancers into groups based on whether or not they can be removed (resected) with surgery: q Resectable q Borderline resectable q Unresectable (either locally advanced or metastatic) Resectable If the cancer is only in the pancreas (or has spread just beyond it) and the surgeon believes the entire tumor can be removed, it is called resectable. Borderline resectable this term is used to describe some cancers that might have just reached nearby blood vessels, but which the doctors feel might still be removed completely with surgery. Some type of surgery might still be done, but it would be a less extensive operation with the goal of preventing or relieving symptoms or problems like a blocked bile duct or intestinal tract, instead of trying to cure the cancer. Surgery might still be done, but the goal would be to prevent or relieve symptoms, not to try to cure the cancer. International consensus on definition and criteria of 19 American Cancer Society cancer. Last Medical Review: December 18, 2017 Last Revised: December 18, 2017 Survival Rates for Pancreatic Cancer Survival rates can give you an idea of what percentage of people with the same type and stage of cancer are still alive a certain amount of time (usually 5 years) after they were diagnosed. Talk with your doctor about how these numbers may apply to you, as he or she is familiar with your situation. A relative survival rate compares people with the same type and stage of pancreatic cancer to people in the overall population. Instead, it groups cancers into localized, regional, and distant stages: 20 American Cancer Society cancer. They do not apply later on if the cancer grows, spreads, or comes back after treatment. Treatments improve over time, and these numbers are based on people who were diagnosed and treated at least five years earlier. They want to answer all of your questions, so that you can make informed treatment and life decisions. Not all of these questions may apply to you, but asking the ones that do may be helpful. Th isterm fitsth e inclusioncriteriaasarelevantterm forcardiac 10084280 F oetalcardiacarrest Cardiacdisorders X arrh yth mias. Perinatalh epatitisC inpediatricpatientsmayrange from asymptomaticto fulminanth epatitis. 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Restricting liberty in the interest of public health by measures such as quarantine erectile dysfunction rings for pump order eriacta cheap online. Priority setting new erectile dysfunction drugs 2013 100mg eriacta overnight delivery, including the allocation of scarce resources erectile dysfunction exercise eriacta 100mg generic, such as vaccines and antiviral medicines erectile dysfunction treatment psychological cheap eriacta online american express. Decision makers and the public need to be engaged in the discussions about ethical choices erectile dysfunction rates eriacta 100 mg free shipping, so plans reflect what most people will accept as fair erectile dysfunction doctors in lafayette la order eriacta with amex, and good for public health erectile dysfunction causes cycling order 100 mg eriacta fast delivery. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 3 A erectile dysfunction treatment singapore cheap eriacta online master card. There will be choices about the level of risk health care workers should face while caring for the sick, the imposition of restrictive measures such as quarantines, the allocation of limited resources such as medicines, and the use of travel restrictions and other measures to contain the spread of disease. Governments and health care leaders have been working on pandemic plans in many parts of the world. However, most of their communication to the public has focussed on technical issues, such how to obtain, stockpile and distribute medicines, and the assignment of duties. Planners have not generally communicated the ethical underpinnings of their choices in a clear manner. When medications are distributed, should children come before or after health care and emergency services workers, or decision makers such politicians Government and health care leaders need to make the values behind their decisions public. They should discuss the values with people who could be affected, ranging from health care workers, who will find themselves on the front lines, to government officials, who are making decisions about the allocation of limited resources, to the public at large, because people will be affected in many ways. They need to do this in advance of a health crisis, not when people are lining up at emergency ward doors. Openly discussing the choices and confirming that they are based on ethical values that are shared by members of a society brings important benefits. If ethics are clearly built into pandemic plans in an open and transparent manner, and with buy-in from multiple sectors of society, the plans carry greater trust, authority and legitimacy. People will be more likely to cooperate, and accept difficult decisions made by their leaders for the common good. It is a goal of this paper to provide guidance and to spur a broad public discussion of the often difficult ethical issues underlying decisions. The Province of Ontario in Canada built a significant ethics Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 4 component into its Ontario Health Plan for an Influenza Pandemic of June 2005. The Toronto Academic Health Science Network, made up of all the teaching hospitals in Toronto, is working on a collaborative pandemic plan that will include references to using an ethical framework. It also found that health care systems had generally not prepared themselves to deal with the hard ethical choices that rapidly arose. People started raising the issues of whose values should prevail during a public health emergency. Decision makers had to balance individual freedoms against the common good, fear for personal safety against the duty to treat the sick, and economic losses against the need to contain the spread of a deadly disease. Decisions had to be rapid, and were as transparent as possible given the limitations of the time. Therefore the lesson learned is to establish the ethical framework in advance, and to do it in a transparent manner. The Working Group recommends using these principles to develop a preventive ethics approach. This will have many benefits, including the reduction of conflicts during a crisis. While much of the research was done in Canada, the lessons are generally applicable around the world. They should be part of the democratic process of making decisions that affect a society. Following is a comprehensive ethical guide for planning for and dealing with major communicable disease outbreaks, such as pandemic influenza. The guide was developed with expertise from clinical, organizational and public health ethics, and validated through a stakeholder engagement process. It includes both substantive and procedural elements for ethical pandemic influenza planning. Next comes a section exploring four key ethical issues that will arise during a flu pandemic. Drawing from the ethical framework, the group identified the applicable key ethical values for each issue, and provides recommendations for dealing with each. The recommendations are particularly addressed to governments and decision-making bodies, mainly in the health care sector, around the world. These may not be the only ethical issues that the world will face in an influenza pandemic, but they are critically important issues that the Working Group has identified. Planners and decision-makers need to be vigilant for other ethical challenges that will need to be managed. