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Compelling Ethical Challenges in

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Andrej Michalsen
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Compelling Ethical
Challenges in Critical Care
and Emergency Medicine

Andrej Michalsen
Nicholas Sadovnikoff
Editors

123
Compelling Ethical Challenges in Critical
Care and Emergency Medicine
Andrej Michalsen • Nicholas Sadovnikoff
Editors

Compelling Ethical
Challenges in Critical Care
and Emergency Medicine
Editors
Andrej Michalsen Nicholas Sadovnikoff
Department of Anesthesiology and Department of Anesthesiology, Perioperative
Critical Care and Pain Medicine
Tettnang Hospital Brigham and Women’s Hospital Harvard
Medizin Campus Bodensee Medical School
Tettnang Boston, MA
Germany USA

ISBN 978-3-030-43126-6    ISBN 978-3-030-43127-3 (eBook)


https://doi.org/10.1007/978-3-030-43127-3

© Springer Nature Switzerland AG 2020


This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
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claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

I am delighted that Drs. Andrej Michalsen and Nicholas Sadovnikoff asked me to


write the Foreword to this volume on Compelling Ethical Challenges in Critical
Care and Emergency Medicine. These two medical specialties have always been
at the tip of the sword when it comes to ethical challenges in the practice of medi-
cine. In reflecting back over the past few decades, I am struck by the extent to
which thinking about ethical issues has evolved. As recently as the 1980s, few
physicians sought advice or counsel when faced with challenging ethical ques-
tions, and when they did, it was almost always from senior physician colleagues
in their field.
As reflected in the essays contained in this volume, the focus of ethical decision-­
making has shifted away from considering physicians to be the only experts to rec-
ognize the importance of deliberation among teams, between professionals, and
especially with patients and their families. At a time when moral distress and burn-
out are becoming a true threat to the viability of our profession, the essays in this
volume serve to remind us how a robust ethics service can support clinicians caring
for critically ill patients. They also provide valuable advice on how honest prognos-
tication can help patients and families make difficult decisions, how to use advance
directives and surrogate decision-makers when patients cannot make decisions for
themselves, and how to apply principles for supporting genuine shared decision-
making with patients and families.
The fields of emergency and critical care medicine are developing to the point
where the biological functioning of essentially every organ system can be artifi-
cially supported and maintained. Technologies for supporting the many and varied
functions of human body will soon reach the point where biological death as we
know it will become virtually optional, such that patients will die only when we
cease to support the functions that are sustaining them. As emergency and critical
care practitioners assume the burden of caring for these patients, we are being
forced to address fundamental existential issues: what are the goals of medicine,
when does continued treatment become disproportionate in terms of suffering and
cost, and how do we educate our patients and society to the reality of the limits of
medicine?

v
vi Foreword

Most of all, however, this volume should remind us how important it is to keep
our moral compass firmly in front of us, directing us to the true north of wise and
compassionate care, not only for our patients, but also for ourselves.

June 2020 Robert D. Truog


Department of Anesthesiology,
Critical Care and Pain Medicine
Boston Children’s Hospital
Boston, MA
USA
Preface

Practitioners of medicine are frequently called upon to make moral decisions.


Those who practice in the most acute care settings, such as in emergency depart-
ments (EDs) and intensive care units (ICUs), find themselves in such situations
more frequently, and typically with less time within which to act, than in most other
specialties. When this occurs, they call upon an ethical framework within which to
decide what is the “right” or “good” thing to do for a given patient. For most prac-
titioners, though, such a framework is largely intuitive, guided by experience and
perhaps some rudimentary didactic education during their training. They may seek
guidance from textbooks of bioethics, only to find the instruction to be more theo-
retical and academic than practical. They may seek advice from colleagues only to
find that they, too, are lacking in ethical training or expertise. It is for those practi-
tioners in the acute care setting of EDs and ICUs that we humbly offer this volume
as a practical resource. We do not purport to provide solutions for all imaginable
ethical challenges. Rather, we seek to identify compelling ethical challenges cur-
rently faced in the high-acuity care setting and to offer suggestions and potential
approaches that might be of practical value at the bedside.
As experienced practitioners of critical care and emergency medicine (both in
the prehospital and in-hospital settings), bolstered with additional training in medi-
cal ethics, we, the editors of this collection, hope to provide an assemblage of chap-
ters that comprise a broad representative sample of ethically difficult scenarios
commonly faced in EDs and ICUs
We first acknowledge that we remain challenged by questions that have existed
for decades. Not uncommonly, for instance, whether from fear of litigation or sim-
ply aversion to conflict, clinicians can find themselves continuing life-sustaining
interventions in an elderly patient with multiple organ failure and a dismal progno-
sis, simply because the surrogate decision-maker insists that “everything” be done,
claiming that is what the patient would have wanted. Should our respect for auton-
omy extend so far as to exclude our clinical judgment of a foreseen poor outcome in
such cases? Does the institutional culture accommodate the possibility of overriding
the patient’s wishes or surrogate’s instructions?

