text:
Race The Sun – A Relaxing Review
Endless running games aren't really all that new when you look at the grand scheme of things. Games like Bit.Trip Runner have shown up all over the indie landscape even in the flash game market. Race the Sun, created by indie developer Flippfly, ... Read More»
New Video of Quantum Rush: Champions explains Racer Properties
A few days ago Quantum Rush: Champions, the single player version of the online future racer Quantum Rush was published in Early Access on Steam. Today, GameArt Studio, the Berlin based developer published a new video that allows insights into the various properties of the different racers. In Quantum Rush: Champions there are three different ... Read More»
Future Racer Quantum Rush: Champions published on Steam
Quantum Rush: Champions, the single player version of the online future racer Quantum Rush is now available on Steam in an Early Access version. Players worldwide can now jump into racing fights full of action and begin a career as a racer pilot. The developer team from Berlin, Germany recently announced that an Early Access ... Read More»
Quantum Rush: Champions – Soon in Steam Early Access
Great news: The Quantum Rush Team announced that Quantum Rush: Champions, the offline version of Quantum Rush: Online just received permission for release in Steam Early Access! This means that soon the Early Access Version of Quantum Rush: Champions will be available on Steam! Fans of the game living outside of Europe will be especially ... Read More»
Quantum Rush – New Track Deuterium Rally
Great news from the free2play racer Quantum Rush Online! Today the future racer team published a new update which contains not only bug fixes but also a brand new race track. New tracks as far as the eyes can see! After two new tracks and an update were published two weeks ago, the Selenit Tunnel ... Read More»
Video Game Sequels To Look Forward To In 2014
15 more ways to enjoy cult classics as well as their modern day counterparts... Read More»
Super Smash Bros. 4 | Trailer
Brought to you by: http://masternessp.com Get Paid To Play Video Games! http://3bc32hhe635dqi53tbfalhfxjd.hop.clickbank.net/ See More: http://www.youtube.com/user/MNPGameVideos/videos Super Smash Bros. 4 trailer... Read More»
25 Games That Will Push Graphical Boundaries In 2014
25 reasons why 2014 is going to truly be a 'Happy' New Year!... Read More»
Dangerous Games: Prisoners of Destiny Collector's Edition Download PC Game
Have you ever dreamed of a deck of cards like in The Chronicles of Amber by Roger Zelazny, able to transport you to another place in a moment? OR maybe for a deck of cards with useful tools and items, for example, when you need a car, you just played a card with car image ... Read More»
How To Get Started in FIFA 14 Ultimate Team
Stunning passes. Epic goals. Find out how to get started in FIFA 14 Ultimate Team... Read More»
Goozernation's Picks for Black Friday Deals
Black Friday, what a crazy shopping day for anyone. Goozernation has looked at a lot of sites and decided to put together a small list of must buys for games from a variety of stores including Best Buy, Amazon, Target, Walmart, Gamestop, Toys R Us, and Amazon... Read More»
100 Jaw Dropping Features In GTA 5 You Might Not Know About
Moments that will make you wonder and ask yourself, "why aren't other games like this?"... Read More»
Bandit Gaming: Genso Suikogaiden Volume 2 on Playstation One Fan Translation Released
Suikoden was one of those surprise releases on Playstation One back in the mid to late 1990′s from Konami. Having been lucky enough to play it when it first released helps with understanding the value of this fan translation of volume 2 of the digital/visual novels (think Choose Your Own Adventure books but in a ... Read More»


