Just a note about the discussions at today's m&M conference; a main teaching point was use of radiocontrast media. As usual I was prompted to check fro recent articles. Here is one of the best I found.
Comments are welcome on this topic.
JTE.
Chapter 32. Prevention of Contrast-Induced Nephropathy
Lorenzo Di Francesco, M.D.
Mark V. Williams, M.D.
Emory University School of Medicine
Background
Radiocontrast-induced nephropathy (RCIN) represents an increasingly common cause of treatment-related renal failure1-3and increases mortality independent of other risk factors.4 Major risk factors for RCIN include chronic renal insufficiency,2,3,5 diabetes mellitus2,3,5 (especially when accompanied by renal insufficiency1), any condition associated with decreased effective circulating volume,6 and use of large doses of contrast media.2,3,5,6
For at-risk patients, clinicians must use their judgment to determine if imaging modalities that do not involve contrast media are an acceptable alternative to contrast studies. In many cases, however, such alternatives do not exist. Moreover, RCIN occurs in patients without obvious risk factors. Thus, strategies for reducing the incidence of RCIN include not just risk factor identification, but modification of these risk factors, choice of contrast media less likely to cause RCIN, and administration of therapeutic agents that further reduce the risk of RCIN.
Practice Description
The specific practices reviewed in this chapter are:
Use of high versus low osmolar iodinated contrast media to prevent RCIN.7
Use of a standard intravenous or oral hydration protocol for patients with risk factors for RCIN.8-10 Typical intravenous protocols evaluated consist of normal saline administered at 75 mL/hr beginning at 12 hours before and ending 12 hours after the procedure. Oral protocols require ingestion of 1000 mL of water during the 10 hours prior to the procedure, followed by intravenous normal saline at 300 mL/h for 30-60 minutes and continued for a total of 6 hours after the procedure.
Use of a standard hydration protocol supplemented by pretreatment with theophylline11-15 (various doses and schedules).
Use of a standard hydration protocol supplemented by pretreatment with N-acetylcysteine16 (600 mg bid one day before and day of procedure).
Single studies evaluating atrial natriuretic peptide, prostaglandin E117 and captopril18 were not reviewed, as the data are too preliminary, despite findings that suggest a reduction in the risk of RCIN. Although the evidence supporting the use of N-acetylcysteine largely comes from a single study as well, we do review this practice because the study was large, published in a prominent journal, and has received considerable attention among clinicians.16
The use of calcium channel blockers in preventing RCIN was not evaluated, as the existing literature predominantly indicates the practice is ineffective.19-23
Prevalence and Severity of the Target Safety Problem
While definitions of RCIN vary, most study definitions include a 25% increase in serum creatinine (SCr) and/or at least a 0.5 mg/dL increase in SCr within 48 hours of contrast administration. Using this definition, one large community-based study of 1826 patients undergoing invasive cardiac procedures reported a rate of RCIN of 14.5%.2 A controlled prospective study of the onset of RCIN after contrast-enhanced brain CT found an incidence of 2.1% in low-risk patients without diabetes mellitus or chronic renal insufficiency versus 1.3% in a similar control group that did not receive any contrast (p=NS).24 In comparison, patients in a prospective controlled study undertaken to determine the risk of nephrotoxicity from contrast radiography in patients with diabetes and renal insufficiency (SCr >1.7mg/dL) found a 9% incidence of RCIN.1
The cumulative effect of multiple risk factors increasing the risk of RCIN was demonstrated in one uncontrolled study that evaluated the effect of 5 factors (contrast volume >200 mL, albumin <3.5 g/L, diabetes, serum sodium <135 mmol/l, SCr>1.5 mg/dL).3 When all risk factors were present the risk of RCIN was 100%, compared with just 1.2% when none were present. While most patients with RCIN suffer little morbidity and recover to near baseline renal function within 7-10 days (and thus we characterize it as a Level 2 outcome), rare patients require temporary dialysis. Two studies suggested that the development of RCIN may lead to longer lengths of stay8,11and one large retrospective study showed that hospitalized patients who develop RCIN had a mortality rate of 34% compared with 7% in control subjects, even after controlling for underlying co-morbidities.4 The development of RCIN appeared to increase the risk of death from non-renal causes such as sepsis, bleeding, respiratory failure and delirium.
Opportunities for Impact
