Principio de Arm´s Length

After the death of a hospitalized patient, the clinician is called upon to perform a number of tasks, both required and recommended. The clinician must plainly and directly inform the family of the death, complete a death certificate, contact an organ procurement organization, and request an autopsy. Providing words of sympathy and reassurance, time for questions and initial grief, and a quiet private room in the hospital or other healthcare facility for the family is appropriate and much appreciated.

»The Pronouncement & Death Certificate

In the United States, state policies direct clinicians to con- firm the death of a patient in a formal process called “pro- nouncement.” The diagnosis of death is typically easy to make, and the clinician need only verify the absence of spontaneous respirations and cardiac activity. Attempting to elicit pain in a patient who has died is unnecessary and disrespectful and should be avoided. A note describing these findings, the time of death, and that the family has been notified is entered in the patient’s medical record. In many states, when a patient whose death is expected dies outside of the hospital (at home or in prison, for example), nurses may be authorized to report the death over the tele- phone to a physician who assumes responsibility for sign- ing the death certificate within 24 hours. For traumatic deaths, some states allow emergency medical technicians to pronounce a patient dead at the scene based on clearly defined criteria and with physician telephonic or radio supervision.

While the pronouncement may often seem like an awk- ward and unnecessary formality, clinicians may use this time to reassure the patient’s loved ones at the bedside that the patient died peacefully and that all appropriate care had been given. Both clinicians and families may use the ritual of the pronouncement as an opportunity to begin to pro- cess emotionally the death of the patient.

Physicians are legally required to report certain deaths to the coroner and to accurately report the underlying cause of death on the death certificate. This reporting is important both for patients’ families (for insurance pur- poses and the need for an accurate family medical history) and for the epidemiologic study of disease and public health. The physician should be specific about the major cause of death being the condition without which the patient would not have died (eg, “decompensated cirrho- sis”) and its contributory cause (eg, “hepatitis B and hepa- titis C infections and chronic alcoholic hepatitis”) as well as any associated conditions (eg, “acute kidney injury”)—and not simply put down “cardiac arrest” as the cause of death.

»Autopsy & Organ Donation

Discussing the options and obtaining consent for autopsy and organ donation with patients prior to death is usually the best practice. This approach advances the principle of patient autonomy and lessens the responsibilities of dis- tressed family members during the period immediately following the death. However, after a patient dies, or in the case of brain death, designated organ transplant personnel are more successful than treating clinicians at obtaining consent for organ donation from surviving family mem- bers. Federal regulations require that a designated repre- sentative of an organ procurement organization approach the family about organ donation if the organs are appropri- ate for transplantation. Most people in the United States support the donation of organs for transplants. Currently, however, organ transplantation is severely limited by the availability of donor organs. Many potential donors and the families of actual donors experience a sense of reward in contributing, even through death, to the lives of others.

Clinicians must be sensitive to ethnic and cultural dif- ferences in attitudes about autopsy and organ donation. Patients or their families should be reminded of their right to limit autopsy or organ donation in any way they choose, although such restriction may limit the utility of autopsy. Pathologists can perform autopsies without interfering with funeral plans or the appearance of the deceased.

The results of an autopsy may help surviving family members and clinicians understand the exact cause of a patient’s death and foster a sense of closure. A clinician– family conference to review the results of the autopsy pro- vides a good opportunity for clinicians to assess how well families are grieving and to answer questions.

»Follow-up & Grieving

Proper care of patients at the end of life includes following up with surviving family members after the patient has died. Following up by telephone enables the clinician to assuage any guilt about decisions the family may have

made, assess how families are grieving, reassure them about the nature of normal grieving, and identify compli- cated grief or depression. Clinicians can recommend sup- port groups and counseling as needed. A card or telephone call from the clinician to the family days to weeks after the patient’s death (and perhaps on the anniversary of the death) allows the clinician to express concern for the family and the deceased.

After a patient dies, the clinician also may need to grieve. Although clinicians may be relatively unaffected by the deaths of some patients, other deaths may cause feel- ings of sadness, loss, and guilt. These emotions should be recognized as the first step toward processing and healing them. Each clinician may find personal or communal resources that help with the process of grieving. Shedding tears, the

support of colleagues, time for reflection, and traditional or personal mourning rituals all may be effective. Attending the funeral of a patient who has died can be a satisfying personal experience that is almost universally appreciated by families and that may be the final element in caring well for people at the end of life.