text:
Futility and hospital policy.
such judgments are ethically defensible in principle, our question will be whether that which is defensible in theory can be implemented ethically in practice. We won't, therefore, take the time to provide a comprehensive theoretical defense of futility judgments (we think a successful defense has already been articulated),[1] or to review all of the large number of articles that have been published on this aspect of the debate. Nevertheless, we still need to highlight the most significant elements of the argument over futility, since these will help set some of the criteria by which a hospital futility policy should be judged.
In what follows, we will focus chiefly on issues and policies surrounding futile resuscitation and say little about other treatment interventions, except by implication. Futile resuscitation deserves this special attention because it is the only intervention that requires consent for an order to withhold it; other futile interventions are typically not offered or discussed. Thus, decisions about resuscitation raise the most acute and perhaps the most frequent conflicts between patient or family demands and physician judgments. Certainly, however, there can be similar conflicts regarding other interventions, particularly regarding the withdrawal of an intervention that the physician has come to believe is futile. Much of what we say about problems for futile resuscitation policies may apply as well to policies aimed at futile treatments more generally, but discussion of the particulars will have to wait for another occasion.
The Futility Debate: Lessons for Policy
There are two fundamental considerations that support hospital authority over futile or grossly harmful interventions: the moral integrity of the health professions, and the obligation to enable autonomous choices by patients.
Physicians and nurses have an obligation to help rather than hurt their patients by what they do. If health professionals could never say no to patient or family demands for interventions, they could not have control over the consequences of the procedures they perform. Without this control, physicians and nurses could not fulfill their moral obligation to promote the patient's welfare, an obligation that is fundamental to ethical practice. We in fact recognize the exercise of this moral authority every day, across the whole range of medical interventions. Patients with (or without) angina don't have a right to demand that a surgeon perform a bypass operation despite the risks of death or the likelihood of benefit; why should they have such a right with respect to CPR?
By necessity, judgments by health professionals not to provide particular treatments are value laden. They require assumptions about what counts as a reasonable chance of success, as well as judgments about the proper goals of medicine. The surgeon, and not just the patient, gets to decide whether an 80 percent chance of death is too high, and whether a patient's fascination with surgical suites defines an acceptable goal of surgical practice.
The second consideration arguing for physician authority over futile treatment only has the appearance of paradox. The appearance is that limiting the patient's power to demand futile treatments must undermine his autonomy rather than enable it. The appearance is deceiving for two reasons. The first is that autonomy is enabled or enhanced only when there is a real choice being offered between significantly different options. In cases where resuscitation is genuinely futile, the choice between attempting resuscitation or not is a bogus choice, and the offer of it is a deception. Second, the denial of choices is an infringement of the patient's right to autonomy only if the patient has the right to demand the option in question. If the patient's right to autonomy is limited by the rights of others, then limitations of patient choice made on behalf of protecting those other rights are not ethically objectionable. To assert that limiting choices regarding futile treatment is per se a violation of patients' rights of autonomy begs the question, unless the only precept in medicine is "The customer is always right."
There are several common objections leveled against giving physicians this authority over futile or harmful treatment. A review of them will help identify some valid concerns that may need to guide policy.
One of these is that since futility judgments make value-laden assumptions, they should be shaped only by the patient's values. When shaped by the values of the physician or profession, they are an illegitimate infringement of patient autonomy and represent a resurgence of unwarranted paternalism.
As an objection in principle against the exercise of futility judgments this argument is unsuccessful, for the reasons sketched above. In highlighting the value-laden character of these decisions, however, it reminds us that the value assumptions made in cases of futility will have to receive their warrant from somewhere. If the warrant is not found in the patient's right to self-determination, neither can it be found in the individual physician's values. When backed by institutional policy, the refusal to provide futile treatments is made on behalf of professional integrity, not merely individual conscience. Therefore, a futility policy will have to incorporate some means for articulating the professional values at stake and for certifying that they are indeed values for the profession, not values that are ethically optional for individual professionals.
The objection suggests another important concern: that the values employed in futility judgments will be insulated from the values of the wider society the profession is licensed to serve. The futility judgments that result will be at odds with widely understood public convictions about the proper social role of the medical enterprise. This is again a concern that is practical rather than theoretical. Futility policies designed successfully to avoid such a gap between professional and public values and goals will not be objectionable on this score.
Another common objection against physician authority over futile treatment is that it justifies the decision not to discuss resuscitation status with patients or families, and encourages the all-too-common avoidance of uncomfortable conversations about death, dying, and the limits of medicine. This argument is also unsuccessful as a criticism of the ethical justification for permitting futility judgments. There are a number of good reasons supporting an obligation to discuss decisions not to provide futile resuscitation with patients and families, short of reliance upon the patient's right of self-determination.[2] There is no incompatibility between rejecting the patient's right to select futile resuscitation and insisting on the physician's obligation to inform patients about their plan of care, a point apparently missed by some critics of futility judgments. The objection does, however, point to another concern that must be addressed by policy: how to grant authority to physicians to limit futile therapy while encouraging full, honest, and supportive communication.
A third objection made against futility judgments is that the resulting focus on the biomedical aspects of medical interventions will lead to neglect of the worthy social and psychological needs that might be served by biomedically futile interventions. To repeat, a judgment not to provide an intervention always makes implicit assumptions about the proper goals of medicine. The sheer fact that certain needs of patients or families might remain unmet because of a decision not to provide a medical intervention is not a decisive objection against authorizing futility judgments. The truth behind the objection .is that a comprehensive justification for not meeting a demand for treatment requires consideration of all the goals that might be served by the intervention, and not just the narrowly biomedical ones. Good futility policies will encourage that breadth of review.
Finally, the argument has been made that unilateral physician authority over futile resuscitation is unnecessary, because in virtually all cases when physicians would think resuscitation futile, patients and families would agree. Authority over futile treatment therefore offers nothing of benefit, only the opportunity for mischief An equally effective approach to reducing demands for futile treatment is to help physicians to lead better discussions with patients and families about treatment limitation choices.
The difficulty with the objection and the alternative it espouses is that it is extremely difficult for patients and families to make informed, autonomous choices about futile resuscitation. When the only way to authorize a DNR order under hospital policy is by the consent of patients or their representatives, discussions about futile resuscitation are inherently misleading offers of bogus choices, increasing the likelihood that a choice will be made in favor of futile treatment. Adamant demands for futile resuscitation are less likely when the goal of discussion is not to have the patient or family make a choice, but rather to gain their understanding and acceptance of the choice already made and presented by the physician against attempting resuscitation. But creating the context for that sort of discussion requires a policy that grants physicians the authority to make such a decision.
There is still a practical lesson here for futility policies: the policy should incorporate a process of negotiation by which patients and families are invited to accept the futility judgment, since indeed most of the time they will, and premature or unnecessary confrontation can be avoided.
This brief discussion of the ethical rationale for futility judgments has suggested several guidelines that should shape defensible futility policies:
* Policy should not empower the solitary judgment of an attending physician, but should require some level of peer review.
* Policy should require validation from a broad spectrum of opinion in cases that may turn on differences between professional and nonprofessional values.
* Policy should require disclosure and discussion of any DNR decisions, and should encourage rather than inhibit discussion around death, dying, and treatment limitations.
* Policy should not define futility in a narrow manner that discourages consideration of nonbiomedical goals for medical care.
* Policy should attempt to negotiate patient and family acceptance of futility judgments, without requiring or asking for their consent to a DNR order.
The Practical Context: More Lessons
In addition to the cautions that emerge from an analysis of the ethical arguments surrounding the use of futility judgments, there are also those confusions, difficulties, and unintended side-effects that any policy will generate. Consideration of our two-year experience with application of a futility policy will suggest some further rules of thumb for developing sound futility policy.
The first practical problem with futile CPR judgments is a tendency for caregivers to broaden the scope of futile to include interventions other than CPR, or to make inferences from a futility judgment that are not warranted. Once CPR is thought to be futile, physicians may be tempted to withhold scarce resources such as blood products, or expensive diagnostic or treatment interventions such as MRI scanning or renal dialysis, or "marginal" treatments such as admission to an intensive care unit or insertion of a PEG feeding tube. A futile CPR policy can in practice slop over into a futile treatment policy, without due regard for the relevant clinical differences between CPR and other treatment modalities.
A related difficulty with drawing boundaries between the futility of CPR and the potential appropriateness of other interventions is with communicating that distinction to patients or their surrogates. Success here frequently influences whether the futility judgment will be acceptable to the patient or surrogate decisionmaker. The problem here is similar to one that arises commonly in discussions of CPR, where a fear surfaces among patients and families that if they agree to forgo CPR, that means the medical staff will give up on the patient or not try as hard to ameliorate or stabilize the patient's condition. It becomes necessary to provide explicit reassurance that other interventions will be discussed and evaluated separately, on their own merits.
As we noted above, any policy that authorizes a futility judgment should also require that the attending physician inform the patient or the patient's surrogate that CPR is considered futile and will not be attempted, along with the rationale for that judgment. The objective here is to seek the patient's or family's acceptance of that plan, rather than seek their consent or permission for it.
But this vital theoretical distinction proves to be difficult to embody in practice. There are well-entrenched habits of communication, linked to the consent approach to DNR, that need to be overcome or broadened with a larger repertoire. Even in cases where the physician has made a sound prior determination of futility, when she gets face-to-face with the family, she will often revert to the language of consent by faithfully presenting the dismal facts of prognosis and then asking the family what they would like done. This is, after all, the habitual way in which nontreatment decisions are discussed. It may also seem to be less "threatening" or "confrontational" than directly asserting any claims of medical authority. Such an apparently more benign approach, however, is a trap that gets sprung when the family takes up the invitation to make the decision themselves, and makes "the wrong one" by opting for futile resuscitation. They are understandably angry and confused when the staff responds with aggressive efforts to persuade them to change their mind, which the family readily interprets as an attempt to take back the offer.
The aftermath frequently produces another of the practical difficulties we've found with the application of a futility policy. Frustrated by the family's persistence in making the wrong choice, physicians will turn to the futility policy and the authority it grants to physician judgments as a trump card that is played as an ultimatum. Rather than being used in a manner that facilitates family understanding and acceptance of the futility of CPR, the policy becomes just one more ratchet in an escalating confrontation. Any subsequent ethics consultation that arises becomes doubly difficult, less likely to succeed in winning the family's confidence in the original futility judgment.
Finally, our experience has shown that implementing a futility policy also involves recognizing that the delivery of medical care within a hospital is a public event, and the perception that it is wrong to take the "choice" of attempting futile CPR away from the patient or the surrogate is the equivalent of received moral opinion. Any shift of authority away from the family or patient may bring to the surface questions among hospital staff about whether the futility judgment will be used in an inconsistent and biased way. A direct expression of the concern we have encountered is the accusation that some vulnerable minority patients will have the futility judgment made unilaterally by a physician, but other more socially powerful or acceptable patients with the same medical condition will be given the choice of CPR.
The practical dangers of futility policies need to be recognized by addressing their causes through several different approaches. These will establish some further parameters for development of a defensible futility policy.