Few studies have rigorously evaluated current practice patterns among radiologists or cardiologists with respect to evaluation of a patient's threshold creatinine prior to ordering contrast procedures. One survey study of academic and private practice radiology departments found that only about 20% of practices routinely obtain serum creatinine levels before contrast administration.25 Interestingly, when patients were known to have a high-risk condition like diabetes, approximately 60% of the same practices would require a serum creatinine before contrast administration. Therefore, many high-risk patients are not identified prior to undergoing contrast radiography studies. In addition, no studies have evaluated the frequency with which physicians recommend pre-hydration for patients prior to contrast studies. Overall, physicians and institutions do not follow a consistent practice in screening patients for risk factors for RCIN prior to the use of contrast radiography. If rigorous evidence identifies patients at risk for RCIN, and effective, standardized preventative measures are developed and implemented, there is substantial opportunity to reduce morbidity.
Study Designs
The literature on strategies for preventing RCIN includes: one meta-analysis evaluating the nephrotoxicity of high versus low-osmolality iodinated contrast media,7 one randomized controlled study of pre-treatment with acetylcysteine16 for high-risk patients, one randomized controlled trial of pre-treatment with prostaglandin E117 for high-risk patients, and 5 randomized controlled trials assessing the impact of theophylline11-15 in preventing RCIN. Unfortunately, each of the studies of theophylline employed different routes and dosages (and, in fact, one of the studies used aminophylline, rather than theophylline). Table 32.1 summarizes the salient features of these studies.
One randomized trial compared inpatient versus outpatient hydration regimens,26 but we found no randomized controlled trial that evaluated pre-hydration versus no hydration. Thus, support for the standard use of pre-hydration to prevent RCIN is extrapolated from randomized controlled studies of saline versus saline plus additional pre-treatment agents like mannitol, furosemide and dopamine8-10 and smaller observational studies6,27,28 evaluating the benefits of pre-hydration.
Study Outcomes
Studies evaluated Level 2 outcomes, primarily by measuring changes in serum creatinine, creatinine clearance or glomerular filtration, and assessing the frequency of developing acute renal failure after radiocontrast infusions. Most studies defined RCIN as a 25% increase in creatinine and/or at least a 0.5 mg/dL increase in serum creatinine within 48 hours of contrast administration.
Evidence for Effectiveness of the Practice
All of these studies (Table 32.1) evaluated the effects of various prophylactic measures to reduce the incidence of RCIN. Use of low-osmolar contrast media was supported by one large meta-analysis 7 that compared low versus high osmolar contrast media. Low osmolar contrast media was found to be less nephrotoxic than high osmolar contrast media, with an odds ratio for RCIN of 0.61. Among patients with baseline renal insufficiency (SCr >1.4 mg/dL) the odds ratio of developing RCIN was 0.5 if low osmolar instead of high osmolar contrast media was used.
As previously noted, no randomized controlled trials have evaluated the efficacy of pre-hydration versus no pre-hydration. Data from 3 randomized controlled trials8-10 using pre-hydration versus other pre-treatments and pre-hydration revealed that pre-hydration alone was equivalent to pre-hydration and low dose dopamine or mannitol,8 and, in one study, superior to pre-hydration and furosemide.10 The incidence of RCIN in patients with SCr >1.6 mg/dL or creatinine clearance <60 mg/min treated with pre-hydration alone undergoing cardiac catheterization was 11%; excluding the patients with SCr >3 mg/dL, the incidence was only 4%.8 One retrospective, observational study of high-risk patients undergoing cardiac catheterization supports the benefit of pre-hydration (>500 mL of 0.9% NS in the pre-catheterization period, p≤0.01) in reducing RCIN.6 In addition, 2 observational studies without controls27,28 showed that pre-hydration in high-risk patients was associated with low rates of RCIN, although one of these studies27 used a stricter definition for RCIN (increase in BUN by 50% or 20 mg/dL, and/or increase in SCr of 1 mg/dL within 24 hours).
A recent study of the oral antioxidant acetylcysteine in combination with pre-hydration in high-risk patients with renal insufficiency showed significant protective effect against RCIN versus pre-hydration plus placebo.16 This protective effect appeared to be even more significant among patients with more advanced renal dysfunction and SCr >2.5 mg/dL. The overall relative risk reduction of 90% observed in this study is so large that it raises the possibility of some sort of bias or other explanation for the observed results. Additional studies of this practice would be valuable, despite the safety and low cost of N-acetylcysteine.
Studies employing theophylline are more controversial. Three randomized control trials showed a significant protective effect of various dosages and administration routes of theophylline among low-risk patients with relatively normal baseline renal function.12-14 All 3 studies showed theophylline to be protective against a decrease in glomerular filtration rate (GFR) or creatinine clearance (CrCl) after contrast administration. On the other hand, 2 studies conducted in high-risk patients with renal dysfunction showed no effect for theophylline in reducing RCIN.11,15 Thus, insufficient evidence supports the use of theophylline as prophylaxis against RCIN in high-risk patients.