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 6 B. This guide is composed of 15 ethical values, of which 10 are substantive values and five are procedural values. They should be seen as a package of interdependent values that are important in any democratic society. Ten substantive values to guide ethical decision-making for a pandemic influenza outbreak Substantive Description value Individual liberty In a public health crisis, restrictions to individual liberty may be necessary to protect the public from serious harm. Protection of the To protect the public from harm, health care organizations and public from harm public health authorities may be required to take actions that impinge on individual liberty. Proportionality Proportionality requires that restrictions to individual liberty and measures taken to protect the public from harm should not exceed what is necessary to address the actual level of risk to or critical needs of the community. In a public health crisis, it may be necessary to override this right to protect the public from serious harm. Duty to provide Inherent to all codes of ethics for health care professionals is the duty to provide care and to respond to suffering. Health care Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 7 care providers will have to weigh demands of their professional roles against other competing obligations to their own health, and to family and friends. Moreover, health care workers will face significant challenges related to resource allocation, scope of practice, professional liability, and workplace conditions. Reciprocity Reciprocity requires that society support those who face a disproportionate burden in protecting the public good, and take steps to minimize burdens as much as possible. Measures to protect the public good are likely to impose a disproportionate burden on health care workers, patients, and their families. Equity All patients have an equal claim to receive the health care they need under normal conditions. During a pandemic, difficult decisions will need to be made about which health services to maintain and which to defer. Depending on the severity of the health crisis, this could curtail not only elective surgeries, but could also limit the provision of emergency or necessary services. Trust Trust is an essential component of the relationships among clinicians and patients, staff and their organizations, the public and health care providers or organizations, and among organizations within a health system. Decision makers will be confronted with the challenge of maintaining stakeholder trust while simultaneously implementing various control measures during an evolving health crisis. A pandemic can challenge conventional ideas of national sovereignty, security or territoriality. It calls for collaborative approaches that set aside traditional values of self-interest or territoriality among health care professionals, services, or institutions. Stewardship Those entrusted with governance roles should be guided by the notion of stewardship. Inherent in stewardship are the notions of trust, ethical behaviour, and good decision-making. This implies that decisions regarding resources are intended to achieve the best patient health and public health outcomes given the unique circumstances of the influenza crisis. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 8 B2. Five procedural values to guide ethical decision-making for a pandemic influenza outbreak Procedural Description value Reasonable Decisions should be based on reasons. Open and the process by which decisions are made must be open to transparent scrutiny, and the basis upon which decisions are made should be publicly accessible. Inclusive Decisions should be made explicitly with stakeholder views in mind, and there should be opportunities to engage stakeholders in the decision-making process. Responsive There should be opportunities to revisit and revise decisions as new information emerges throughout the crisis. Accountable There should be mechanisms in place to ensure that decision makers are answerable for their actions and inactions. Defence of actions and inactions should be grounded in the 14 other ethical values proposed above. National, provincial/state/territorial, and municipal governments, as well as the health care sector, should consider incorporating both substantive and procedural values in the ethical component of their pandemic plans. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 9 C. Below, each of these issues is described in turn to illustrate how this ethical guide can be used. The workers were torn between these fears and a sense of duty to their patients and solidarity with fellow workers. A flu pandemic will mean virtually all health care workers will face such difficult choices. Overview the duty to care for the sick is a primary ethical obligation for health care workers for a number of reasons, including: 1. They faced an unknown and deadly communicable disease, a coronavirus for which there was no known effective treatment. They were rapidly forced to weigh serious and imminent health risks to themselves and their families against their duty to care for the sick. A flu pandemic would put far greater pressures on health care systems around the world. Faced with a very serious disease for which there may be no absolute protection or cure, health care workers will find themselves facing overwhelming demands. They will be forced to weigh their duty to provide care against competing obligations, such as their duty to protect their own health and that of families and friends. Initially the primary care and emergency services workers will take the full brunt of responding to the flu, and therefore bear a disproportionate risk compared to more specialized care providers. There will likely be pressure on other health care providers to come to the front lines. Some believe that under dire circumstances, professionals should have minimal self-regard and pursue their duties at potential cost to their own lives. By analogy, firefighters do not have the freedom to choose whether or not they have to face a particularly bad fire, and police do not get to select which dark alleys they walk down. Others claim that it is unreasonable to demand extreme heroism from health care workers as the norm, and even more unreasonable to demand that workers put the lives of their families at high risk or make themselves unavailable to care for them should they become ill. It is important for health care professionals, from doctors to nurses to hospital and ambulance staff, to articulate codes or statements of ethical conduct in high-risk situations, so that everyone knows what to expect during times of communicable disease crises. