Serratia Marcescens in a Special Baby Unit

Richard Primavesi

Serratia Marcescens in a Special Baby Unit

Richard Primavesi

1982, The Lancet

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It would be comforting to think that a simple answer could be found to the difficult problem of informed consent in medical practice. Dr Brewin (Oct. 23, p. 919) and Mr Bywater (Nov. 6, p. 1051) appear to have found it-the doctor should inform only those patients who ask for information. It would be a grave error, however, to regard this as an acceptable approach to the problem. As the British Medical Association's Handbook on Medical Ethics states (para 1.9): "The onus is always on the doctor carrying out the procedure to see that an adequate explanation is given." Were it otherwise, informed consent would become the luxury of those patients sufficiently articulate, self-confident, and foresighted to ask questions of their doctor. To say that "those who don't ask, don't want" is surely a complete non-sequitur in the context of the consulting room.

1164 CONSENT TO RANDOMISED TREATMENT SIR,-It would be comforting to think that a simple answer could to the difficult problem of informed consent in medical Dr Brewin (Oct. 23, p. 919) and Mr Bywater (Nov. 6, p. practice. 1051) appear to have found it-the doctor should inform only those patients who ask for information. It would be a grave error, however, to regard this as an acceptable approach to the problem. As be found the British Medical Association’s Handbook on Medical Ethics states (para 1.9): "The onus is always on the doctor carrying out the procedure to see that an adequate explanation is given." Were it otherwise, informed consent would become the luxury of those patients sufficiently articulate, self-confident, and foresighted to ask questions of their doctor. To say that "those who don’t ask, don’t want" is surely a complete non-sequitur in the context of the consulting room. Faculty of Law, University of Leicester, Leicester LE1 7RH G. B. ROBERTSON SiR,-Dr Brewin has raised several objections the simplistic view that full disclosure of material information is always the best policy when discussing treatments with patients. This is especially true to patients who are specially prone to anxiety, misunderstanding, and fear-the very old and the dying. Only the most rigid moralist would insist that informed consent can never be tempered by the clinician’s need to be "flexible, considerate, and discreet" in interacting with his patient. Physicians, lawyers, and philosophers who are disposed to force informed consent upon those who are unwilling or unable to bear the costs of consent are in danger of espousing, if not medical, then at least moral paternalism. Nevertheless, despite the validity of many of Brewin’s worries to about risks attendant and informed consent to randomised treatment, a strong case can be made for placing the burden of moral proof for ignoring, waiving, or over-riding informed consent upon those clinicians who propose to do so. For while there may be situations where the side-effects of informing are more likely to cause harm than to have any other effect, the moral presumption governing therapy, randomised or not, still ought to be that informed consent is a requisite. Most patients, contrary to Brewin’s suggestions, do seem to want to know as much as they are able to understand about their treatment and the alternatives. Surveys of Americans from widely divergent economic, racial, and ethnic groups have found that the vast majority "have a universal desire for information, choice and respectful communication about decisions". While most of those interviewed acknowledged the need for flexibility and discretion on the part of clinicians, they expected to have much information about their treatment options as physicians could reasonably be expected provide. prime factor in non-compliance with and refusal of treatment seems to be the nature and extent of information provided to patients. An informed patient is a more cooperative patient. Patients who suspect that they are not receiving optimal treatment because a physician is conducting research or for reasons of misunderstanding or fear are more likely to refuse risky or painful therapies. Informed consent should be the presumptive moral policy that ought to govern all treatment contexts, even those involving randomisation: self-determination and active participation are compatible with and perhaps even parts of the therapeutic process. Brewin has done a service by noting that matters of informed consent are often more complex in clinical practice than many nonphysicians seem to believe. He has also correctly warned that the burdens of obtaining informed consent in all situations may come at a cost of decreasing the willingness of some physicians to subject their treatments and investigations to systematic evaluation. However, these problems should not be deemed so overwhelming that they displace the moral priority of informed consent. to A Hastings Center, Hastings-on-Hudson, New York 10706, U.S.A. NOVEL METHOD FOR MEASURING SPECIFIC GRAVITY OF URINE SiR,-Leaving aside the question of the value of measuring the specific gravity of urine-which in our opinion is a simple, outdated, and time-honoured test of no clinical relevance in modern medicine- we were interested to read the letter by Dr Taylor and Dr Walker (Oct. 2, p. 775), who reported an excellent correlation between the specific gravity as measured with a strip test (Ames Division of Miles Laboratories) and that measured by hydrometer. These findings are in sharp contrast to our experience with the Ames ’N-Multistix SG’. In a study of 50 consecutive patients attending an outpatient clinic, random urine samples were tested for specific gravity with the strip test and with a recently calibrated glass hydrometer and for urine osmolality by osmometer. Using Spearman’s rank correlation coefficient, we found poor correlations between the strip test and both the hydrometer and urine osmolality (dip stick vs hydrometer, r=0’72, strip test vs osmolality, r=0’85). In our hands the strip test was clearly an inaccurate test of specific gravity. There were also technical problems with the length of the strip and the difficulty in interpreting the colour change in the middle range. We would strongly encourage more widespread use of measurement of urine osmolality. Department of Nephrology, Christchurch Hospital, Christchurch, New Zealand SERRATIA MARCESCENS IN A SPECIAL BABY UNIT SIR,-We read with interest the letter from Dr Ives and his colleagues (Oct. 30, p. 994) concerning Serratia marcescens pseudobacteraemia associated with a contaminated blood-gas analyser. We are currently experiencing a genuine outbreak ofS. marcescens infection on our special care baby unit. Of twenty-four babies investigated, eleven have been colonised (in nose, umbilicus, rectum, or perineum) and of these, five have had significant illness, four with positive blood cultures. Two babies with septicaemia have died; one had concurrent necrotising enterocolitis and the other had an associated serratia meningitis. Of the other two babies with positive blood cultures, one had a transient bacteraemia after a urinary tract infection with pyuria and the other was clinically septicaemic but responded to antibiotic therapy. S. marcescens was first grown from the conjunctiva and tracheal aspirate of a 26-week gestation neonate with purulent conjunctivitis and pneumonia. This baby and others found to be colonised were isolated as a cohort. The later finding of more colonised babies, and an appreciation of the severity of infection in some of these (notably the death ofapreviously well infant) necessitated closure of the unit. The insensitivity of the strain to aminoglycosides and other antibiotics required the use of recently introduced cephalosporins; the mechanisms of antibiotic resistance are under investigation. Extensive investigation of staff and environment has failed to reveal a source for the serratia. The blood-gas analyser in our unit has yielded a strain of S. marcescens but this differs from the epidemic strain in both antibiotic sensitivity and serotype. It is possible, however, that a blood-gas analyser could act as a source of infection for babies, and hand-washing should be routine after its use. This outbreak clearly illustrates the pathogenic and colonising potential of S. marcescens in a neonatal unit. Clinically significant infection by serratia in such a unit has been reported previously.1 Departments of Neonatology and Microbiology, Bristol Maternity Hospital, Bristol BS2 8EG RICHARD PRIMAVESI DEIRDRE A. LEWIS PETER J. FLEMING DAVID C. E. SPELLER ARTHUR L. CAPLAN GD, Korones SB, Reed L, Bulley R, McLaughhn B, Bisno AL. Epidemic marcescens in a neonatal intensive care unit: Importance of the gastrointestinal tract as a reservoir. Infect Control 1982, 3: 127-33. 1. Christensen 1. RICHARD A. ROBSON ELSPETH BLAKE ROSS R. BAILEY Making health care decisions. Washington: President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982: 2. Serratia

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