Potential for Harm
The impact of a system to identify high-risk patients prior to contrast radiography and implement aggressive prophylactic measures to reduce the incidence of RCIN has not been studied. While most patients will not experience any harm from contrast, the potential for "harm" due to delayed or cancelled investigations may be greater than the harm prevented by screening for risk factors, aggressive hydration, or use of particular pre-treatment regimens.
Costs and Implementation
At least 4 studies have evaluated the cost-effectiveness of low-osmolality versus high-osmolality contrast media.29-32 In all 4 studies, the selective use of low-osmolar contrast media was more cost-effective than its universal use because of the overall small benefits were outweighed by the considerable increased institutional costs. Alternatively, a standardized system to identify high-risk patients and implement the simple prophylactic treatment of pre-hydration would diminish the frequency of the target problem. It would require collaboration between the patients' own physician and the personnel performing the particular contrast study (radiology department, radiologist, diagnostic/interventional cardiologist). This type of intervention could be implemented as part of a hospital-based pathway (see Chapter 52) targeted at reducing radiocontrast-induced nephropathy.
There are no cost-effectiveness or feasibility studies that evaluate protocols for aggressive identification of high-risk patients undergoing contrast radiography and utilization of standardized hydration protocols to reduce RCIN. Two studies suggest most patients with normal renal function (SCr <1.7 mg/dL) can be easily identified by simple questionnaire, resulting in significant cost savings from a reduction in the number of routine serum creatinine levels obtained prior to imaging.33,34 The cost-effectiveness of using pharmacologic pre-treatment with N-acetylcysteine or theophylline has not been studied.
Comment
In summary, patients with multiple risk factors for RCIN who need radiography with contrast media should receive pre-hydration and low osmolar iodinated contrast. Overall, there appears to be indirect evidence that RCIN can be attenuated by pre-hydrating high-risk patients. Clearly, the use of low osmolar contrast media is associated with less RCIN, but its high cost militates against routine use in all patients. We believe that it should continue to be reserved for the patient with multiple risk factors for RCIN. While newer pre-treatment regimens like N-acetylcysteine, prostaglandin E1, and captopril look very promising in preventing RCIN, these results need to be replicated in further studies. Finally, many institutions would benefit from a hospital-based pathway that identifies patients with multiple risk factors for RCIN prior to contrast radiography. Guidelines (Chapter 51) for appropriate pre-hydration and the timely use of low osmolar contrast media to reduce the development of RCIN would be beneficial.
Table 32.1. Studies of strategies for preventing radiocontrast-induced nephropathy (RCIN)*
Study Setting Study Design, Outcomes Results
Low osmolar contrast media Meta-analysis of the relative nephrotoxicity of high (HOCM) vs. low (LOCM) osmolar iodinated contrast media7 Level 1A,
Level 2 LOCM less nephrotoxic than HOCM; pooled p=0.02
Odds of ARF with LOCM 0.61 times that of HOCM (95% CI: 0.48-0.77). Patients with RF at baseline, odds of ARF were 0.5 (CI: 0.36-0.68).
Pre-hydration plus diuresis Patients with SCr >1.8mg/dL randomized to IVF, IVF + furosemide, IVF + furosemide + low dose IV dopamine +/- mannitol (if post-cardiac catheterization, PCWP <20 mmHg)9 Level 1,
Level 2 No differences in rates of renal failure between groups. Rates of RCIN 21.6% if UOP >150 mL/h, 45.9% if UOP <150 mL/h.
Patients with SCr >1.6mg/dL or CrCl <60mL/min randomized to IVF, IVF + mannitol or furosemide pre-cardiac catheterization8 Level 1,
Level 2 No statistically significant difference in RCIN, among the three groups. After exclusion of patients with SCr >3 mg/dL, RCIN in patients with IVF alone 4%, IVF + mannitol 24% (p=0.02), IVF + furosemide 25% (p=0.02). LOS increased by 4 days in RCIN group.
Patients with SCr >1.7 or CrCl <60mL/min randomized to IVF + furosemide vs. discretion of treating physician during contrast radiography10 Level 1,
Level 2 SCr increased by 0.42 mg/dL +/- 0.20 treatment group vs. 0.023 mg/dL +/- 0.073 (p<0.01) controls. Significant weight loss in treatment group vs. controls (p<0.03)
Observational study of "high risk" patients with SCr >1.9 mg/dL who underwent cardiac cath6 Level 3,
Level 2 Statistically significant risk factors for RCIN: volume of contrast used (168+/- 11 vs. 122+/16 mL, p=0.001) and use of prehydration (>500mL 0.9% normal saline in preceding 24 hrs, p<0.01)
Table 32.1. Studies of strategies for preventing radiocontrast-induced nephropathy (cont.)*

