Continuous, high volume, venous-venous haemofiltration was used as renal support in 28 critically ill patients with acute renal failure. Fifteen patients survived and were subsequently discharged from the ITU. Although haemofiltration was highly effective in reducing the blood urea and serum creatinine, only survivors demonstrated a significant increase in arterial pH (medians before and at two days 7.28 and 7.49 respectively, p less than 0.005) with a reduction in severity of their illness (median APACHE II scores before and at two days 23 and 16, p less than 0.005). Patients who died remained severely ill and acidotic (median APACHE II scores before and at two days 26 and 28; median arterial pH values 7.32 and 7.31 respectively) and by day two of treatment, marked differences between the patient groups in APACHE II scores, mean arterial pressure, arterial pH and urine flow rate had developed. Haemofiltration with the correction of acute uraemia alone does not necessarily lead to a reduction in the severity of illness which in the critically ill more frequently reflects other organ dysfunction.
It has been claimed that beneath the government rhetoric of patient choice, no real choice exists either in law or in National Health Service (NHS) policy (Whiteman in Health Care Anal 21:146-170, 2013). Thus, choice is considered to be a fallacy in that patients are not able to demand specific treatment, but are only able to express preferences amongst the available options. This article argues that, rather than considering choice only in terms of patient autonomy or consumer rights, choice ought to be seen as serving other functions: Choice serves as a mechanism of destabilisation, i.e., as a lever for change. This is apparent at the level of patient and doctor, and at the level of patient and health authority, but even more so, at the level of government. Patient choice, rather than benefiting the individual, can have effects on a wider scale. It encourages change and reform in healthcare practices and in the NHS institutions.
Historically, pregnant women have generally been excluded from clinical trials. One of the reasons for this exclusion has been the belief that pregnant women are vulnerable as research participants. Although this view has now largely fallen into disfavour, this article argues that in the situation where the pregnant woman is newly diagnosed with a fetal condition for which the only option, other than watchful waiting, is enrolment in a clinical trial, she should be considered a cognitively and medically vulnerable research participant. This is because she is in a highly stressed emotional state and so less able to decide completely freely whether or not to participate in the clinical trial. In other words, she is under a higher risk of therapeutic misconception and of not understanding what she is consenting to. This article suggests that in order for the consent of these women to be given freely and without emotional pressure, it has to be ensured that strategies are developed to ensure they are fully informed and actually understand the information. This surpasses the requirements of the English law of informed consent and also of General Medical Council (GMC) guidance on consent to research but such an approach would help safeguard that, despite these women's poor bargaining position, their trial participation is really free, voluntary and informed.
Despite the unproven effectiveness of many practices that are under the umbrella term 'complementary alternative medicine' (CAM), there is provision of CAM within the English National Health Service (NHS). Moreover, although the National Institute for Health and Care Excellence was established to promote scientifically validated medicine in the NHS, the paradox of publicly funded, non-evidence based CAM can be explained as linked with government policy of patient choice and specifically patient treatment choice. Patient choice is useful in the political and policy discourse as it is open to different interpretations and can be justified by policy-makers who rely on the traditional NHS values of equity and universality. Treatment choice finds expression in the policy of personalised healthcare linked with patient responsibilisation which finds resonance in the emphasis CAM places on self-care and self-management. More importantly, however, policy-makers also use patient choice and treatment choice as a policy initiative with the objective of encouraging destabilisation of the entrenched healthcare institutions and practices considered resistant to change. This political strategy of system reform has the unintended, paradoxical consequence of allowing for the emergence of non-evidence based, publicly funded CAM in the NHS. The political and policy discourse of patient choice thus trumps evidence based medicine, with patients that demand access to CAM becoming the unwitting beneficiaries.
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