1. The implementation of a futility policy requires a systemwide plan for educating physicians as well as other careproviders involved in the clinical setting.
Education should involve not only formal presentations concerning the elements of the policy, but also workshops, simulated interviews, or other formats directed to reforming the consent-based habits of communication just discussed, and to providing effective and honest strategies for communication about death and dying, and not just about the futility judgment itself.
Another focus for these educational efforts must be to help nursing and other care providers understand the ethical rationale and the medical basis for futility judgments. Nurses, therapists, and social workers are often the first line of counselors sought by patients and families as they process their understanding of die medical facts as well as their feelings in circumstances of catastrophic and terminal illness. The staff's understanding of the policy and the basis for its application is important not only to avoid working at cross purposes with attending physicians. It is also necessary to winning the staffs confidence in the fairness of the policy's application to patients. This objective can be well served by the use of interdisciplinary educational activities that not only provide information about the rationale for futility judgments and the conditions under which the judgment may be made, but also offer continuing open dialogue with all who are intimately involved in the care of patients.
2. A futility policy should be embedded within a larger policy and process for making decisions about limitation of treatment, which will include some specific elements.
First, a policy must offer multiple avenues for decisions about limitations of care that do not unduly restrict the freedom of patients, families, and care providers to make such decisions based on considerations of both prior patient preferences and of the patient's best interest. The availability of these avenues will help take the pressure off using the futility policy as an all-purpose treatment limitation tool, and reduce the temptation to draw unwarranted inferences from the DNR decision to other limitations of treatment.
Second, a futility policy will function best in institutions with strong and broadly representative ethics. committees involved in providing clinical ethics consultation. Using the committee to affirm or reject support for futility judgments in contested cases can help win staff confidence in the process. For the same reason, ethics consultation or other forms of committee assistance should be available to all caregivers, patients, and families, and not only physicians.
In addition, clinically active members of an ethics committee can provide informal consultation to assist physicians in counseling patients or surrogates about the rationale for the futility judgment, to provide communication strategies for the treatment team, and to help distinguish cases of futile CPR from other circumstances when a DNR order might be justified by a patient's or surrogate's judgment about a particular quality of life.[3]
With these ethical and practical cautions in mind, we can work toward developing a sound futility policy.
Defining Futility
When setting out to develop a hospital policy regarding futile treatment, it is tempting to think that the first, essential task is to formulate an explicit operational definition of futility that will serve to identify unambiguously those patients to whom the policy should apply. We think that this impulse is mistaken, because it runs afoul of the principles just established.
There are several prominent examples of this approach. Lawrence Schneiderman, Nancy Jecker, and Albert Jonsen propose both a quantitative and a qualitative standard of futility, which set independent thresholds for identifying futile procedures. Quantitatively, a procedure like CPR is futile if it has less than a 1 percent probability of succeeding, p [less than or equal to] 0.05. Qualitatively, a procedure is futile if it "merely preserves permanent unconsciousness or ... fails to end total dependence on intensive medical care."[4]
Donald Murphy and Thomas Finucane define several categories of patients who should not be provided "futile" CPR.[5] The major rationale for their categories--which range from bedfast patients with metastatic cancer, to patients with dementia requiring longterm care, to patients with coma lasting longer than forty-eight hours--is cost control. Both the predicted likelihood of success and the quality of the supporting evidence offered vary significantly among categories.
Policies that define futile by reference to a benchmark probability of success fail our standards in several respects. First, they create the illusion of specificity where none is possible, and warrant superficial medical evaluations. If Mrs. Jones has a diagnosis associated with less than 1 percent chance of survival, then such a policy permits the physician to pigeonhole her case as one of "futile" CPR, without any consideration of her individual clinical circumstances and whether they provide reasons for thinking that she may be an exception to the necessarily crude profile that generated the statistic. It is not difficult, for example, to find studies suggesting that the success rate for CPR in patients with metastatic cancer is close to zero.[6] On the other hand, one can find other studies suggesting that a simple diagnostic category like "cancer" may hide numerous clinical complexities that are relevant to a thorough prognostic evaluation.[7] Accordingly, in our experience few thoughtful and experienced clinicians are satisfied with a medical judgment based simply on any one diagnostic or other medical category.
Of course, one might try to respond to this objection by requiring that the prognosis of a less than 1 percent chance be based on a thorough evaluation of each individual case. But then the judgment of futility will not be wholly based in any quantifiable set of prior cases, since one will not be able to identify the previous 100 cases "just like this one." "Failure to survive in the last 100 cases of metastatic cancer" is then only relevant to the judgment of futility of CPR, it is not definitive of it.
A second difficulty created by reliance on probabilistic definitions of futile is that the probability of success is pegged to a narrowly biomedical goal--the extension of biological life for the patient. Typically, no allowance is made for the possibility that other goals might be served in special, individual circumstances that could justify attempts at resuscitation. An example from our experience was a ninety-year-old man with renal failure, ventilator-dependent adult respiratory distress syndrome, hyperosmolar coma, and other conditions that justified the medical judgment that a CPR attempt would be futile; this patient would not survive to leave the hospital. It was more difficult to say whether a CPR attempt might briefly restore pulse and blood pressure. This limited possibility was a significant one for his family, given their hope that the patient's sister would be able to arrive from out of state before he died. They convinced us to honor their request to attempt resuscitation for the sake of that nonbiomedical goal, which would not be at stake in all medically similar cases.
Definitions of futile err too much in the other direction when the definition is tied to specific quality-of-life judgments. Such judgments make assumptions about the proper goals of medicine that have not been validated through broad and open public dialogue. Why is it "futile," for instance, to provide resuscitation or other life-prolonging intervention for someone who is permanently unconscious? Assuming the patient is not suffering from other medical conditions that would mitigate against it, resuscitation of such a patient could well be successful at extending the patient's life. Extending a patient's life, even one of such attenuated quality, is most certainly among the traditional goals of medicine. Without the backdrop of such a tradition, there would have been no need to make any ethical or legal arguments on behalf of terminally ill patients' rights to limit life-prolonging treatments. A policy that defines futile by reference to permanent unconsciousness, then, departs from this tradition and attempts to change it by fiat. It is a departure, however, that at this stage in our history does not have the clear warrant of broad social agreement. Witness both the Missouri and U.S. Supreme Court reasoning in the Cruzan case,[8] the state advance directive statutes that explicitly exclude PVS from among the conditions within the scope of the act,[9] and court rulings in the Helga Wanglie[10] and Baby K cases,[11] all of which assume that being permanently unconscious is not "as good as dead." These considerations are not philosophical ones, and are not intended as such. Perhaps a case can be made that extended life serves no genuine interest of PVS patients. But until those philosophical arguments have succeeded in expanding public consensus on the question, they are not relevant to the justification of a futility policy, which requires broad public warrant for the values that underly it In a democratic polity, the imperialism of moral philosophers is hardly less objectionable than the imperialism of physicians.
The other objection to quality-of-life definitions of futile is that they may rely on dangerous generalizations. What is it about "total dependence on intensive medical care" that makes resuscitation in all such cases futile? Of course, generally speaking, these patients will be moribund and have overwhelming medical problems, such as multiple organ failure, which will in turn make a successful resuscitation highly unlikely. But exceptions are possible. Sometimes, for example, patients are de facto dependent on intensive care because of the lack of alternative settings for the delivery of treatments such as ventilator support. This is once again the danger in definitions of which we complained earlier: reliance on any simple categories of "futile" care encourages superficial evaluations.
Policies such as Murphy's would justify quality-of-life expansions of the meaning of futile in the name of cost containment. But first of all, any policy that defines futile to mean "not costworthy" has distorted the plain meaning of futile beyond all recognition. Of course, any intervention that is futile for achieving any worthy goals whatever is not costworthy by definition. But the inference does not run in the other direction. Many interventions are not costworthy because they consume too many resources relative to their benefit, not because they offer no benefits at all. Linking futility with cost containment also fundamentally alters the moral basis for the caregivers' claims of authority over "futile" interventions. That authority would no longer be exercised solely on behalf of professional moral integrity, focused on the obligation to the patient's welfare, but will instead be an exercise of social agency, focused on the welfare of the aggregate of patients. This would in turn poison any efforts at gaining patient or family acceptance of the "futility" judgment. So long as the physician is acting out of professional integrity, she has no apparent motive for misrepresenting the real chances for success. When she's acting as a social agent, she's lost that credibility. A sound futility policy should encourage, rather than obstruct, trust and mutual agreement about the wisdom of forgoing CPR.
Patient-Centered Definitions
Some policy proposals attempt to avoid conflict with patient or family wishes by defining futile subjectively, including some reference to the patient's expressed goals. On this approach, futility should in some part be judged relative to the patient's values: "Resuscitative efforts should be considered futile if they cannot be expected either to restore cardiac or respiratory function to the patient or to achieve the expressed goals of the informed patient" (AMA Council on Ethical and Judicial Affairs,[12] following John Lantos and colleagues.[13]) Nevertheless, "In the unusual circumstance when efforts to resuscitate are judged by the treating physician to be futile, even if previously requested by the patient, CPR may be withheld" (emphasis theirs).
These definitions can't have it both ways. One can't give the patient all the power to determine the goals of treatment, and leave the physician any power to refuse a requested intervention. If the intervention is being demanded by the patient, then it necessarily serves one of his goal--satisfaction of his demand. The physician might reason that the patient's demand is motivated by unrealistic expectations, but then he will be making judgments about the patient's values, namely, that because the patient's demand is unrealistic, it is not the duty of the physician to satisfy it. Despite the hope of such definitions, the possibility of conflict with the patient's values is always there when the physician judges what level of probability determines that CPR "cannot be expected" to restore function, or when she judges whether the use of a ventilator counts as "restoring" respiratory function. Faith in any value-free "physiological" concept of futility is misplaced.
A related, widely quoted example comes from the Santa Monica Hospital Medical Center, which defines "futile care" as "any clinical circumstance in which the doctor and his consultants, consistent with the available medical literature, conclude that further treatment (except comfort care) cannot, within a reasonable possibility, cure, ameliorate, improve, or restore a quality of life that would be satisfactory to the patient." The following examples are then given: irreversible coma or persistent vegetative state; terminal illness when the application of life-sustaining procedure would serve only to prolong the moment of death artificially; permanent dependence on ICU care.[14] A disjointed policy like this can provide no unambivalent guidance regarding what will count as "futile" care. On the one hand, the doctor is given the authority to make notoriously value-laden judgments regarding what will count as "reasonable," "cure," "ameliorate," "terminal," and so on; and on the other, the patient is left with complete authority over what quality of life is worth serving. Is life-sustaining care "futile" for those patients who might maintain PVS to be a satisfactory quality of life? Policies like Santa Monica's give us two different answers at once.
All of the considerations we've been urging in this section argue against any attempt to base a futility policy on some concrete definition of futility. Any such definition by itself is bound to fail as the basis for defensible judgments of when a physician or hospital can refuse to provide demanded treatment. The defensibility of such judgments must ultimately rest on the existence of a consensus within the profession and between the profession and the public about the proper goals and acceptable means for the moral practice of medicine. A consensus can only be developed, it can't be dictated. Moreover, the test of any consensus on a definition of futility is whether the consensus survives the interpretation and application of the definition to contested cases. Is it agreed that CPR is "futile" in all cases of advanced metastatic cancer? We can only see how we respond to the application of this principle to the real people who, one by one, make up those cases to which our policy on futility is to apply.