Study Setting Study Design, Outcomes Results
N-Acetylcysteine Patients with SCr >1.2 mg/dL or CrCl <50 mL/min randomized to pre-hydration (IVF) with oral acetylcysteine or placebo prior to contrast CT16 Level 1,
Level 2 RCIN developed in 2% treatment group vs. 21% control group (p=0.01). Among patients with SCr >2.5 mg/dL, RCIN 0% treatment vs. 42% controls (p=0.02)
Theophylline Patients randomized to theophylline (165mg IV x 1) vs. placebo prior to contrast radiography.12 Level 1,
Level 2 GFR reduced 85.4 +/- 3.8 mL/min controls vs. 107 +/-3.6 mL/min treatment group (p≤0.001).
Patients randomized to theophylline (2.8 mg/kg orally q12 x 2 days) vs. placebo prior to contrast radiography with LOCM or HOCM.13 Level 1,
Level 2 CrCl after LOCM decreased by ~18% at 24 hrs in control (p<0.05) vs. no significant change over 48 hrs in treatment group. CrCl after HOCM decreased by ~40% at 24 hrs and remained low at 48 hrs in controls (p<0.01) vs. ~24% at 24/48 hrs in the treatment groups (p<0.05). CrCl after HOCM significantly lower in control vs. treatment group (p<0.01).
Patients randomized to pre-hydration + theophylline (5mg/kd IV) or placebo prior to contrast CT or DSA.14 Level 1,
Level 2 GFR decreased at 4 hrs and 2 days in placebo (88 +/- 40 to 75 +/- 20 mL/min, 89+/- 41 mL/min to 66+/- 32 mL/min, p<0.01) with no significant change in CrCl in the treatment group.
Patients with SCr >1.5mg/dL randomized to pre-hydration vs. pre-hydration with low dose dopamine or aminophylline prior to cardiac catheterization.11 Level 1,
Level 2 Overall incidence of RCIN was 38%. No significant differences were noted among the groups. LOS was longer in patients with RCIN (7.1 days vs. 3.1 days, p=0.02).
Patients randomized to pre-hydration + theophylline (270 mg q am/540 mg q pm 2d before, 3d after) or placebo prior to contrast CT or DSA.15 Level 1,
Level 2 No significant differences in SCr or CrCl between groups (RCIN 3.4% controls, 5.7% in treatment, p=NS).