vii
viii Preface

Similarly, consider the situation of a patient who comes to the emergency


department in coma after attempting suicide by overdose, but his reason for
doing so was his diagnosis of stage IV metastatic cancer with a prognosis mea-
sured in weeks to months, and no further therapies to be offered. Must he be
treated as we do most patients with suicide attempts and resuscitated to then be
treated for his suicidal depression? On the contrary to the patient’s wishes as
such a resuscitation might seem, can the emergency physician withhold such
interventions?
Finally, there can be no disputing that the advent of more and increasingly com-
plex and exotic medical technologies has allowed many lives to be saved or at least
prolonged, but with each advance come new and vexing questions. We must now
face, for example, the ICU patient who is fully awake and cognitively intact on
extracorporeal membrane oxygenation (ECMO), for whom no cure, device, or
transplant is possible; this patient must be told that ECMO will now be withdrawn
– how are we to meet such an ethical challenge? How do we plan even to approach
such a conversation?
By calling upon a broad, diverse, and international cadre of authors, we have
sought to aggregate a shared understanding of a practical bedside approach regard-
ing ethical challenges, in an effort to answer the question, “What constitutes ethi-
cally appropriate care for a particular patient at a particular stage in the course of
his/her treatment?”
As editors, we would like to thank all authors for their time and their expertise
they devoted to this book, resulting in a comprehensive and stimulating “state of
affairs” regarding present ethical challenges in emergency and critical care medi-
cine. Furthermore, we are indebted to Andrea Ridolfi, Milano, from Springer
Nature – Clinical Medicine Books, for his continuous obliging support of this proj-
ect: Grazie mille!
I would like to express my sincere gratitude to my “ethics mentors” for their
prudent leadership and their sustained encouragement: Robert D. Truog, Charles
L. Sprung, J. Randall Curtis, and Uwe Janssens. Moreover, I would like to thank my
wife, Joanne Vincenten, and our daughter Anna for their patience, prudence, and all
their encouragement in the months this book took shape [AM].
I would like to acknowledge all the contributors to my education in medical eth-
ics at the Harvard Center for Bioethics, but in particular Bob Truog, Dan Brock, and
Millie Solomon, who all taught me to reach a little deeper into moral thinking. I
must also thank Martha Jurchak for her longstanding and ongoing tutelage in the
practical application of clinical ethics. Finally, I cannot thank enough my wife,
friend, companion, and mother of our children, Dr. Marcie Rubin, for her patience,
tolerance, and love [NS].

