Although some clinicians are extraordinarily sensitive to the legitimate roles of patients' families in medical crises, a persistent tendency to equate families with trouble is evident in both the literature and the practice of medicine. Some negative presumptions about families derive from western medicine's almost exclusive focus on the individual patient in codes of ethics, training, and practice. Modern bioethics has reinforced this individualistic approach. Physicians' primary responsibilities are unequivocally to their patients, but a complete understanding of the patient's personhood must include consideration of the significant persons who help define the patient's core identity. One source of tension between professionals and families lies in differing perceptions of the roles that family members should play and how they should play them. Members of a family may act as advocates, provide or manage care, serve as trusted companions on the journey through illness and death, and make decisions on behalf of an incompetent patient. Each role presents potential conflicts. Other sources of conflict include disagreement within a family; challenges to physician authority; fear of litigation; and differing religious, ethnic, or cultural traditions. An ethic of accommodation emphasizes the need to negotiate care plans that do not compromise patients' basic interests but that recognize the capacities and limitations of family members. Family caregivers want understandable and timely information, better training, compassionate recognition of their anxiety, guidance in defining their roles and responsibilities, and support for the setting of fair limits on their sacrifices. Health care professionals can better meet these needs through education and skills acquisition, the establishment of partnerships with families, and regular dialogue and communication.
Central venous catheter needleless connectors (NCs) have been shown to develop microbial contamination.A protocol was developed for the collection, processing, and examination of NCs to detect and measure biofilms on these devices. Sixty-three percent of 24 NCs collected from a bone marrow transplant center contained biofilms comprised primarily of coagulase-negative staphylococci.Intravenous (i.v.) access lines (6, 7) and needleless connectors (NCs) (3, 4) have been demonstrated to be a risk factor for blood stream infection (BSI). Patients who require long-term i.v. access, such as bone marrow transplant patients, are at even greater risk for BSI. To deliver i.v. fluids (e.g., medication, blood products, or nutrients), tubing must be connected to i.v. catheters that enter the patient's bloodstream. Until recently, such connections have been made using beveled, hollow-bore needles that pierce an elastic membrane on a catheter end cap. Because of the potential for needle-stick injuries and health care worker exposure to bloodborne pathogens, many institutions have recently adopted the use of NCs. Though safer for health care workers, the potential for NCs to increase BSI risk to patients has been documented in outbreaks of nosocomial BSI (3,4). In October 1998, the Centers for Disease Control and Prevention (CDC) was asked to investigate a BSI outbreak at a bone marrow transplant center in which NCs were involved. As part of this investigation, CDC assessed the ability of NCs to harbor biofilms that could act as a reservoir for BSI pathogens. It is well established that biofilms may develop on intravascular devices, including central venous catheters (CVCs) (1,2,8). Though contamination of NCs by various organisms has been observed (3, 4), the occurrence of biofilms on these devices has, to our knowledge, not been documented. The objectives of this study were (i) to develop a standardized protocol that could be used to collect, ship, and process NCs for biofilm contamination and (ii) to determine whether biofilms could develop on these devices and what organisms were the primary colonizers. Hickman NCs were collected from patients with long-term CVCs in a single bone marrow transplant center in which an outbreak of BSIs had occurred.Collection and shipment of NCs. Female-female luer couplings (no. 06359-42; Cole Parmer, Niles, Ill.) were autoclaved and then used to connect two 5-ml syringes. One of the syringes contained 5-ml of phosphate-buffered saline (PBS; pH 7.2; Life Technologies, Grand Island, N.Y.). Syringe pairs were placed into zip-lock bags and shipped on ice packs to the bone marrow transplant center for the collection of NCs. By using an aseptic technique, the NCs were removed from the patient's CVC and placed into an unused sterile Petri dish and transported to the laboratory. After the two syringes were separated, the luer coupling remained on one syringe. The smaller end of the NC was then wiped with a sterile alcohol pledget and connected to the syringe without the luer coupling. The other end o...
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The authors assert that a system that requires ever greater direct and indirect participation from families must change the negative presumption that families equal trouble to one that acknowledges legitimate family interests in decision making and care delivery and treats families as partners in caregiving.
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