*ARF indicates acute renal failure; CI, confidence interval; CrCl, creatinine clearance; CT, computed tomography scan; DSA, digital subtraction angiography; GFR, glomerular filtration rate; IVF, intravenous fluids; LOS, length of stay; NS, not statistically significant; PCWP, pulmonary capillary wedge pressure; SCr, serum creatinine; and UOP, urine output.

References

1.Parfrey PS, Griffiths SM, Barrett BJ, Paul MD, Genge M, Withers J, et al. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufficiency, or both. A prospective controlled study. N Engl J Med 1989;320:143-149.

2.McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 1997;103:368-375.

3.Rich MW, Crecelius CA. Incidence, risk factors, and clinical course of acute renal insufficiency after cardiac catheterization in patients 70 years of age or older. A prospective study. Arch Intern Med 1990;150:1237-1242.

4.Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality. A cohort analysis. JAMA 1996;275:1489-1494.

5.Lautin EM, Freeman NJ, Schoenfeld AH, Bakal CW, Haramati N, Friedman AC, et al. Radiocontrast-associated renal dysfunction: incidence and risk factors. AJR Am J Roentgenol 1991;157:49-58.

6.Brown RS, Ransil B, Clark BA. Prehydration protects against contrast nephropathy in high risk patients undergoing cardiac catheterization. J Am Soc Neprhol 1990;1:330A.

7.Barrett BJ, Carlisle EJ. Metaanalysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media. Radiology 1993;188:171-178.

8.Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents. N Engl J Med 1994;331:1416-1420.

9.Stevens MA, McCullough PA, Tobin KJ, Speck JP, Westveer DC, Guido-Allen DA, et al. A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy: results of the P.R.I.N.C.E. Study. Prevention of Radiocontrast Induced Nephropathy Clinical Evaluation. J Am Coll Cardiol 1999;33:403-411.

10.Weinstein JM, Heyman S, Brezis M. Potential deleterious effect of furosemide in radiocontrast nephropathy. Nephron 1992;62:413-415.

11.Abizaid AS, Clark CE, Mintz GS, Dosa S, Popma JJ, Pichard AD, et al. Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency. Am J Cardiol 1999;83:260-263, A5.

12.Kolonko A, Wiecek A, Kokot F. The nonselective adenosine antagonist theophylline does prevent renal dysfunction induced by radiographic contrast agents. J Nephrol 1998;11:151-156.

13.Katholi RE, Taylor GJ, McCann WP, Woods WT, Jr., Womack KA, McCoy CD, et al. Nephrotoxicity from contrast media: attenuation with theophylline. Radiology 1995;195:17-22.

14.Erley CM, Duda SH, Schlepckow S, Koehler J, Huppert PE, Strohmaier WL, et al. Adenosine antagonist theophylline prevents the reduction of glomerular filtration rate after contrast media application. Kidney Int 1994;45:1425-1431.

15.Erley CM, Duda SH, Rehfuss D, Scholtes B, Bock J, Muller C, et al. Prevention of radiocontrast-media-induced nephropathy in patients with pre-existing renal insufficiency by hydration in combination with the adenosine antagonist theophylline. Nephrol Dial Transplant 1999;14:1146-1149.

16.Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med 2000;343:180-184.

17.Koch JA, Plum J, Grabensee B, Modder U. Prostaglandin E1: a new agent for the prevention of renal dysfunction in high risk patients caused by radiocontrast media? PGE1 Study Group. Nephrol Dial Transplant 2000;15:43-49.

18.Gupta RK, Kapoor A, Tewari S, Sinha N, Sharma RK. Captopril for prevention of contrast-induced nephropathy in diabetic patients: a randomised study. Indian Heart J 1999;51:521-526.

19.Seyss C, Foote EF. Calcium-channel blockers for prophylaxis of radiocontrast-associated nephrotoxicity. Ann Pharmacother 1995;29:187-188.

20.Khoury Z, Schlicht JR, Como J, Karschner JK, Shapiro AP, Mook WJ, et al. The effect of prophylactic nifedipine on renal function in patients administered contrast media. Pharmacotherapy 1995;15:59-65.

21.Russo D, Testa A, Della Volpe L, Sansone G. Randomised prospective study on renal effects of two different contrast media in humans: protective role of a calcium channel blocker. Nephron 1990;55:254-257.

22.Neumayer HH, Junge W, Kufner A, Wenning A. Prevention of radiocontrast-media-induced nephrotoxicity by the calcium channel blocker nitrendipine: a prospective randomised clinical trial. Nephrol Dial Transplant 1989;4:1030-1036.