Tettnang, Germany Andrej Michalsen


Boston, MA  Nicholas Sadovnikoff
June 2020
Contents

Part I Introduction
1 How Ethics Can Support Clinicians Caring for Critically
Ill Patients ��������������������������������������������������������������������������������������������������   3
Aimee B. Milliken and Nicholas Sadovnikoff
1.1 Introduction��������������������������������������������������������������������������������������   3
1.2 Background ��������������������������������������������������������������������������������������   3
1.3 Vignettes ������������������������������������������������������������������������������������������   4
1.4 Conclusion����������������������������������������������������������������������������������������   9
References����������������������������������������������������������������������������������������������������   9
2 Patients and Teams Caring for Them: Parallels Between
Critical Care and Emergency Medicine�������������������������������������������������� 13
Spyros D. Mentzelopoulos
2.1 Introduction�������������������������������������������������������������������������������������� 13
2.2 Initial ED Care and Triage for ICU Admission�������������������������������� 14
2.3 Ethical Challenges in the ED and ICU Settings�������������������������������� 15
2.4 Vulnerable ED and ICU Patients������������������������������������������������������ 15
2.5 Challenges Associated with Surrogate Decision-Makers ���������������� 18
2.6 Family Presence During Patient Care and Resuscitation������������������ 19
2.7 Advance Directives (AD), Advance Care Planning (ACP)�������������� 20
2.8 Shared Decision-Making������������������������������������������������������������������ 21
2.9 Equal Access to Best-Quality Care �������������������������������������������������� 22
2.10 Dignity and End-of-Life Care���������������������������������������������������������� 22
2.11 Emergency/Critical Care Research Issues Besides Consent������������ 23
2.12 Conclusions and Future Directions�������������������������������������������������� 24
References���������������������������������������������������������������������������������������������������� 24

Part II Goal of Therapy, Teams and Patients


3 Indication and Prognostication���������������������������������������������������������������� 29
Armand R. J. Girbes
3.1 Introduction�������������������������������������������������������������������������������������� 29
3.2 Patient-Centered Indication and Prognostication������������������������������ 30

ix
x Contents

3.3 The Gap Between Attainable and Desirable Outcome �������������������� 31


3.4 The Will of the Patient���������������������������������������������������������������������� 33
3.5 Summary ������������������������������������������������������������������������������������������ 33
References���������������������������������������������������������������������������������������������������� 34
4 Consent, Advance Directives, and Decision by Proxies�������������������������� 35
Annette Robertsen, Susanne Jöbges, and Nicholas Sadovnikoff
4.1 Introduction�������������������������������������������������������������������������������������� 35
4.2 Legal Bases �������������������������������������������������������������������������������������� 36
4.3 Informed Consent������������������������������������������������������������������������������ 36
4.3.1 Decisional Capacity or Competence�������������������������������������� 36
4.3.2 Voluntariness�������������������������������������������������������������������������� 38
4.3.3 Information���������������������������������������������������������������������������� 38
4.3.4 Documentation���������������������������������������������������������������������� 38
4.4 Advance Directives and Power of Attorney�������������������������������������� 39
4.4.1 Advance Directives (ADs) ���������������������������������������������������� 39
4.4.2 Durable Medical Power of Attorney for Health Care������������ 39
4.4.3 Are ADs Valid, Applicable, and Legally Binding?���������������� 40
4.5 Ethical Challenges and Solutions in the Context
of Emergency Medicine and Intensive Care ������������������������������������ 42
4.5.1 Emergencies �������������������������������������������������������������������������� 42
4.5.2 Barriers to Informed Consent in the ED/ICU������������������������ 43
4.5.3 UN Convention on the Rights of Persons
with Disabilities �������������������������������������������������������������������� 43
4.5.4 Lack of ADs and Consequences for the Extent of
Treatment ������������������������������������������������������������������������������ 44
4.5.5 Availability of ADs���������������������������������������������������������������� 45
4.5.6 How to Make an Ethics-Based Decision�������������������������������� 45
4.6 Conclusion���������������������������������������������������������������������������������������� 46
References���������������������������������������������������������������������������������������������������� 46
5 Cultural Diversity�������������������������������������������������������������������������������������� 49
Victoria Metaxa and E. Wesley Ely
5.1 Introduction�������������������������������������������������������������������������������������� 49
5.2 Caring for Critically Ill Patients�������������������������������������������������������� 50
5.3 When Cultural Diversity Leads to Conflict�������������������������������������� 52
5.4 Conclusion���������������������������������������������������������������������������������������� 54
References���������������������������������������������������������������������������������������������������� 54
6 Interprofessional Shared Decision-Making �������������������������������������������� 57
Andrej Michalsen and Hanne Irene Jensen
6.1 Introduction�������������������������������������������������������������������������������������� 57
6.2 Definitions and Evidence Base �������������������������������������������������������� 58
6.3 Recommendations���������������������������������������������������������������������������� 59
6.4 Conclusions�������������������������������������������������������������������������������������� 63
References���������������������������������������������������������������������������������������������������� 63
Contents xi

