연명치료중지시 의사의 역할과 의무

고윤석 대한의사협회 2009 대한의사협회지 Vol.52 No.9

Patients should be treated with dignity and respect toward the end of their lives, being freed from unnecessary and painful life-sustaining therapy in hospitals. In Korea, the quality of endof- life (EOL) care has been variable, a major factor being the physicians’ perception to the care. A firm consensus of EOL care decision-making has not yet explicitly stated in Korean law and ethics until recently. However, movements to make a law of so-called “the death with dignity act” are presently making its way to the National Assembly, initiated by a law case that allowed the hospital to withdraw mechanical ventilator support per request by the patients’ family of a permanently vegetative patient. Socially agreed guidelines for EOL care can facilitate clinical decision process and communication between health service provider and the patient or his/her family. At the same time, EOL care should be individualized also in the same line of guideline to meet patient’ and patient’ family wish regarding the withdrawal of life-sustaining therapy. The painful EOL care experience of the loved one remains in the memory of the relatives who live on. Physicians should identify, document, respect, and act on behalf of the hospitalized patients’ needs, priorities, and preference for EOL care. It has been advocated that competent patients can express their right of self-determination on EOL care through advance directives in Western countries. Advance directives are considered as a tool to facilitate EOL decision making. However, there are barriers to adopt the advance directives as a legitimate tool for an EOL decision making in Korea. For one thing, the reality of death and dying is rarely discussed in our society. In addition, the discussion about EOL care with chronically and critically ill patients has been considered as a taboo in the hospitals. In spite of these difficulties, physicians could do better EOL care by the open communication with patients or with their surrogates. Through the communication, physician should set a goal how to manage the EOL patient. The set goal should be shared among the caregivers to achieve the maximum benefit of the patient. The lack of open discussion with patient prior to EOL care results in inappropriate protraction of a patient’s dying process. In summary, physicians, who know the clinical significance of delivering treatments to EOL patients, should play a central role in assisting patients’ and their families’ to make the best decision on EOL care. Moreover, the concerted actions to improve EOL care in our society among general public, professionals, stakeholders for EOL care, and governmental organizations are required to address ongoing social requests, although a policy or a guideline is made in this time.

패혈증 증후군환자에서 성인성 호흡곤란 증후군 발생의 예측 지표서의 혈중 Tumor Necrosis Factor-$\alpha$와 Interleukin-$1{\beta}$에 관한 연구

고윤석,장윤혜,김우성,이재담,오순환,김원동,Koh, Youn-Suck,Jang, Yun-Hae,Kim, Woo-Sung,Lee, Jae-Dam,Oh, Soon-Hwan,Kim, Won-Dong 대한결핵및호흡기학회 1994 Tuberculosis and Respiratory Diseases Vol.41 No.5