23.Cacoub P, Deray G, Baumelou A, Jacobs C. No evidence for protective effects of nifedipine against radiocontrast-induced acute renal failure. Clin Nephrol 1988;29:215-216.

24.Cramer BC, Parfrey PS, Hutchinson TA, Baran D, Melanson DM, Ethier RE, et al. Renal function following infusion of radiologic contrast material. A prospective controlled study. Arch Intern Med 1985;145:87-89.

25.Lee JK, Warshauer DM, Bush WH, Jr., McClennan BL, Choyke PL. Determination of serum creatinine level before intravenous administration of iodinated contrast medium. A survey. Invest Radiol 1995;30:700-705.

26.Taylor AJ, Hotchkiss D, Morse RW, McCabe J. PREPARED: Preparation for Angiography in Renal Dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction. Chest 1998;114:1570-1574.

27.Eisenberg RL, Bank WO, Hedgcock MW. Renal failure after major angiography. Am J Med 1980;68:43-46.

28.Teruel JL, Marcen R, Herrero JA, Felipe C, Ortuno J. An easy and effective procedure to prevent radiocontrast agent nephrotoxicity in high-risk patients. Nephron 1989;51:282.

29.Barrett BJ, Parfrey PS, Foley RN, Detsky AS. An economic analysis of strategies for the use of contrast media for diagnostic cardiac catheterization. Med Decis Making 1994;14:325-335.

30.Michalson A, Franken EA, Smith W. Cost-effectiveness and safety of selective use of low-osmolality contrast media. Acad Radiol 1994;1:59-62.

31.Caro JJ, Trindade E, McGregor M. The cost-effectiveness of replacing high-osmolality with low-osmolality contrast media. AJR Am J Roentgenol 1992;159:869-874.

32.Steinberg EP, Moore RD, Powe NR, Gopalan R, Davidoff AJ, Litt M, et al. Safety and cost effectiveness of high-osmolality as compared with low-osmolality contrast material in patients undergoing cardiac angiography. N Engl J Med 1992;326:425-430.

33.Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology 2000;216:481-484.

34.Choyke PL, Cady J, DePollar SL, Austin H. Determination of serum creatinine prior to iodinated contrast media: is it necessary in all patients? Tech Urol 1998;4:65-69.

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Well it was another interesting night on call. This was one of thoose rare times when the main teaching objective was when not to operate. We admitted a middle-age male with an attack of presumed diverticulitis. He had a CT scan that was not indicative of an acute free perforation, his abdominal exam showed mostly localized left lower quadrant tenderness, but no signs of peritoneal irritation. He was started on IV fluids and antibiotics and after 12 hours shows some improvement. He will continue to be observed for improvement or worsening. JTE.

Well, it is another day of call. The ER has been modestly busy and there have been floor consults as well. I had a chasnce to help on of the residents on his way to being credentialed to do central lines. JTE.

After further research on blog construction and functions, I am proud to proclaim that there is now a counter in place on the Joy of Surgery. I would like to thank everyone who visits and encourage feedback in the form of comments. JTE.

Well fellow surgeons, here is part of my first foray into tracking down more information on Narrative Medicine.Book Reviews