A workable futility policy, therefore, cannot be a policy that imposes a definition on practice. It must instead be a policy that creates a process for negotiating and developing, case by case, a consensus on the rightful limits of patients' demands for treatment.
Proposal for a Model Policy
We would like to conclude with an outline of a model policy, which addresses the principles and problems we have identified as significant aspects of a defensible futility policy.
I. Resuscitation will be attempted for all patients in cardiopulmonary arrest unless:
A. The patient is brain-dead and declared legally dead, as documented in the progress notes in accordance with approved hospital protocol;
This element is important because it sets out the paradigm case of futile resuscitation and offers the basis for analogies to some other situations for example, other cases of irreversible unconsciousness combined with imminent cardiac death. Of course, some hospitals may have some such principle already incorporated in a brain death policy; but there is an advantage to reiterating it within the context of a futility policy, so that it serves as one clinical anchor for interpreting the meaning of futility.
or B. The patient or the patient's qualified representative has requested a Do-Not-Resuscitate order, documented in the progress notes in accordance with approved hospital procedures;
This option assumes that the futility policy is part of a broader policy concerning the right to refuse CPR or other medical treatment, and recognizing the authority of surrogate decisionmakers. It is especially important that this larger policy encourage communication between physicians and patients or surrogates concerning the overall disease process, treatment and nontreatment alternatives, and prognosis for survival or for an acceptable quality of life. As we've discussed, there must be multiple avenues available for limiting treatment besides appeal to a futility policy, in order to reduce the temptation to expand the concept into an all-purpose justification, as well as to recognize that the patient's authority over refusals of treatment is based solely on his or her own values and purposes.
or C. There has been a determination, following the process described in Section II, that attempted resuscitation would be futile or harmful.
II. Futile or harmful attempted resuscitation.
A. Attempted resuscitation is futile when it provides no meaningful possibility of extended life or other benefit for the patient. Attempted resuscitation is harmful when the additional suffering or other harm injected on the patient is grossly disproportionate to any possibility of benefit.
For reasons that we have explained, no attempt should be made to further specify what futile or harmful resuscitation refers to. That specification is given within the context of a particular patient's clinical circumstances, and from the perspective of the attending physician's evaluation of the patient's diagnosis and prognosis and the physician's individualized understanding of the patient's values, needs, and preferences. For purposes of policy, any significant possibility of extending life counts as a benefit, for reasons discussed earlier. Thus, the PVS patient is not per se a case of futile resuscitation. Moreover, possible benefits to the patient other than extended life require consideration--one of the chief reasons that judgments of futility must be individualized rather than defined a priori.
B. The preliminary judgment of whether attempted resuscitation would be either futile or harmful is made by the attending physician, and confirmed in the progress notes by consultation with an appropriate specialist.
This helps to guard against hasty or controversial medical judgments, and confirms some minimal level of professional consensus about futility of care. It also provides public notice to the community of caregivers, so that they become aware of the determination and its justification in a timely way. This offers an opportunity to ask questions, express disagreement, or seek ethics committee consultation or advice. The authority to initiate the judgment of futility rests entirely with the attending physician, the person with primary ethical and legal responsibility for the patient's welfare.
1. The attending physician will inform
the competent patient, or the incompetent
patient's representative, that
he or she will not attempt resuscitation,
and will explain the reasons for the
physician's judgment that attempted
resuscitation would be either futile or
harmful. The physician will seek the
patient's or representative's acceptance
of this course of action.
The first step is to pursue communication and accommodation, not confrontation. For the reasons mentioned earlier policy must require that patients or families be informed of the plan of care. In our experience, almost all cases are resolved at this stage. Either everyone comes to agree that resuscitation should not be attempted, or the physician will learn of social, psychological, or medical considerations that lead to a revised judgment.
2. If the patient is incompetent and no
legal or natural representative can be
identified, the case will be brought to
the ethics committee consultation team
for disposition under Section D.
Unwarranted or controversial expansions of the futility judgment are most likely for patients who have no family or other concerned persons who might protest. Ethics consultation review is necessary both to protect these vulnerable patients and to maintain institutional control over the way in which the futility concept is being interpreted in practice.
C. If the patient or representative agrees that a futile or harmful resuscitation should not be attempted, then the physician should document the substance of the discussion and its resolution in the medical record. A DNR order may then be put into effect without any formal, signed consent from patient or family.
Other decisions about limitations of treatment will normally require more extensive documentation, including a signed consent from the patient or representative. Relaxing this requirement in cases where there is agreement about the futility of CPR serves to emphasize the difference between seeking acceptance and seeking permission. This in turn reduces the temptation to fall into the habitual language of consent, with its attendant dangers and confusions. As we have mentioned, it will also be necessary to reform habits of communicating by means of education and training, and not just policy.
D. If the patient or family does not agree with the physician's judgment, or if the incompetent patient has no representative, then the attending physician will seek the assistance of the ethics committee consultation team. The Purposes of the consultation are: (1) to evaluate the physician's judgment of futility to determine whether it is within the scope of the institution's policy; and (2) when necessary, to assist with continuing efforts to enhance communication and negotiate mutual understanding.
Required ethics consultation here helps to maintain a relatively narrow conception of futility that is in keeping with the policy's intentions, putting a check on the tendency to expand the notion in unwarranted directions, particularly for vulnerable patients. It can also help to resolve those cases where patient or family disagreement with the physician's futility judgment is the product of misunderstanding or botched communication, rather than fundamental value differences.
E. If ethics consultation confirms the physician's judgment, and family or patient disagreement persists, the medical director will attempt to identify another physician within the hospital willing to assume care, including provision of resuscitation, and will transfer care to that physician. If no such physician can be identified within the hospital, and if transfer would not jeopardize the patient medically, the medical director will attempt to identify another health care facility willing to assume care of the patient, and arrange for transfer
This step protects the professional and ethical integrity of the attending physician or institution, while accommodating the demands of the patient or family. Push shouldn't come to shove when it can be avoided. It also in effect imposes a requirement to consult with a broader community of professional judgment and values in cases of conflict, rather than overriding patient or family demands merely on the basis of individual or local idiosyncrasies. That broader community will either nullify the original futility judgment or ratify it.
F. If no alternative care provider can be identified, or if the patient or representative refuses to accept the transfer of care, then the case will be presented to the ethics committee, which, in consultation with legal counsel and hospital administration, will determine the course of action to be taken on behalf of the hospital
This is the second level at which the physician's determination that resuscitation should not be attempted is put to the test of wider community opinion, although here the emphasis will most likely be on the inherently value-laden judgments concerning the "reasonableness" of the chance of success, and the selection of worthy goals of medicine, rather than on the factual basis of the medical prognosis. Since these judgments may be used to justify overriding the demands of families or patients, they require the validation of community discussion and consensus, not the exercise of any one individual's expertise. Obviously, the credibility of the ethics committee's judgment will depend on its makeup, in particular on how well the lay patient population is represented. Moreover, the institutional representatives will help assure that a respectful eye is kept on the potential judgment of wider legal and public opinion.
Options to be considered include:
1. To ratify the physician's and consultation
team's judgment that resuscitation
should not be attempted because
it is futile or harmful, and coordinate
further attempts to persuade the
patient or representative to agree width
the judgment.
2. To ratify the physician's and consultation
team's judgment that resuscitation
should not be attempted because
it is futile or harmful, and enter
a DNR order in the progress notes,
cosigned by the attending physician,
the chairperson of the ethics committee,
and appropriate institutional authority,
such as a director of medical affairs.
3. To ratify the physician's and consultation
team's judgment that resuscitation
should not be attempted because
it is futile or harmful and seek
custody of the patient through the probate
court for the purpose of entering a
DNR order:
Which option is chosen will depend on the circumstances; for example, for the incompetent patient with no identifiable representative, option 2 makes sense. For the incompetent patient whose court-appointed guardian is insisting on resuscitation, option 3 may be necessary (one reason the hospital's legal counsel would need to be involved at this stage). These don't exhaust the possibilities, of course. At least one remains:
4. To reject the physician's and consultation
team's judgment that resuscitation
should not be attempted because
it is futile or harmful.
If the attending physician remained adamant in his or her original conviction, this outcome might require the physician to sign off the case. Obviously, in that circumstance, the institution would need to have some provision for transferring care, probably to a physician within the medical administration of the institution.
III. Attending physicians, house staff, or nursing staff who follow a DNR order that has been properly entered in the progress notes in accordance width the above provision are acting in conformity with hospital policy.
This provides some possible legal protection to physicians and nurses who do not resuscitate a patient under the provisions of the hospital policy. Withholding such protection also puts pressure on the physician whose judgment has not been accepted by the community, and discourages physicians from trying to act in secrecy, or unilaterally beyond the bounds of policy.
Good DNR Decisions
A hospital futility policy cannot simply endorse the principle that physicians retain authority over futile resuscitation, or be content with a simple operational definition. Consideration of the ethical limits and dangers of futility determinations and of the professional and institutional contexts in which those determinations are made will demand much more than that. Careful procedural safeguards, supplementary policies regarding other limitations of treatment, provision of education and training to caregivers, the availability of effective ethics consultation, and a well-functioning ethics committee are all essential ingredients for an effective and trustworthy policy.
A policy that meets these demands, like the model we have proposed, will be conservative and cautious in conflicts, but liberal and permissive in reviewing agreed-upon plans of care. The best test of the policy's effectiveness will not be in how forcefully it can impose the individual physician's will on patients and families. More important will be how effectively it has reduced these recalcirant conflicts, by realigning the ethics of resuscitation decisions and infusing more honesty into DNR discussions.
[1.] Tom Tomlinson and Howard Brody, "Futility and the Ethics of Resuscitation," JAMA 264 (1990): 1276-80. [2.] Stuart J. Youngner, "Who Defines Futility?" JAMA 260 (1988): 2094-95. [3.] Tom Tomlinson and Howard Brody, "Ethics and Communication in DNR Orders," NEJM 318 (1988): 43-46. [4.] Lawrence J. Schneiderman, Nancy S. Jecker, and Albert R. Jonsen, "Medical Futility: Its Meaning and Ethical Implications," Annals of Internal Medicine 112 (1990): 949-54, at 952. [5.] Donald J. Murphy and Thomas E. Finucane, 'New Do-Not-Resuscitate Policies: A First Step in Cost Control,' Archives of Internal Medicine 153 (1993): 164148. [6.] Mark H. Ebell, "Prearrest Predictors of Survival Following In-Hospital Cardio-pulmonary Resuscitation: A Meta-Analysis," Journal of Family Practice 34 (1992): 551-58. [7.] Mark Rosenberg et al., "Results of Cardiopulmonary Resuscitation: Failure to Predict Survival in Two Community Hospitals," Archives of Internal Medicine 153 (1993): 1370-75. [8.] See George J. Annas, "Nancy Cruzan and the Right to Die," NEJM 323 (1990): 670-73; Ronald Dworkin, "The Right to Death," The New York Review of Books, 31 january 1991, pp. 14-17. [9.] See David Orentlicher, "Advance Medical Directives," JAMA 263 (1990): 2365-67. [10.] Steven H. Miles, "Informed Demand for `Non-Neneficial' Medical Treatment," NEJM 325 (1991): 512-15. [11.] George J. Annas, "Asking the Courts to Set the Standard of Emergency Care: The Case of Baby K," NEJM 330 (1994):1542-45. [12.] Council on Ethical and Judicial Affairs, "Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders," JAMA 265 (1991):1868-71. [13.] John D. Lantos et al., "The Illusion of Futility in Clinical Practice," American Journal of Medicine 87 (1989): 81-84. [14.] Santa Monica Hospital Medical Center, "Futile Care Guidelines," supplement, Medical Ethics Advisor, October 1993, p.9.
Tom Tomlinson is an associate professor at the Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing Diane Czlonka is a clinical East specialist at Sinai Hospital of Detroit.
Tom Tomlinson and Diane Czlonka, "Futility and Hospital Policy," Hastings Center Report 25, no. 3 (1995):28-35.
Reader Opinion
|Printer friendly Cite/link Email Feedback
|Tomlinson, Tom; Czlonka, Diane
|The Hastings Center Report
|May 1, 1995
|Previous Article:
|Punishing medicine.
|Next Article:
|Conflicts of conscience: hospice and assisted suicide.