7 Shared Decision-Making With Patients and Families���������������������������� 65


Nancy Kentish-Barnes, Chris Danbury, Julie Benbenishty,
and Elie Azoulay
7.1 Introduction�������������������������������������������������������������������������������������� 65
7.2 The Relevance of Shared Decision-Making ������������������������������������ 66
7.3 Shared Decision-Making in Critically Ill Patients���������������������������� 66
7.4 Families in the ED and the ICU: Shared Decision-Making
in a Context of High Emotional Distress������������������������������������������ 67
7.5 Impact of Shared Decision-Making
on Families’ Well-Being ������������������������������������������������������������������ 68
7.6 Team-Centered Challenges �������������������������������������������������������������� 69
7.7 Strategies to Improve Shared Decision-Making ������������������������������ 69
7.7.1 Family Conferences: The VALUE Approach������������������������ 69
7.7.2 Support for the Family ���������������������������������������������������������� 70
7.7.3 Dealing With Discordance and Conflict�������������������������������� 71
7.7.4 Mediation ������������������������������������������������������������������������������ 71
7.8 Conclusion���������������������������������������������������������������������������������������� 72
References���������������������������������������������������������������������������������������������������� 72

Part III Extent of Treatment


8 Emergency Medicine and Critical Care Triage�������������������������������������� 77
Joseph L. Nates and Charles L. Sprung
8.1 Introduction�������������������������������������������������������������������������������������� 77
8.2 Triage in the Emergency Department ���������������������������������������������� 79
8.2.1 Triage Scales�������������������������������������������������������������������������� 79
8.2.2 Patient Flow and Overcrowding�������������������������������������������� 80
8.3 Triage in the Intensive Care Unit������������������������������������������������������ 81
8.3.1 Under- and Over-Triage �������������������������������������������������������� 82
8.3.2 Logistical Challenges/Patient Flow Inefficiencies���������������� 82
8.4 Rapid Response Teams/Early Warning Systems������������������������������ 82
8.5 Ethical and Legal Challenges������������������������������������������������������������ 83
8.6 Other Human-Related Challenges: Variability
and Scarce Resources������������������������������������������������������������������������ 85
8.7 Conclusions�������������������������������������������������������������������������������������� 86
References���������������������������������������������������������������������������������������������������� 87
9 Usage of Cutting-Edge Technology: ECPR �������������������������������������������� 89
Lionel Lamhaut and Alice Hutin
9.1 Introduction�������������������������������������������������������������������������������������� 89
9.2 The Concept of ECPR���������������������������������������������������������������������� 90
9.3 Challenges Regarding the Implementation
of Prehospital ECPR ������������������������������������������������������������������������ 91
9.3.1 Inclusion Criteria ������������������������������������������������������������������ 91
9.3.2 Accessibility with Regards to Time Limits���������������������������� 93
9.3.3 Distributive Justice and Equality of Care������������������������������ 93
xii Contents