Stories Matter: The Role of Narrative in Medical Ethics
Reviewed by: Beverly Steinman, MD
Medscape General Medicine 5(1), 2003. © 2003 Medscape
Posted 01/24/2003
Edited by Rita Charon and Martha Montello
Routledge
Copyright 2002
242 pages
ISBN: 0-415-92838-9
$24.95 paperback
Medical ethics is more than a theoretical abstract to be discussed in committees and academic environments. Every human life is at some time affected by this discipline. The collection of essays presented in Stories Matter: The Role of Narrative in Medical Ethics, skillfully edited by Rita Charon, MD, PhD, and Martha Montello, PhD, broadens and deepens the understanding of how medical ethics is interwoven into our lives, through an illustration of the role of narrative in medical care. Readers from all fields -- clinicians, ethicists, and anyone associated with providing healthcare -- will benefit from this book. Those with no previous experience in medical ethics may also find the text stimulating, although its concepts may be challenging for those without literary and/or clinical background.
Both Charon and Montello are at the forefront of the narrative medicine movement, which advocates that physicians must learn to become close readers of their patients' stories (or histories) in order to identify and respond effectively to moral and clinical questions posed. Charon, Editor-in-Chief of the journal Literature in Medicine, and Montello, a Professor of History and Philosophy of Medicine at the University of Kansas, bring together 23 bioethicists and literary theorists, such as Howard Brody, MD (Stories of Sickness), and critic Wayne C. Booth, PhD (The Rhetoric of Fiction), each individually recognized as an expert in their area of focus.
By linking their essays in a logical and iilluminating sequence, the editors have produced a text that educates and inspires. While each author makes a unique contribution, they collectively make the case for the importance of the narrative approach to bioethics.
The editors accomplish their goal of guiding readers "toward a cognitive, practical, emotional, and aesthetic familiarity with the conceptual frameworks, methods, and powers of narrative ethics." (p. x) While the average clinician may find some of the terminology (such as reliability, intersubjectivity, and textuality) and citations unfamiliar, it is well worth the effort to immerse oneself in new territory throughout this text. Many ideas and perspectives are presented that, when incorporated into everyday clinical practice, can change us and our ability to ethically care for patients.
For example, case studies using the narrative ethics approach are presented, aptly illustrating how the concepts work to accomplish the goal of a more complete and accurate consultation. Richard Martinez states, "Narrative methods help us to listen and see with intensified accuracy and reach -- a hermeneutic stethoscope of a sort." (p. 131) This comparison to a common diagnostic tool provides a powerful visual linkage, likely to be understood by all clinicians.
Some of the material is assimilate, such as a section introducing the importance of context, voice, time, character, plot, and reader response in the narrative approach to bioethics. This simple comparison to the basic components of stories is very effective in providing a manageable framework by which we can expand our view and methodology in the consultation process.
It was quite refreshing to find frank and straightforward observations from the authors of Stories Matter, especially dealing with the reality of the current medical world. For example, the authors noted that, currently, a few "experts" often dominate the ethical consultative process in an organization. They suggest that a narrative approach causes a change to a more democratic process, as each person's perspective is valued.
In addition, very practical advice is given on how to train practitioners on the use of narrative ethics, including the range of educational opportunities available. A listing of the specific competences for narrative medical ethics is suggested and is compared to the original competences for ethics committees. Realizing that the work in narrative bioethics has been in progress for 25 years helps the reader to both understand the dedication of those involved and prepare for what is most likely to be a slow transition in one's own organization.
The ever-present issue of time will undoubtedly be one of the greatest challenges. The comprehensive narrative approach involving multiple perspectives will take longer than a "sidewalk" consult or a 1- or 2-sided presentation at an ethics committee meeting. It would have been helpful to have this dilemma addressed more fully.
The book ends appropriately with a look at the future of narrative medical ethics. By reviewing the additional case stories, healthcare data, and concepts presented, the reader will be further convinced that this approach is essential to the provision of quality ethical care. In the last chapter, Joanne Trautmann Banks states it well: "...narrative is fundamental to our bodies, minds, communities, and souls." (p 219)
Through the authors' passionate, logical, and credible sharing of their knowledge and experience, readers will gain the ability to understand and participate in an improved approach to medical ethics, both in their own practices and within their organizations. Incorporating multiple perspectives, understanding "stories" in all their complexity, becoming more aware of what each individual brings to the situation, and managing this challenging methodology in a systematic, thoughtful way, will take medical ethics to a new, more proficient and complete level.
The authors are clear that the previous or current methodology used in medical ethics, usually the principlist approach, is not necessarily to be abandoned, but most likely will be complementary to the narrative approach. Hence, we will be building on the past as we strive toward a future that will be guided by the concepts shared in this book.
Beverly Steinman, MD, consultant and educator in healthcare communication with the Northwest Center for Physician-Patient Communication