subset: commoncrawl


text:
This isn't your ordinary romance novel. Instead, each book is customized with your and your lover's names, descriptions, and even the type of car you drive. Choose from several different levels of how tame you want the story to be. We liked Fever in France! (ustarnovels.com, $39.95)
Personalized Romance Novel
18 Ways You Know You Grew Up Puerto Rican
For one, tu eres Boricua pa' que tu lo' sepas!
Mother Shot by her 3-Year-Old Son in Horrible Accident
Christa Engles, 26, was shot and killed by her son while changing her other child's diaper.
And You Thought YOUR Thanksgiving Travel Was Bad
In Siberia, where it's minus 58 degrees, travelers pushed their own plane down the runway.
Twitter Might Buy Justin Bieber's Selfie App
A now-deleted tweet from CFO Anthony Noto suggests Twitter is looking at Shots Mobile.
More From Lifestyle


text:
Russian Navy's Second Mistral-Class Ship Floated Out
Russian Navy's second Mistral-class helicopter carrier Sevastopol has been floated out of Saint Nazaire shipyard's dry dock in France. Sevastopol is one of two Mistral-class vessels ordered by the Russian ...read more →
USS Boxer Celebrates Re-Opening of Ship Store
Sailors from USS Boxer's (LHD 4) ship sales division participated in a ribbon cutting ceremony to celebrate the ...read more →
Russian Navy's Corvettes Join in Firing Drills
During recent missile and artillery exercises, the Russian Baltic Fleet's corvettes Soobrazitelnyy ...read more →
Sri Lankan Naval Academy Holds Certificate Awarding Ceremony
The Certificate Awarding Ceremony of the 15th Sub Lieutenant Technical (Executive) Course was held at the Admiral ...read more →
US Naval Academy Class of 2015 Receives Service Assignments
The US Naval Academy Class of 2015 received notification of their service assignments, Nov. 20, informing them ...read more →
Australian Navy Shows Its Newest Maritime Combat Helicopter
The Royal Australian Navy's newest maritime combat helicopter, the MH-60R Seahawk 'Romeo', was introduced to the ...read more →
USCG Engages in This Year's IMCMEX
During the sea phase of this year's International Mine Countermeasures Exercise (IMCMEX) four U.S. Coast ...read more →
T-AGOS/T-AGM Fleet Maintenance Contract Awarded
Crowley Technical Management Inc., Jacksonville, Florida, is being awarded a $31,8 million firm-fixed-price ...read more →
LCS Crew 111 Commissioned in Coronado
Littoral combat ship (LCS) Crew 111 was formally commissioned during a ceremony at Tidelands Park in Coronado, Nov. ...read more →
USS John C. Stennis Starts Preps for INSURV
Sailors aboard USS John C. Stennis (CVN 74) began preparations for a Board of Inspection and Survey (INSURV) ...read more →
Busan, Korea Welcomes USS Cape St. George
The Ticonderoga-class guided-missile cruiser USS Cape St. George (CG 71) arrived in Busan, Republic of Korea, for a ...read more →
USS Olympia Docks in Yokosuka, Japan
The Los Angeles-class fast-attack submarine USS Olympia (SSN 717) arrived at Fleet Activities Yokosuka, Japan, Nov. ...read more →
CACI Wins NAVSEA Support Services Deal
CACI International Inc was awarded a $182 million contract to provide integrated logistics and acquisition support ...read more →
Iwo Jima ARG Finishes ARG/MEU Ex
The USS Iwo Jima Amphibious Ready Group (ARG) completed a 23-day ARG/Marine Expeditionary Unit Exercise (ARG/MEU ...read more →
Commander CTF-150, MARCOM Discuss Interaction in Indian Ocean
The future Commander of Combined Maritime Forces Task Force 150 (CTF-150), Commodore Brian Santarpia (CAN N), ...read more →
Image of the Day: LCACs Conduct Back-Load
Landing Craft Air Cushion (LCAC) vehicles 31 and 75, attached to Assault Craft Unit (ACU) 5, conduct an equipment ...read more →
Danish Navy Rescues Two during Survey Ops in Greenland
Royal Danish Navy's inspection vessel EJNAR MIKKELSEN recently rescued two teenage girls during the testing ...read more →
Commander of French Submarine Forces Pays Visit to NATO ...
The Commander of French Submarine and Strategic Oceanic Forces (ALFOST), Vice Admiral Louis-Michel Guillaume, and ...read more →
George Washington CSG Welcomes JMSDF during Keen Sword 15
Japan Maritime Self-Defense Force (JMSDF) Rear Adm. Akira Saito, commander, Escort Flotilla (CCF) One, along with ...read more →
US Navy's 7th Fleet Sailors Get Protective Garments
Specialists with Griffin Technologies fit US Navy's 7th Fleet Sailors with chemical, biological and ...read more →
Two US Naval Ships Collide in the Gulf of Aden
Two U.S. Naval supply ships collided in the Gulf of Aden Nov. 20 at 5:26 a.m. (GMT) with no injuries to crew ...read more →
JSS Karel Doorman Brings Aid Supplies to Freetown, ...
The Netherlands Navy's Joint Logistics Support Ship Karel Doorman arrived in Freetown, Sierra Leone and ...read more →
US, Japanese Military Leaders Discuss Future Cooperation
US and Japanese military leaders embarked Nimitz-class aircraft carrier USS George Washington (CVN 73) Nov. 18 ...read more →
Exercise Cooperation Spirit Launches in China
Defence force personnel from Australia are in China for Exercise Cooperation Spirit 2014 which begins today. The ...read more →
USS Abraham Lincoln Gets Ready to Fight a Fire
Sailors aboard the Nimitz-class aircraft carrier USS Abraham Lincoln (CVN 72) received training on hose-handling ...read more →


text:
Is this man running for office? It sure looks that way. He just filed "an appoinment of a campaign treasurer" for a still-unspecified position.
In a Q&A with the Atlantic, Kentucky senator Rand Paul handicaps his father's presidential campaign and its larger impact on the Republican Party.
In a huge departure from its past stances on immigration, the Republican Party of Texas came out in favor of a heavily regulated guest worker program in its 2012 platform.
Ron Paul as a Romney-appointed chairman of the Federal Reserve? Rand Paul as a running mate? Don't laugh. Politics has made stranger bedfellows.
Republican primary voters will be asked if they're in favor of the Eighty-third Legislature redrawing the maps.
Now that the High Court has turned its lofty gaze on the issue, here are the five things you should know about latest news in the redistricting saga.
Exactly seven days before the originally scheduled March 6 primary, the San Antonio federal court released a new set of maps that should lock in the May 29 election.
Joe Hagan profiles the Bush dynasty for New York magazine.
Rick Perry's fifth-place finish leaves the governor reeling, while Ron Paul's campaign stays on track with his third-place showing.
Emergency U.S. Supreme Court case? Delayed March primary? The reactions to the federal panel of judge's interim map pour in.


text:
How does lamotrigine interact with methadone?
- Posted:
- 13 May 2010 by nelsonconnie
- Topics:
- lamotrigine, methadone
|Question is Closed
|Report Mark as Favorite
Answers (1)
13 May 2010
This is what I found on this subject.
Individuals in methadone treatment are known to have high rates of mood disorders. Lamotrigine is an anticonvulsant approved by the FDA for the treatment of bipolar disorder, particularly for bipolar depression. Rash has been reported as the most frequent adverse effect of lamotrigine, whereas blood dyscrasias have been noted rarely.1 We report the occurrence of rash, thrombocytopenia, and neutropenia associated with lamotrigine in a methadone-treatment patient with hepatitis C infection.
So it looks like you shouldn't have a problem taking the two. Does the methadone doctor not know about the Lamotrigine? If he/she doesn't then you need to let them know... Good luck... Dave
Further Information
Search for questions
Still looking for answers? Try searching for what you seek or ask your own question.
Similar questions
Does Tramal interact with methadone?
I have been told that Tramal and methadone have an agonist/antagosist type effect, in that one cancels out the pain relief of the other.
1 answer • 1 Aug 2010
Can anyone tell me if they have heard of the drug lamotrigine being used to treat?
headaches ? they are giving that drug to my brother as well as morphine for the switch from suboxone to opiates, the last dose of sub he took was at ...
2 answers • 25 Jan 2012
Does trazadone interact with methadone?
2 answers • 11 Feb 2012
My question is if I take lamotrigine with divalproex sod dr. will that hurt me at all?
i have trouble sleepin at night so my dr put me on lamotrigine 75mg that wasnt workin' so he add this new medicine divalproex sod dr 250mg. will ...
1 answer • 19 Jul 2012


text:
Websites and Resources for Writers Mardi Gras or not, let's not hide behind any masks, agreed? Make me a happy reveler and check out the Websites for Writers Toolkit. You'll be surprised to find some pretty colorful links there. Share this:RedditPinterestPocketStumbleUponFacebookTwitterTumblrLinkedInRedditMoreEmailPinterestGooglePrint Related By Lee Tyler | December 22, 2012 | authors, platform, publishing, tech, tips, website, websites, writers, writers helping writers, writing, writing on writing | No Comments | ← Via Author Media My Wish for You → Leave a Reply Cancel reply Your email address will not be published. Required fields are marked * Name * Email * Website Prove you\'re not a spambot please. * × 9 = seventy two Comment You may use these HTML tags and attributes:   <acronym title="">
      <q cite="">   Notify me of follow-up comments by email. Notify me of new posts by email.