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 11 In the past, particularly after the 1919 influenza pandemic, such issues were explicitly addressed by some codes. The disappearance of this stringent demand from medical codes of ethics is unexplained, perhaps related to belief in recent decades that dangerous communicable diseases had been vanquished. The resurgence of communicable diseases for which there are no ready defences raises the need for clarity from the professions. If workers are to take high risks, there is a duty upon society, in particular on their institutions, to support them. The institutions need to plan to help workers cope with the high stress of a pandemic, to acknowledge that their work is dangerous. For example, they need to provide for the health and safety of workers, and for the care of those who fall ill on duty. Also, there is a need for fair and workable human resource plans for emergency situations. The imposition of employment restrictions should not result in financial hardship or job loss and should not unduly affect part-time staff. Senior decision makers and physicians will have to make many hard choices about care and the assignment of staff. They need to feel that they have the support of the highest levels of administration, including boards of directors. That paper recommended that health care institutions develop ethical frameworks in collaboration with their workforce, establish explicit work expectations in times of communicable disease, and make them available to their staffs. Ethical values and processes Based on the guide of substantive values and process for ethical decision making, the substantive values most applicable to this issue are: duty to provide care, reciprocity, trust, and solidarity. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 12 Recommendations 1. Existing mechanisms should be identified, or means should be developed, to inform college members as to expectations and obligations regarding the duty to provide care during a communicable disease outbreak. Governments and the health care sector should develop human resource strategies for communicable disease outbreaks that cover the diverse occupational roles, that are transparent in how individuals are assigned to roles in the management of an outbreak, and that are equitable with respect to the distribution of risk among individuals and occupational categories. The number of people affected could be far higher during a global flu pandemic, and people subject to restrictive measures will need to have their basic needs met, including some protection for their income and jobs. Overview Until a new flu vaccine is developed or other medications are found to control pandemic flu, restrictive measures may be one of the important public health tools to reduce spread of this communicable disease. Governments may need to limit three basic personal freedoms that we take from granted: mobility, freedom of assembly and privacy. They may close schools, cancel public gatherings and Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 13 sporting events, and impose quarantine, isolation and even detention, where needed. A major flu pandemic could result in very large numbers being subjected to such measures. People may be cut off from family, friends, work, shopping, entertainment, travel, and most other activities, including some forms of medical care. People may feel stigmatized if they are put into quarantine or identified as being affected by pandemic flu. However, our data also indicate that if decision makers expect full compliance with restrictive measures, the decisions need to be made in a fair manner, and people affected by such measures need support. Reciprocity requires society in turn to ensure that those affected receive adequate care, and do not suffer unfair economic penalties. If leaders expect people exposed to or suffering from communicable diseases to act in a manner that does not put others at risk, it is important that they create a social environment that does not leave people without supports. For example, if quarantine is implemented, governments should ensure that people have adequate food supplies and are able to carry out essential functions. Their jobs should be protected, and they should not suffer an undue financial burden. Volunteer organizations will have a vital role to play, but since they are voluntary, they do not have the same ethical obligations as governments. There will be related issues, including the privacy of personal information and the public needs to know about high risks of disease. Governments also have an obligation to reduce stigmatization by respecting the value of privacy as much as possible, and by providing accurate information, and only the information that will give the public a realistic view of such key public health issues as the spreading of disease. The world could face the possibility of other measures that could be used to contain the disease, including mandatory vaccination, surveillance cameras, monitoring devices, and even imprisonment for people who failed to comply with quarantine orders. Ethical considerations in preparedness planning for pandemic influenza Stand on Guard for Thee 14 Restrictive measures are a reminder of the legitimate limits to our highly prized individual liberties. When making such decisions, leaders will need to balance individual freedoms against the common good of society, fear for personal safety against the duty to treat the sick, and economic losses against the need to contain the spread of a deadly disease. Authorities exercising public health powers should do so in a way that is relevant, legitimate, legal, proportional, and necessary. They should use the least restrictive methods that are reasonably available to limit individual liberties, and should apply restrictions without discrimination. People need to be fully informed about issues, including risks and benefits of public health measures. Decision makers need to turn for guidance to documents such as charters of rights and freedoms and human rights legislation. The principles stipulate the extent to which state powers should be exercised in times of public health emergencies. The principles hold that public health may be invoked as grounds for limiting certain rights in order to manage a serious threat to the health of individuals or a population. These measures must be specifically aimed at preventing disease or injury, or providing care for the sick and injured. In November 2005, the American Medical Association issued guidelines for protecting patient rights if they have to be quarantined during an epidemic.
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