First a reminder to any readers, if you want to add comments to the blog all you need to do is click on the blue word comment after each posting and you can add your comments. Second, what a great night this was for me. I had the opportunity to be one of the senior faculty at a dinner meeting with the purpose of recruiting a new faculty surgeon. Well as usual, there was a generous amount of discussion about the profession of surgery. Naturally, a lot of it was centered around job satisfaction. Everyone wants to be sure that a prospective faculty member gets a favorable impression. However, the fact that the surgeons at the meeting really like what they do is just not possible to be supressed. The central focus in surgery is always about the positive and immediate feedback of a job well done and the tangible results of improved patient care. I found the most interesting discussion of the night to center on the coming change of the critcal care to be provided at one of the hospitals to a system of intensive physician monitoring of patients in the ICU by physicians in a command module with protocols of algorithm driven interventions and patient resuscitaion regimens. Wellas hte old song goes "the times are a changin". Since I don't practice in the hospital to be so affected, I will be able to view the result with less personal emotional investment as to the result of such a new undertaking. All my best dear readers. JTE.

Tuesday - one of the always interesting days. Today in clinic, there was one of the major reasons for liking what I do. One of the patients who was an innocent victim of a hold-up was kind enough to leave a Thank you card for everyone. In trauma, our patients are often very grateful. JTE.

It is Monday morning and I am on my way to the OR. I have cases to do and residents to teach. It is another good day for enjoying surgery. JTE.

Well, another incremental increase in my blogging skills. I have now added Blogger Forum and Google Search to the Blog. JTE.

Well it is late Sunday afternoon and I have just finished part of my Sunday ritual - The Sunday New York Times. My attention was naturally drawn to the New York Times Magazine for this week. I was particularly drawn to the article entitled The Writing Cure by Melanie Thernstrom on page 42. This is an article which deals with the topic Narrative Medicine. I admit to not being able to judge if this is a balanced and fair article, but it seems to be. Certainly, it should provide the lay reader and physicians who are neophytes in regards to Narrative Medicine a good introduction. I suppose in many ways what I am setting out to do is utilize this blog to engage in a modified form of narrative medicine about Surgery and to invite others to participate. Certainly would like to hear from those interested in Narrative Medicine!! I certainly hope my college Professor who taught me courses in both creative writing and the modern novel since 1914 is not reading this blog on a computer somewhere in the hereafter. I must say that I am now destined to embark on expanding my horizons in the world of Narrative Medicine. Guess I will be doing some searches and getting some journal articles. Naturally, I found one of those quotes which triggered my " I disagree" response. It was from Jerome Groopman who is quoted as follows: "It's not only students but also physicians who find the structure of contemporary hospital life unsatisfying." and as follows: "They're all looking for more meaningful relationships." Some of you more astute readers may ask " How can you disagree with someting so abstract and poorly defined as 'the structure of contemporary hospital life'? Well, the structure of contemporary hospital life is what I know best. Surgeons who do major operations are required to be immersed in the hospital life. A well equipped and staffed OR is necessary for surgery. Trauma surgeons at a Level One regional trauma center are virtually immersed in contemporary hospital life. Surprisingly, this is where the great rewards are found for myself and others. To further develop the questioning of Groopman's assumptions, we must only guess at what could be 'more meaningful' ? Naturally, from a syntax point of view, since he has to use an adverbial description - he must concede that the relationships of contemporary hospital life are meaningful, just that some are seeking the ever elusive "more". Greener grass has always been prized. I think I will stop at this point and have a cup of tea. JTE.

Well folks today is the third day of this Blog. I was on call from Saturday at 7 AM till Sunday at the same time. Our last case was an interesting one - small bowel obstruction requiring exploratory laparotomy and lysis of adhesions. The case went well and the patient should do well despite multiple underlying co-morbidities. I took the chance of being with my residents to tell them about this Blog. Hopefully, it will stimulate interest in the idea of a surgical blog devoted to the discussion of the joys of surgery and the surgical life. My chief resident acknowledged that he had seen the article in the General Surgery News which details the results of a survey which calls into question the dedication of young doctors. I do not remember recieving the survey mentioned so I guess maybe they knew in advance who to avoid. Well, I am still having fun doing surgery. Looking for those comments. James T. Evans, M.D.

This is my new Blog dedicated to emphasizing the Joy of being a surgeon. I like what I do and I am sure there are others who feel the same way. I think it is very important to be proactive in discussing the positive things about being a surgeon.