연구배경: ARDS발생 기전에 있어 TNF-$\alpha$나 IL-$1{\beta}$의 역할은 이들이 폐혈관 내피세포에 작용하여 모세혈관의 투과성을 증가시키는 것으로 추정되나 ARDS환자 발생 예측 지표로서의 TNF-$\alpha$ 및 IL-$1{\beta}$의 임상적 유용성에 대한 지금까지의 연구결과는 부정적이다. 이는 기존연구들이 다양한 질환들을 대상으로 함으로써 ARDS 발생기전의 다양성이 ARDS환자 발생 예측지표로서의 TNF-$\alpha$의 유용성을 부정적으로 나타나게하였을 가능성을 배제할 수 없다. 이에 저자들은 ARDS 발생이 내독소와 cytokines등에 의한 작용인 것으로 알려지고 있는 패혈증 증후군 환자들을 대상으로 TNF-$\alpha$와 IL-$1{\beta}$의 ARDS 발생의 예측 표지자로서 임상적 효용성을 검토하고자 본 연구를 시행하였다. 방법: 패혈증 증후군환자들을 대상으로 ARDS발생군(이하 ARDS군, 16명)과 호흡부전 상태에서 ARDS로는 진행하지않은 급성호흡 부전군(Acute hypoxemic respiratory failure group, 이하 AHRF군, 20명)으로 분류하여 등록시, 24시간 및 72시간후에 채혈하여 ARDS군은 ARDS 발생시에, AHRF군은 동맥혈 산소분압에 대한 폐포 산소분압의 비가 가장 낮은 시점의 TNF-$\alpha$와 IL-$1{\beta}$의 농도를 비교하였다. 또한 ARDS 및 AHRF군에서 쇽 발생군과 비발생군으로 분류하고 쇽 발생시에 측정된 TNF-$\alpha$와 IL-$1{\beta}$를 비발생군의 TNF-$\alpha$ 및 IL-$1{\beta}$의 값과 비교하였다. 대조군은 건강 대조군으로서 1회만 채혈하였다. 결과: 1) 혈중 TNF-$\alpha$의 농도: 본 연구에 사용한 Predicta kit의 TNF-$\alpha$ 농도 측정의 민감도는 평균${\pm}2$표준편차의 하한값이 10pg/mL이며, 특이도는 100%로, ARDS군 16명중 8명이, AHRF군 20명중 12명이 10pg/mL 이상으로 측정되어 두 군사이에서 혈중 TNF-$\alpha$가 10pg/mL 이상 발현된 비율의 차이는 없었다. ARDS 및 AHRF군의 혈중 TNF-$\alpha$의 중앙값 농도는 각각 10.26pg/mL(<10-16.99pg/mL, 사분위수범위, interquartile range), 10.82pg/mL(<10-20.38pg/mL)로서 두 군 사이에는 유의한 차이가 없었으며 (Fig. 1), ARDS 발생 전후의 혈중 TNF-$\alpha$의 농도도 중앙값이 10pg/mL미만(<10-15.32)pg/mL 및 10pg/mL미만(<10-10.22)pg/mL로서 유의한 차이가 없었고 6명중 2명만이 ARDS 발생 전에 비하여 TNF-$\alpha$의 값이 증가되었다. ARDS 및 AHRF군에서 패혈성 쇽이 발생한 환자들(26명)의 TNF-$\alpha$의 농도는 12.53(<10-20.82)pg/mL로서 비발생군(10명) <10pg/mL에 비해 유의하게 높았으나(p<0.01)(Fig. 2), 전체 생존군(<10, <10-12.92pg/mL)과 사망군(11.80, <10-20.8pg/mL)사이에는 유의한 차이가 없었다(P=0.28). 2) 혈중 IL-$1{\beta}$의 농도: 본 연구에 사용한 Quantikine kit의 최저 측정치는 0.3ng/mL로서 건강 대조군 10명중 1명을 제외한 모두에서 IL-$1{\beta}$측정치가 0.3pg/mL이하였다. ARDS 및 AHRF군의 검체 중 0.3ng/mL 이하로 측정된 경우는 ARDS, AHRF군에서 각각 1예가 있었다 ARDS 및 AHRF군의 혈중 IL-$1{\beta}$의 농도는 각각 2.22(1.37-8.01)ng/mL, 2.13(0.83-5.29)ng/mL으로서 두 군사이에는 유의한 차이가 없었으며(Fig. 3), ARDS 발생전(2.53, 0.3-8.38ng/mL)과 발생후(5.35, 0.66-11.51ng/mL)에서도 차이가 없었다. 패혈성 쇽 발생군(2.51, 1.28-8.34ng/mL)과 비발생군(1.46, 0.15-2.13ng/mL)사이에서는 통계적인 유의한 차이는 없었으나 비발생군에서 낮은 경향을 보였다(각각 P=0.44, P=0.054)(Fig. 4). 생존군과 Background: Tumor necrosis factor(TNF)-$\alpha$ and Interleukin(lL)-$1{\beta}$ are thought to play a major role in the pathogenesis of the septic syndrome, which is frequently associated with adult respiratory distress syndrome(ARDS). In spite of many reports for the role of TNF-$\alpha$ in the pathogenesis of ARDS, including human studies, it has been reported that TNF-$\alpha$ is not sensitive and specific marker for impending ARDS. But there is a possibility that the results were affected by the diversity of pathogenetic mechanisms leading to the ARDS because of various underlying disorders of the study group in the previous