text:
Love the recent holiday billboard ad for the beloved Coca-Cola brand! Having said that, whenever I see branding around the sound Mmm, for food and beverage products, even if it is only one Mmm, and not back-to-back Mmm, Mmms, I'm thinking old school: Campbell's Soup. No wonder, Campbell's M'M! M'M! GOOD! slogan has lasted nearly… Continue Reading
Category Archives: BrandingSubscribe to Branding RSS Feed
Sweating Out a COREPOWER CoexistencePosted in Branding, Marketing, Trademarks
Aside from my propensity for laughter, there are few things that can instantly improve my mood quite like an impromptu dance party or hot yoga sculpt. Yes, hot yoga sculpt – yoga with weights and cardio in a very hot room for an hour. I was scared too, but allowed a friend to drag me… Continue Reading
TRENDING: Minnesota's Midwestern "Identity Crisis"Posted in Advertising, Branding, Marketing, Mixed Bag of Nuts, SoapBox
The usual suspects did it again Tuesday. My Minnesota friends who, like me, tend to indulge in a bit too much Minnesota-centric navel gazing took high interest to a Minneapolis Star Tribune column that posed an interesting question: "Does Minnesota's region have an identity crisis?" My Facebook feed lit up with links to Kim Ode's… Continue Reading
Villainous Big BrandsPosted in Branding, Famous Marks, Guest Bloggers, Marketing, Mixed Bag of Nuts, Social Media
- Chuck Sanchez, BatesMeron Sweet Design Comcast. Electronic Arts. AT&T. Walmart. Dell. Time Warner. Fox News. McDonald's. Chances are, at least one of those company names kind of pissed you off just now. Despite this likelihood, each of these brands is immediately recognizable due to widespread financial success in its respective industry. So must a… Continue Reading
Love Is All You NeedPosted in Branding, Goodwill, Guest Bloggers, Marketing, Mixed Bag of Nuts
- Mark Prus, Principal, NameFlash With apologies to The Beatles for borrowing a lyric from their song "All You Need Is Love" from The Magical Mystery Tour album, branding that uses "Love" or its symbols are scientifically proven to give persuasion a boost. Southwest Airlines has understood the power of love for quite a while… Continue Reading
Trending Topic: The Branding Influence of the Ad World on the Legal WorldPosted in Branding
We're fans here of saying that we aren't Dr. Nos; we try to create a symbiotic relationship between creatives and their lawyer counterparts. But more often than we realize, the advertising world affects the legal one. I may not yet have a decade in the legal business, but I can spot trends when I see… Continue Reading
Microsoft's New Battle: ToadsPosted in Branding, Famous Marks, Trademarks, USPTO
It isn't often that Forbes and Arcade Sushi are reporting on the same story. But some news is so big, so ground breaking, and so important that all media outlets cannot, in good moral consciousness, fail to comply with their duty to inform the public. Obviously, I'm talking about Microsoft's potential reboot of the Battletoads… Continue Reading
Does the United States Patent and Trademark Office Perpetuate Sexism in Branding?Posted in Advertising, Branding, First Amendment, Guest Bloggers, Marketing, Mixed Bag of Nuts, Trademarks, TTAB, USPTO
- Draeke Weseman, Weseman Law Office, PLLC Now the dilemma…what to name the place. Simple. What else brings a gleam to men's eyes everywhere besides beer, chicken wings and an occasional winning football season? Hence the name Hooters. Supposedly they were into owls. Strange. — Hooters This NFL season, civil rights advocates continue to make… Continue Reading
It's a Marathon, Not a SprintPosted in Branding
Unless you've been living under rock this past week, you've likely heard the story of new viral sensation "Alex from Target." Apparently, some teenage girl took a picture of him bagging items at Target, tweeted it, and watched the entire world fall head over heels for no apparent reason. According to TMZ (which is actually… Continue Reading
SwitcherooPosted in Branding
Long suffering Vikings fans–a population of which I am a proud/depressed member–received emotionally confusing news earlier this week. Adrian Peterson, scourge of the NFL, pled out of his felony child abuse case for a lesser charge, thereby concluding his case and avoiding jail time. This news was emotionally confusing because, while Peterson is a… Continue Reading
Photoshopping: One Lingerie Company is Bucking the Trend while Making a BuckPosted in Advertising, Branding, Fashion, Goodwill, Marketing
It's no secret that the advertising industry relies heavily on physical appearance to sell products, especially for clothing, accessories, and even cheeseburgers. About a year ago, Brent (Lorentz, of the fellow Duets Blogger fame) discussed the prevalence of unrealistic expectations of beauty in advertising. As Brent mentioned, while ethical standards are applied to all sorts of industries,… Continue Reading
Fair Comparative Vodka Advertising?Posted in Advertising, Branding, Fair Use, Marketing, Trademarks
Love the simplicity of this comparative vodka advertisement: Fair use by Platinka? Sorry Grey Goose, I think so. Dear readers, do you agree?
Mayhem: Ahem, Metaphorically SpeakingPosted in Advertising, Articles, Branding, Marketing, Non-Traditional Trademarks, Sight, Television, Trademarks, USPTO
Metaphors are a good choice for trademarks. A metaphor typically requires some thought, imagination or perception to understand the connection between the mark and what's for sale. Remember what a floating feather might suggest metaphorically? Yes, a good night's sleep. So, the symbol works well as a distinctive non-verbal trademark for a pharmaceutical sleep aid…. Continue Reading
Does Your Business Have a Chief Branding Officer?Posted in Branding, Goodwill, Guest Bloggers, Marketing, Mixed Bag of Nuts
- Debbie Laskey, MBA Who owns the brand in your business? If your business is top heavy with numerous members in the C-Suite, this may be a difficult question to answer if you don't have a Chief Marketing Officer. Your Chief Sales Officer may claim ownership, or your Chief Information Officer may claim ownership. Perhaps,… Continue Reading
I DON'T GET ITPosted in Branding, Goodwill, Guest Bloggers, Mixed Bag of Nuts, Trademarks
- Abby V. Reiner, Brand Director, Wounded Warrior Project The more people understand the depth of meaning and enormous value a so-called "simple logo" has to a non-profit organization and the people it serves, the fewer infringements and the more money goes where we all want it to go – those served by charitable institutions…. Continue Reading
Amy, Whatcha Wanna Do (About this TM)?Posted in Articles, Branding, Infringement, Law Suits, Marketing, Trademarks, TTAB, USPTO
As we start to think about welcoming in the weekend, why don't we all hum this Pure Prairie League tune, while viewing this image and reading this very brief blog post: As this image (that I snapped this morning) shows, the skyway in downtown Minneapolis is sporting a relatively new snack shop called Amy's. I'm… Continue Reading
Targeting an Old Liquor StorePosted in Branding, Famous Marks, Marketing, Trademarks
When I moved from Minnesota to Wisconsin to go to college, among the local customs that I had to get acclimated to were the revulsion against the word "pop" for carbonated beverages named "soda;" hearing classmates say "I just need to find the time machine" when they meant an ATM branded with Tyme; and the… Continue Reading
Right to Use/Register TMs: Webinar Friday!Posted in Branding, Infringement, Law Suits, Trademarks, TTAB, USPTO
We have spent quite a bit of time here discussing the critical difference between a brand owner's right to register a trademark, as compared to a brand owner's right to use a trademark. We have noted that these are distinct rights — they are not coextensive rights. Just because a brand owner is denied the… Continue Reading
Bottega Veneta Unties a Trademark KnotPosted in Advertising, Articles, Branding, Fashion, International, Look-For Ads, Marketing, Non-Traditional Trademarks, Product Configurations, Sight, Trademarks, USPTO
It is easy for some to get all tied up in knots at the USPTO when facing challenging grounds for refusal against federal registration of a claimed non-traditional trademark. Not Bottega Veneta. Last week the Swiss-owned fashion house and luxury brand was able to persuade the USPTO to approve for publication the three dimensional knot… Continue Reading
Star Wars: Redefining Trademark and Copyright Law Since A Long Time AgoPosted in Advertising, Branding, Copyrights, Famous Marks, Goodwill, Non-Traditional Trademarks, Social Media, Sound, Television, Trademarks, USPTO
The Star Wars series is truly an exceptional franchise, having broken box office records, creating legions of fans, and bringing the idea of collateral merchandise licensing to an unprecedented level. Also, how many other films are top hits at the box office in three different decades, even when all you've done is add a few… Continue Reading
HOW To Support a Lawsuit in 140 Characters or LessPosted in Advertising, Almost Advice, Branding, Infringement, Law Suits, Marketing, Social Media, Trademarks
It's not too often that we see a trademark dispute that affects the marketing and advertising community directly (rather than just their clients), but the facts on this one read like answers to the Five W's: Who? Popular Greek yogurt manufacturer Chobani, its ad agency Droga5, and corporate leadership guru Dov Seidman. What? A trademark… Continue Reading
When it Feels Like "Look For" Advertising, How About a Little Follow-through?Posted in Advertising, Almost Advice, Articles, Branding, Food, Look-For Ads, Marketing, Non-Traditional Trademarks, Sight, Trademarks
As we head into the weekend, I thought I'd leave you with a Culver's ad that feels like "look for" advertising: We've spilled a lot of digital ink on the topic of how "look for" advertising greatly enhances a brand owner's ability to federally register non-traditional trademarks. Now, if Culver's would only follow-through and seek… Continue Reading
3 Really Is the Magic NumberPosted in Branding, Guest Bloggers, Marketing, Mixed Bag of Nuts
- Mark Prus, Principal, NameFlash Schoolhouse Rock fans already know this, but it took a January 2014 publication in the Journal of Marketing for marketers to get confirmation. I blogged about Procter & Gamble's "Secret of the Number 7" a few years ago on DuetsBlog, and later observed that their "magic number" had dropped to… Continue Reading
Coca-Cola's Significant Interest in Zero MarksPosted in Articles, Branding, Food, Genericide, Infringement, Law Suits, Loss of Rights, Marketing, Trademarks, TTAB, USPTO
Coca-Cola just announced it is introducing Coke Zero in India, which will make it the sub-brand's 149th market in the world, a truly remarkable reach. As the popular Coke Zero brand is approaching its tenth anniversary in the U.S., it seems like a good time to explore Coca-Cola's trademark position in COKE ZERO and COCA-COLA… Continue Reading


text:
Jay Cutler
FPPG: Torrey up, Jonas Gray down
Smith, but even if the Jets can get to Buffalo this weekend, he's in a tough spot to produce. Play, play, play: Jay Cutler , Bears (vs. Bucs) For all the panic after Cutler's bad outings against the Patriots and Packers, let's remember
Return to Chicago presents opportunity for bruised Lovie Smith and Josh McCown
his five starts with the Bucs making others wonder where that calculated quarterback who performed well last season in Jay Cutler 's absence has gone. One interception in 224 pass attempts in 2013 has turned to six interceptions in 134 pass attempts
Buccaneers-Bears Preview
interception and posting a 108.2 passer rating while going 3-2 as a starter for the Bears in place of an injured Jay Cutler last season. The 35-year old is 1-4 with six TDs, six INTs and an 82.6 rating in 2014, but feels confident facing
Sideline tablets seem here to stay
might have even more input in the future.'' Not everyone can identify the technology being used - Bears quarterback Jay Cutler called it a ''knockoff iPad'' before praising the innovation for ''working great.'' Campbell marvels at the
Vikings report card: Flat performance all around
attempted only one pass beyond 10 yards before the fourth quarter, and only four during the game. While Chicago quarterback Jay Cutler was showing immense trust in his tall -- and very talented -- receivers, Bridgewater didn't seem to want to open
Green Bay heat: Rodgers and Packers unstoppable
embarrassing day for the host Redskins (3-7), who were booed early and often. BEARS 21, VIKINGS 13 At Chicago, Jay Cutler threw for 330 yards and three touchdowns, and the Bears won for just the second time in seven games. Ryan Mundy intercepted
NFL Today, Week 11
Passing - Aaron Rodgers, Packers, passed for 341 yards and three touchdowns as Green Bay routed Philadelphia 53-20. - Jay Cutler , Bears, threw for 330 yards and three touchdowns to lead Chicago past Minnesota 21-13. - Josh McCown, Buccaneers
Fantasy: Final Sunday/Monday rankings for NFL Week 11
Josh McCown @ Washington 16. Mark Sanchez @ Green Bay 17. Andy Dalton @ New Orleans 18. Alex Smith vs. Seattle 19. Jay Cutler vs. Minnesota 20. Derek Carr @ San Diego 21. Drew Stanton vs. Detroit 22. Eli Manning vs. San Francisco 23. Ryan
Cutler leads struggling Bears over Vikings 21-13
CHICAGO (AP) Jay Cutler threw for 330 yards and three touchdowns, and the Chicago Bears won for just the second time in seven games, beating the Minnesota
5 things to watch: Vikings at Bears
missed the past six games. 5. Jay and the giants Chicago was supposed to be led by its offense. Yet, quarterback Jay Cutler and the offense deserve plenty of blame for the string of losses, as well. The biggest issue has been turnovers. The