Chau NG et al. Bereavement practices of physicians in oncology and palliative care. Arch Intern Med. 2009 May 25;169(10): 963–71. [PMID: 19468090]

Simon NM. Treating complicated grief. JAMA. 2013 Jul 24;310(4): 416–23. [PMID: 23917292]

Thornton JD et al. Effect of an iPod video intervention on con- sent to donate organs: a randomized trial. Ann Intern Med. 2012 Apr 3;156(7):483–90. [PMID: 22473435]

Dermatologic diseases are diagnosed by the types of lesions they cause. To make a diagnosis: (1) identify the type of lesion(s) the patient exhibits by morphology establishing a differential diagnosis (Table 6–1); and (2) obtain the ele- ments of the history, physical examination, and appropriate laboratory tests to confirm the diagnosis. Unique clinical situations, such as an immunocompromised or critically ill patient, lead to different diagnostic considerations.

PRINCIPLES OF DERMATOLOGIC THERAPY

»Frequently Used Treatment Measures

A. Bathing

Soap should be used only in the axillae and groin and on the feet by persons with dry or inflamed skin. Soaking in water for 10–15 minutes before applying topical corticoste- roids enhances their efficacy (Soak and Smear). Bath oils can be used, but add little above the use of moisturizers, and may make the tub slippery, increasing the risk of falling.

B. Topical Therapy

Nondermatologists should become familiar with a repre- sentative agent in each category for each indication (eg, topical corticosteroid, topical retinoid, etc).

1. Corticosteroids—Topical corticosteroid creams, lotions, ointments, gels, foams, and sprays are presented in Table 6–2. Topical corticosteroids are divided into classes based on potency. There is little (except price) to recommend one agent over another within the same class. For a given agent, an ointment is more potent than a cream. The potency of a topical corticosteroid may be dramatically increased by occlusion (covering with a water-impermeable barrier) for at least 4 hours. Depending on the location of the skin condition, gloves, plastic wrap, moist pajamas covered by dry pajamas (wet wraps), or plastic occlusive suits for patients can be used. Caution should be used in applying topical corticosteroids to areas of thin skin (face, scrotum, vulva, skin folds). Topical corticosteroid use on the eyelids may result in glaucoma or cataracts. One may estimate the

amount of topical corticosteroid needed by using the “rule of nines” (as in burn evaluation; see Figure 37–2). In gen- eral, it takes an average of 20–30 g to cover the body surface of an adult once. Systemic absorption does occur, but adre- nal suppression, diabetes mellitus, hypertension, osteopo- rosis, and other complications of systemic corticosteroids are very rare with topical corticosteroid therapy.

2. Emollients for dry skin (“moisturizers”)—Dry skin is not related to water intake but to abnormal function of the epidermis. Many types of emollients are available. Petrola- tum, mineral oil, Aquaphor, Cerave, Cetaphil, and Eucerin cream are the heaviest and best. Emollients are most effec- tive when applied to wet skin. If the skin is too greasy after application, pat dry with a damp towel. Vanicream is rela- tively allergen-free and can be used if allergic contact der- matitis to topical products is suspected.

The scaly appearance of dry skin may be improved by urea, lactic acid, or glycolic acid-containing products pro- vided no inflammation (erythema or pruritus) is present. 3. Drying agents for weepy dermatoses—If the skin is weepy from infection or inflammation, drying agents may be beneficial. The best drying agent is water, applied as repeated compresses for 15–30 minutes, alone or with alu- minum salts (Burow solution, Domeboro tablets).

4. Topical antipruritics—Lotions that contain 0.5% each of camphor and menthol (Sarna) or pramoxine hydrochlo- ride 1% (with or without 0.5% menthol, eg, Prax, PrameGel, Aveeno Anti-Itch lotion) are effective antipruritic agents. Hydrocortisone, 1% or 2.5%, may be incorporated for its anti-inflammatory effect (Pramosone cream, lotion, or ointment). Doxepin cream 5% may reduce pruritus but may cause drowsiness. Pramoxine and doxepin are most effective when applied with topical corticosteroids. Topical capsaicin can be effective in some forms of neuropathic itch. Ice in a plastic bag covered by a thin cloth applied to localized areas of pruritus can be effective.

C. Systemic Antipruritic Drugs

1. Antihistamines—H₁-blockers are the agents of choice for pruritus when due to histamine, such as in urticaria. Otherwise, they appear to benefit itchy patients only by

6

Kanade Shinkai, MD, PhD

Timothy G. Berger, MD