reports. The purpose of the present study was to evaluate the roles of TNF-$\alpha$ and IL-$1{\beta}$ as a predictable marker for development of ARDS in the patients with septic syndrome, in which the pathogenesis is believed to be mainly cytokine-mediated. Methods: Thirty-six patients of the septic syndrome hospitalized in the intensive care units of the Asan Medical Center were studied. Sixteens suffered from ARDS, whereas the remaining 20 were at the risk of developing ARDS(acute hypoxemic respiratory failure, AHRF). In all patients venous blood samples were collected in heparin-coated tubes at the time of enrollment, at 24 and 72 h thereafter. TNF-$\alpha$ and IL-$1{\beta}$ was measured by an enzyme-linked immunosorbent assay (ELISA). All data are expressed as median with interquartile range. Results: 1) Plama TNF-$\alpha$ levels: Plasma TNF-$\beta$ levels were less than 10pg/mL, which is lowest detection value of the kit used in this study within the range of the $mean{\pm}2SD$, in all of the normal controls, 8 of 16 subjects of ARDS and in 8 in 20 subjects of AHRF. Plasma TNF-$\alpha$ levels from patients with ARDS were 10.26pg/mL(median; <10-16.99pg/mL, interquartile range) and not different from those of patients at AHRF(10.82, <10-20.38pg/mL). There was also no significant difference between pre-ARDS(<10, <10-15.32pg/mL) and ARDS(<10, <10-10.22pg/mL). TNF-$\alpha$ levels were significantly greater in the patients with shock than the patients without shock(12.53pg/mL vs. <10pg/mL) (p<0.01). There was no statistical significance between survivors(<10, <10-12.92pg/mL) and nonsurvivors(11.80, <10-20.8pg/mL) (P=0.28) in the plasma TNF-$\alpha$ levels. 2) Plasma IL-$1{\beta}$ levels: Plasma IL-$1{\beta}$ levels were less than 0.3ng/mL, which is the lowest detection value of the kit used in this study, in one of each patients group. There was no significant difference in IL-$1{\beta}$ levels of the ARDS(2.22, 1.37-8.01ng/mL) and of the AHRF(2.13, 0.83-5.29ng/mL). There was also no significant difference between pre-ARDS(2.53, <0.3-8.34ngfmL) and ARDS(5.35, 0.66-11.51ng/mL), and between patients with septic shock and patients without shock (2.51, 1.28-8.34 vs 1.46, 0.15-2.13ng/mL). Plasma IL-$1{\beta}$ levels were significantly different between survivors(1.37, 0.4-2.36ng/mL) and nonsurvivors(2.84, 1.46-8.34ng/mL). Conclusion: Plasma TNF-$\alpha$ and IL-$1{\beta}$ level are not a predictable marker for development of ARDS. But TNF-$\alpha$ is a marker for shock in septic syndrome. These result could not exclude a possibility of pathophysiologic roles of TNF-$\alpha$ and IL-$1{\beta}$ in acute lung injury because these cytokine could be locally produced and exert its effects within the lungs.