text:
BBC Newshour
BBC's most experienced correspondents bring you compelling interviews on every subject. From devastating natural disasters to inspiring triumphs of the human spirit, BBC Newshour has the world covered.
Recent Episodes
Newshour: Ukraine ceasefire shaken
Fresh violence threatens truce; first Japanese Grand Slam finalist; 9yr old jazz pianist
Newshour: Former Syria hostage tells story
Former Syria hostage links captor to Jewish museum killings; Milgram's shock experiments re-examined; human rights in Bahrain.
Newshour: Ebola Lockdown
People asked to stay inside in Sierra Leone; Margaret Atwood writes for the future; Dancing to stay young
Newshour: Ukraine ceasefire
Kiev counts cost of peace; using blood to treat Ebola; voter registration: the eyes have it
Newshour: NATO summit
NATO urges Russia to choose peace; Boko Haram gain ground in Nigeria; biggest ever dinosaur


text:
An animal-burning incinerator is not part of New Jersey-based Covance's plans for a large laboratory facility in south Chandler. But that doesn't make opponents to the contract lab company's planned move into the city feel any better.
"Everyone here wants to know how the carcasses will be disposed of," said Aysha Akhtar, a neurologist and spokeswoman for the Washington, D.C.-based group, Physicians Committee for Responsible Medicine while at a public hearing Monday.
The organization, which promotes the vegetarian diet, opposes the use of animals in testing.
Akhtar was one of several people opposing Covance's application for air quality permits from Maricopa County, which would allow it to operate backup generators, a boiler and air-conditioning elements.
The permit is needed for the company to break ground on the project planned in the Chandler Airpark near Gilbert and Queen Creek roads.
More than 150 people attended the hearing at the Chandler Municipal Airport.
Many of Covance's opponents say there's little to stop the company from coming back later and applying for a new permit to build an animal crematorium. The company's other labs use crematoriums.
But Covance officials called those claims by opponents "a smokescreen on their part."
The company has already announced it will use an outside vendor to dispose of dead lab animals. But the company has not yet decided exactly what vendor it will use, said spokeswoman Camilla Strongin.
And besides, even when Covance makes that decision, the company probably won't share the information with the public, she said.
"We have an obligation to our vendors not to put them in the line of fire," Strongin said. "And we're dealing right now with a vendor that is facing tertiary targeting."
Covance could later apply for a permit to build an incinerator, Maricopa County Air Quality Department director Robert Kard said, but the company would face the same process it's going through now, including a public hearing.
"If they were to apply for a permit with us, given the nature of the controversy that we see here before us, we've done this with other companies, not just Covance, we would hold a public hearing," Kard said. "There's no escaping that, quite frankly."


text:
- Age / Gender:
- n/a, Male
- Location:
- Location not disclosed
- Joined:
- 6/15/09
- All Stats >
User Statshot
- Community Stats
Level 7 Gamer
Normal Whistle
Ranked as Civilian
Contact Info / Websites
Recent Game Medals
ZombiModenator I 10 Points Kill 2000 zombies. Medal Stats.
Zombieball 10 Points Make 20 fastkill with the ball. Medal Stats.
Ninja guy 10 Points Make 20 fastkill with the Armor Sword. Medal Stats.
Bullseye 10 Points Make a bullseye hit with the dart. Medal Stats.
Divine Intervention 10 Points Meet Douglas in every town! Medal Stats.
I hate insects! 10 Points Get 10000 points! Medal Stats.
Santa's Little Helper 10 Points Complete 10 sidequests! Medal Stats.
Level 6 5 Points Level 6 Medal Stats.
SECRET MEDAL 10 Points Unlock this medal to see it's details. Medal Stats.
Dethroned! 25 Points Defeat the Watermelon King Medal Stats.
Total Medals Earned: 1,064 (From 134 different games.)
Favorite Movies
Favorite Games
Onslaught 2 Rated 4.3100 Stars Onslaught tower defence. Kill creeps, earn cash, buy defences, last as long as you can! Strategy - Tower Defense mud and blood 2 Rated 4.3969 Stars Lead your men to victory in this bloody WW2 title Strategy - Real-time (RTS) Clarence's Big Chance Rated 4.3737 Stars An ugly 35-year-old virgin must jump around on platforms to impress a girl! Action - Platformer - Hop and Bop Bullet Audyssey Rated 4.4327 Stars Bullet Audyssey is a rhythm-based shoot 'em up where you mustSurvive the Beat. Action - Shooter - Vertical Flight


text:
Originally published December 6, 2011 at 8:03 PM | Page modified December 7, 2011 at 9:07 AM
Why our sunsets are stuck in time
Sunset hits Seattle at 4:18 p.m. through Dec. 17 — the earliest time of the year — though the shortest day of the year isn't until several days later.
Seattle Times staff reporter
Now is our hibernation time, when the sun tucks us in for the night at 4:18 p.m., the earliest sunsets of the year.
By 3:30 in the afternoon through Dec. 17, the sun already is taking on that apricot glow, coloring the sky and west-facing buildings downtown gold, their windows flaring orange with reflected sunset light.
A dramatic darkling is under way long before dinner, before it's time to go home for the day, as night presses in and the Olympics occlude to the west. Holiday lights and shop windows burn in the gathering dark, all the warmer and prettier for the contrast, especially when the streets shine wet with rain.
Sunrise also comes later every morning. By the time winter officially begins Dec. 22, we will be down to the shortest day of the year. A mere stub of a day, out almost before it is lit, with a mere eight hours of daylight.
This seems odd: Sunrise is coming later, even as sunset is stuck at the same time of day for more than a week. And, despite the continued decrease in daylight hours until Dec. 22 (due to later and later sunrises), the sun actually starts setting later as of Dec. 18.
What's going on?
Dale Durran, chairman of the atmospheric sciences department at the University of Washington, says it's a combination of astronomical effects going on at the same time. At the heart of the matter are the positions of the sun and Earth relative to each other.
One of the effects of their changing alignment makes for a difference between clock time and solar time. Noon, it turns out, isn't when you think it is.
It's only high noon — when the sun is directly overhead in its highest position of the sky at noon on the clock — four times a year. The high-noon position of the sun is either behind or ahead of clock time the rest of the year.
That's because of the variable rate of time it takes during the course of the year for Earth to turn all the way around to face the sun in the same place — say solar noon.
The amount of time it takes for the Earth to face the sun in the same spot varies over the course of the year, resulting in an accumulated difference between clock time and solar time by as much as 16 minutes. That would tend to make sunsets later.
But another effect is in play: Earth rotates on a tilted axis. That means the North Pole leans progressively farther from the sun until the arrival of the winter solstice on Dec. 22. That would tend to make the sun rise later and set earlier until then. Yet, because of the combination of the two effects, the time of sunset in Seattle holds steady between Dec. 5 and Dec. 17.
The gradual change in daylight length and difference between clock and solar time cancel each other out. Voilà: Sunset is parked, even as the sun continues to rise ever later.
If all this — the equation of time, the movement of the cosmos, and more — is a bit daunting, you always can take the wake-me-when-it's over approach.
It seems to work for bears.
Lynda V. Mapes: 206-464-2736
On Twitter @lyndavmapes.
Trending on seattletimes.com
Most read
- Thanksgiving: What can and can't be prepped ahead
- Richard Sherman and cutout Doug Baldwin criticize NFL policies
- Seattle-area home prices keep cooling
- In Seattle, a march, 'die-ins' and police pelted with rocks
- Sally Clark says her actions appropriate after hitting cyclist
- Theater of the absurd: Richard Sherman, Doug Baldwin stand up for Marshawn Lynch | Larry Stone
- Guard reinforcements contain damage in Ferguson
- Parents of Lake Stevens boy shot in mouth had argued about guns in home
- Audit: 2 ex-SHA employees got $130,000 in bogus overtime
- SF hotel developer plans 50-story project on Fifth Avenue
Most viewed photo galleries
Most watched
Career Center Blog


text:
Recommended Reading: Non-Coaching Books
Asking Twitter what 'non-coaching' books are recommended for Coaches was a worthwhile exercise. Firstly, the quality of Coach that replied is extremely high (in fact, if you don't follow someone on the list below I'd suggest you do it now More
5 Things Everyone should know about Concussions
Concussion has become one of the major issues facing sport today and this is highlighted on a daily basis, as concussion stories are commonplace in the sports media. Collision sports such as rugby, rugby league, soccer and AFL generate the More
What does David have in common with Goliath?
Regarded as one of the best Strength & Conditioning Coaches in Australia, Brendyn Appleby has switched from working with professional rugby players in the SuperRugby Competition to training the Australian Men's (field) hockey team. Despite the obvious physical differences, there are some key More


text:
Recommended Products
Guests who bought this also bought
Happy Day Handbag
- Sale Price USD$ 19.20
- Regular Price: USD$ 24.00
- You Save: USD$ 4.80 (20%)
Item is available.
Item # 205270
Contains soft versions of everything found in Mom's purse: cell phone, wallet, ID card, credit card, $10 and $1 bills, coin purse, and compact mirror.
Our Happy Day Handbag encourages imaginative play and was given the Canadian Toy Testing Council 2-Star Award for its whimsical design.


text:
Current Percy
Spiderman with his upgrade from The Other
Percy is bloodlusted
Spiderman is bloodlusted
Fight takes place in NYC
Wha- Why is Percy morals on and Spides is bloodlusted? o_O
@fatherchaos: Didn't Percy have like Hypersonic Reaction Feats.....And fight a God?
@bluejay3: Fought a god who didn't show any impressive powers or skills or even just some fancy footwork despite being a god of war. And I don't remember any hypersonic reaction feats, when was that?
Percy FTW
@fatherchaos: Well it's just that every time Percy is in a battle people usually bring up his amazing reaction time.
Percy Jackson's feats are overrated; all of Percy's fights with gods/titans have him being helped in some way or the god is obviously just going easy on him.
Spiderman on the other hand consistently beats villains, on his own merit. What is Jackson gonna do when he's hit by spider webs?
@bluejay3: He deflected a bullet later on in the series, although his current speed is significantly degraded.
Spider-man obviously wins this.
@bluejay3: Percy does have incredible reaction time, but this is book one!! He's twelve!! Maybe if he had a water source and was blood lusted as well, but he's only got a slim chance then. Also, does Percy even have his sword? If so, then you have to specify that it can work on Spiderman because Riptide doesn't affect mortals.
The reason people bring up Percy's fight with Ares is because it's an impressive display of skill for someone at that age and experience level. Ares didn't put in his all, but it's still an impressive feat. They also bring up his reaction time which is incredible. However, in this scenario he is fighting someone with equal or better reaction feats who is bloodlusted.
If you want to make this more even, make either both with morals on or both bloodlusted. Also(and more importantly) make Percy the current version will all his feats and powers.
@fatherchaos: People under power Percy's feats when they argue against him because it's easy to say he fights people with no feats. They say his feats don't count because we haven't seen any feats for the people he's fighting. B.S. These are the classic mythological gods and creatures. You want feats? Go read the original myths. Sorry to unload on you but I see that argument in every argument against Percy.
Having said all this, in this scenario Spiderman kicks @$$.
@hwkfan296: Haha Thanks for the Honest response,but don't you think that current Percy is to OP for the Web Head.
Percy is allowed access to Luke's sword and a bottle of water if that helps.
@bluejay3: It still wouldn't be enough, since this is only book one. He has very little experience with his powers, and isn't as proficient a sword fighter as later in the series (although he still did hold his own against the god of war).
@funsiized: He did much better in HoH
Percy Jackson's feats are overrated; all of Percy's fights with gods/titans have him being helped in some way or the god is obviously just going easy on him.
Spiderman on the other hand consistently beats villains, on his own merit. What is Jackson gonna do when he's hit by spider webs?
Well he does have that trusty pen-sword but yeah i agree.
@bluejay3: Your fight is taking place in NYC, the best place for web slinging and the least amount of salt water available. All a bloodlusted Spider man would have to do is hit Percy with a car. The current Percy Jackson may have a better chance, but not by much. Percy may be able to react like Neo from "The Matrix", but Spider Man has more offence than anything percy can take or dish out.
@nojellykid: Current Percy would do much better than Book One. He would win if they were both in character.
@stormdriven: Yeah against Monsters, he said that was the source of his decay. He hadn't faced a skilled swordsman in a while.
@funsiized: His powers have become a bit of a crutch for him recently :/
@bluejay3: He can only match Aquaman with the Curse of Achilles, since Aquaman wouldn't be able to beat him through physical harm Other than that, and outside of the Curse, Percy is turned into paste. But he certainly isn't Superman tier.
I agree that Percy's current sword skills aren't what they could be, but they are not awful. His powers are immense though. Current Percy with morals could cause the sewers to burst and do his water-fists thing. However, Spidey without morals would probably still win. Spidey with morals would be a close battle. Percy and Spidey both bloodlusted with no morals? NYC is destroyed.
@hwkfan296: But couldn't Percy Teleport and have amazing traverse speed and reaction time underwater ?Some one even told me he was near Lightspeed...
@bluejay3: He does not have the ability to teleport without assistance. He does have incredible reflexes on land with no water, so much so that he can deflect bullets at point blank range. Any contact with water increases his power. His ability to move underwater is the same as that on land. Under NO circumstances can he travel near light speed. Whoever told you that needs to re-read the books.
@hwkfan296: But couldn't Percy Teleport and have amazing traverse speed and reaction time underwater ?Some one even told me he was near Lightspeed...
I don't know where you got that from, but no. He isn't anywhere near that fast.
@stormdriven: where would you put him on reaction time?Hypersonic,Supersonic would he at least be a bullet timer?
@stormdriven: where would you put him on reaction time?Hypersonic,Supersonic would he at least be a bullet timer?
Most likely in that neighborhood. He felt the path of a bullet as he was charging and deflected it in The Titan's Curse
@stormdriven: What about his fight with Hades ?Is it PIS
Peter. Greater physical feats.
Percy can't compete with Parker in physical combat, and that would be the most pertinent issue, to be honest.
Percy sucks at hand to hand combat.
Both bloodlusted should be a more even fight. Now I want to point out that while Percy's sword skills against skilled opponents have dropped, he has not lost them nor does that matter to this fight since Spiderman isn't using a sword or other weapon. His skills against lesser skilled opponents or ones with no weapons are not bad. He has a chance.
@hwkfan296: In terms of H2H I think there about equal.
Unless Percy gets some access to water, he is going to get a web around hes lungs.
@hwkfan296: compared to Spider-Man, Percy and Annabeth are outclassed in speed, strength, abilities, and tools. Spider-mans webs trump Percy's sword, heck Spidey can just grab a lamppost and beat Percy by having longer distanced weapon. Sword skills mean nothing in this battle. Bring this battle to the sea, take Spider's webs then the battle might be even for Percy. Also Annabeth wouldn't be able to beat Captain America in a fight she doesnt even have real powers. Actually she might have the power to bore Spider-man to death with archaeological facts.
Nah Percy Jackson wins
@nojellykid: If she didn't run away first...
As both a Percy Jackson Fan AND a Spiderman Fan. I would say if It's in the Middle of the City Spiderman would win. First Swordmanship doesn't matter, since it is made of Celestial Bronze, which can only hurt Divine or Monstrous beings, which Spiderman is not. Second in terms of pure physical power, Spider-man obviously is superior- having fighting against beings such as Sandman, Rhino, and survive combat with the HULK! Sure Percy manage to fight gods and titans, but most of them are not at full power or are merely toying with him (Ares was toying with Percy in the Lighting Thief, and really all Percy did was nip his ankle). Percy might be a bullet timer. But Spidey dodges lighting and lasers on a daily bases, and even dodge bullets point-blank range. Percy Jackson doesn't have any superman strength other than what a physical fit human would be. While Spiderman can bench-press Elephants and shatter brick walls. Also using sewer water is not going to be an instant win, as Spiderman actually does have experience fighting water-powered villians such as Hydro-man. Of course if they fight in the middle of the sea, or near a beach it is over for Spiderman, but that is a gimme when your a son of a sea god.
Use your keyboard!
Log in to comment


text:
- Meet John Doe: Rockford could benefit from the new Digital Manufacturing and Design Innovation Institute in Chicago
- Tech-Friendly: Surface Pro 3 ad comparing it to MacBook Air is a joke
- Chicago restaurateur Billy Lawless to introduce Obama during immigration speech in Chicago
- Travel Wisconsin Snow Conditions Report assists snow seekers
- Boys' basketball holiday tournament tips off tonight
- Ribbon-cutting for Children's Holiday Shoppe Nov. 26; shop is open Nov. 29-Dec. 21
- Rockford Rescue Mission invites community to Thanksgiving banquet Nov. 26
- Rockton's new business district welcomes family owned Dr. Detail U.S. Cellular
- 2014 Illinois Emerging Writers Competition winners named
- Open house for new library executive director tonight
SwedishAmerican presents Quality Awards
SwedishAmerican Health System recently presented Henry C. Anderson Quality Awards, the organization's highest expression of distinction and appreciation, to two recipients. Both were recognized for their contributions to the organization's pursuit of quality excellence.
Dr. Prakash Pedapati, Radiation Oncology — Dr. Pedapati has been with SwedishAmerican for more than 31 years and has exemplified quality and service excellence for Oncology Services. He has dedicated his time both personally and professionally to ensure the cancer program moves forward. As chairman of the Institutional Review Board, he has spent much time reviewing each clinical trial that was submitted to the committee and ensuring the organization's clinical trial program is in compliance with regulatory bodies. Dr. Pedapati also takes time to review each clinical trial to ensure it is safe and appropriate for SwedishAmerican Health System. He spends many hours in his spare time completing this process. He was instrumental in starting the prostate seed implant and Mammosite programs for the Regional Cancer Center. He completed additional training and worked with the physicists, surgeons and radiation therapist to develop these programs as a standard of care.
Emergency Medical Services (EMS) Team — The second Henry C. Anderson Award for Quality recipient is the EMS Team. This diverse group of 19 individuals united to evaluate the organization's Paramedic Education program to become nationally accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). This process included establishing tools to specifically measure the effectiveness of the program's faculty, support personnel, curriculum, clinical and field internship and learning resources. SwedishAmerican Hospital's EMS Program was the second in the state of Illinois to receive this recognition.
In addition to the national accreditation, the SwedishAmerican EMS System sought out an educational partner that could provide an associate degree program as an option for students in this region. A partnership was formed with Highland Community College in Freeport, Ill., in 2010. SwedishAmerican EMS employees invest a minimum of 1,000 hours of training in each paramedic student enrolled in the program.
EMS Team members include Richard Robinson, Tom Pratt, Linda Edmunds, Brian Murphy, Tonja Radford, Steve Kirschbaum, Penny Lentz, Michelle Messley, Mike Riley, Chad Moe, Trent Brass, Carla Heitter, Jeff Hoster, Will Backus, Chad Thompson, Ann Gantzer, Catherine Lewis, Dr. John Underwood and Dr. Michael Polka.
From the July 11-17, 2012, issue


text:
Prices and availability are subject to change from the time and date that you print this page.
11/29/2014 4:57:40 AM. For Customer Service, please call 800.606.6252
Pickup Check store pickup options
off the grid. Chicago-based designer Noël Ashby squares up a golden grid on rich charcoal grey. Swerving from a precise line, the freeform framework "acts as an interruption and gives a certain unexpected rhythm to something expected." Traditional paste wallpaper is designed for long-term use (adhesive not included).
Details and Dimensions
peeks traditional paste wallpaper. 27"Wx360"H
- Designed exclusively for CB2 by Noël Ashby
- Traditional paste wallpaper; adhesive not included
- For long-term use
- Durable screenprinted design; fade-resistant
- Clean with warm water and sponge
- Straight match pattern
- Please note: Wallpaper rolls that have been cut cannot be returned
- How will it look in your room? Free wallpaper samples are available in stores
- Made in USA
Overall DimensionsWidth: 27" Height: 360"
Return/Exchange Policy
We will accept merchandise returns of non-furniture items within 90 days of purchase. For furniture items, if you are not satisfied with your purchase, please contact us within 7 days of receipt to arrange a return. For Special Order upholstery items, returns and exchanges are limited to transit damage or manufacturing defect. We will accept a furniture return provided the return is completed within 30 days of delivery. For furniture orders placed online, please call us at 800.606.6252. For orders placed through a store, please contact the store where the sale originated. Our policy is simple. If you are not satisfied with your purchase, we promise an appropriate refund, credit or exchange.