종설논문 : 의료인-제약회사 관계윤리의 종설논문을 기획하면서

고윤석 한국의료윤리학회 2011 한국의료윤리학회지 Vol.14 No.2

의료윤리와 의사 자정노력

고윤석 대한의사협회 2013 대한의사협회지 Vol.56 No.4

Consumption of medical services has been expanding since the health insurance system was established in the Republic of Korea. However, physicians do not seem to be satisfied with the current state of medical practice. One of the main reasons for this dissatisfaction seems to be related to underpayment of costs. The monopolistic insurance agency has kept reimbursements for appropriate medical services below cost. The public also seems to have less trust in doctors than in the past because of repeated scandales in the news media such as doctors’accepting inappropriate rebates from the pharmaceutical industry. Patients are vulnerable to illness and depend on their doctors’ decision making and advising. Plus family members and taxpayers must share in caring and the financial burden that patients face. Therefore, society has high ethical standards for physicians. The medical society also has been responding to these practices. To meet society’s expectations, doctors should not abandon self-regulation through the medical society. Furthermore, because the identity of a professional healthcare provider is based on the trust and endorsement of society, physicians should attempt to maintain appropriate care for patients’ best interests. The public should support physicians’ appropriate medical practice via reasonable reimbursement of medical costs. Through self-support and selfregulation to maintain appropriate medical practice for patients, physicians can enhance public trust. In turn, public trust in doctors will address this country’s distorted medical services and restore the eroded reputation of physicians as healthcare professionals.

심포지움 : 기계적 환기 치료중의 감시 및 이탈

고윤석 대한결핵 및 호흡기학회 1993 워크샵 Vol.2 No.-

산업용 분전반 적용을 위한 3상 전력 관리 장치 시작품 제작에 대한 연구

고윤석,신현용,Ko, Yun-Seok,Shin, Hyun-Yong 한국전자통신학회 2010 한국전자통신학회 논문지 Vol.5 No.5

최근, 전력공급의 안정성과 신뢰성 그리고 고품질화를 위해 인터넷을 기반으로 하는 산업용 디지털 분전반이 새롭게 요구되고 있다. 따라서 본 논문에서는 3상 4선식 전력공급방식을 기반으로 하는 산업용 3상 분전반이 설계된다. 그리고 3상 산업용 분전반을 위한 전력관리 모듈이 시험 제작되며, 끝으로, 3상 전구 부하 시험을 통해 시작품의 3상 전압, 전류 측정 기능이 검증된다. Recently, the industrial electric customers require a digital switchgear which can improve the safety and reliability of the power supply, and the quality of electric power by on-line monitoring the electric power information based on the internet under the ubiquitous environments. Accordingly, in this paper, a industrial switch-gear prototype is designed based on the power supply method of three phase, four-line type, and then a three-phase electric management module of the digital switchgear is made for industrial electric customer system. Finally, the three-phase voltage and current measuring function of the prototype is verified from real power load test.

심포지엄 : 의료현장에서 부딪히는 생명윤리의 범주와 해결방안

고윤석 대한내과학회 2010 대한내과학회 추계학술대회 Vol.2010 No.-

심포지엄 : 의료현장에서 부딪히는 생명윤리의 범주와 해결방안

고윤석 대한내과학회 2010 대한내과학회지 Vol.79 No.20

열전 냉각기의 모델링 및 열전달 해석에 대한 연구

고윤석,Ko, Yun-Seok 한국전자통신학회 2014 한국전자통신학회 논문지 Vol.9 No.11

열전 냉각기는 냉온 정밀온도제어가 가능하고, 소형화 및 경량화가 가능할 뿐만 아니라 기계적인 진동이 없어 신뢰성을 높일 수 있다는 장점 때문에 다양한 분야에 적용이 시도되고 있다. 하지만 열적 모델링 및 해석이 요구되기 때문에 적용분야에 최적한 열전 냉각기를 설계하는 것은 쉽지 않다. 따라서 본 연구에서는 SINDA/FLUINT 해석법을 이용하여 열전 냉각기 모델링과 크기 결정 문제 그리고 열적해석 등을 연구함으로서 열전 냉각기의 적용을 위한 기반기술을 확립하고자 한다. The thermoelectric cooler is receiving great interest because of advantages such as the precise temperature control capability, the compact and lightweight cooler, and the mechanical vibrationless structure which enhances the reliability compared with the existing vapor compression cooler. However, it is not easy to design the optimal thermoelectric cooler which appropriate to the application because the thermal analysis should be necessary required. Accordingly, this paper studies the methodology of the modelling, sizing and thermal analysis of the thermoelectric cooler using SINDA/FLUINT analysis tool.

심포지엄 : 의료 및 기술적 측면

고윤석 대한내과학회 2009 대한내과학회지 Vol.77 No.4S