9.3.4 Costs�������������������������������������������������������������������������������������� 94
9.3.5 Organ Donation���������������������������������������������������������������������� 94
9.4 Conclusions�������������������������������������������������������������������������������������� 95
References���������������������������������������������������������������������������������������������������� 95
10 Usage of Cutting-Edge Technology: ECMO�������������������������������������������� 97
Onnen Mörer and Michael Quintel
10.1 Introduction�������������������������������������������������������������������������������������� 97
10.2 Acute Respiratory Failure Due to Potentially Reversible
Causes ���������������������������������������������������������������������������������������������� 98
10.3 Acting with Informed Consent: A Difficult Task for
Acute ECMO Initiation�������������������������������������������������������������������� 100
10.4 ECMO Programs: Ensuring Access to Therapy on
a National Level While Avoiding Uncontrolled Use������������������������ 101
10.5 Decision to Withdraw ECMO Therapy�������������������������������������������� 102
10.6 ECMO as a Bridge to Lung Transplantation������������������������������������ 103
10.7 ECMO in Brain-Dead Potential Organ Donors�������������������������������� 104
10.8 Conclusions�������������������������������������������������������������������������������������� 105
References���������������������������������������������������������������������������������������������������� 105
11 Limiting Life-Sustaining Therapies �������������������������������������������������������� 109
Diederik van Dijk, Carole Boulanger, Gavin Joynt,
Andrej Michalsen, and Jan Bakker
11.1 Introduction�������������������������������������������������������������������������������������� 109
11.2 General Considerations Regarding the Extent of Treatment������������ 110
11.3 Withholding Versus Withdrawing ���������������������������������������������������� 111
11.4 An Intensity- or Time-Limited Trial with Life-Sustaining
Treatments���������������������������������������������������������������������������������������� 112
11.5 Under What Circumstances Is Limiting Life-Sustaining
Therapies Permissible, Advisable, or Even Imperative?������������������ 112
11.6 How to Withdraw?���������������������������������������������������������������������������� 114
11.7 Conclusions�������������������������������������������������������������������������������������� 116
References���������������������������������������������������������������������������������������������������� 117
12 Advancing Palliative Care in Intensive Care and Emergency
Medicine������������������������������������������������������������������������������������������������������ 119
Ann L. Jennerich, Susanne Jöbges, and Marietjie Slabbert
12.1 Introduction�������������������������������������������������������������������������������������� 119
12.2 Advancing Palliative Care in the Emergency Department���������������� 120
12.3 Advancing Palliative Care in the Intensive Care Unit���������������������� 121
12.4 Conclusions�������������������������������������������������������������������������������������� 123
References���������������������������������������������������������������������������������������������������� 124
13 Organ Donation and Transplantation������������������������������������������������������ 127
Dale Gardiner and David Rodríguez-Arias
13.1 Introduction�������������������������������������������������������������������������������������� 127
13.2 Organ Transplantation Can Foster Good End-­of-Life Care�������������� 129
Contents xiii

13.2.1 General Accordance with the Patients’


and Families’ Wishes������������������������������������������������������������ 129
13.2.2 Free from Avoidable Death�������������������������������������������������� 130
13.2.3 Free from Avoidable Suffering for Patients,
Families, and Caregivers������������������������������������������������������ 131
13.3 Organ Transplantation Can Threaten Good End-­of-Life Care���������� 132
13.3.1 Conflicts of Interest�������������������������������������������������������������� 132
13.3.2 Potentially Disrespectful and Potentially
Harmful Practices ���������������������������������������������������������������� 134
13.4 Conclusion���������������������������������������������������������������������������������������� 135
References���������������������������������������������������������������������������������������������������� 136

Part IV Disproportionate Care


14 Disproportionate Care, Ethical Climate, and Moral Distress���������������� 141
Bo Van den Bulcke and Dominique Benoit
14.1 Introduction�������������������������������������������������������������������������������������� 141
14.2 Disproportionate Care and Ethical Climate�������������������������������������� 142
14.3 Results of the DISPROPRICUS Study �������������������������������������������� 143
14.3.1 Measurement of Ethical Climate������������������������������������������ 143
14.3.2 Patient’s Level���������������������������������������������������������������������� 143
14.3.3 Clinicians’ Level: Intent to Leave and Burnout�������������������� 145
14.4 Future Perspectives �������������������������������������������������������������������������� 146
14.5 Conclusion���������������������������������������������������������������������������������������� 146
References���������������������������������������������������������������������������������������������������� 147

Part V The Way Ahead


15 To Treat or Not to Treat: How to Arrive at an Appropriate
Decision Under Critical Circumstances�������������������������������������������������� 151
Andrej Michalsen and Nicholas Sadovnikoff
References���������������������������������������������������������������������������������������������������� 153

Part VI Epilogue
16 Epilogue: Critical Care During a Pandemic – A Shift from
Deontology to Utilitarianism?������������������������������������������������������������������ 157
Andrej Michalsen, Marco Vergano, Michael Quintel,
Nicholas Sadovnikoff, and Robert D. Truog
16.1 Introduction�������������������������������������������������������������������������������������� 157
16.2 Challenges for Emergency Medicine and Critical
Care in Epidemics and Pandemics���������������������������������������������������� 158
16.3 Allocation of Resources in Critical Care������������������������������������������ 159
16.3.1 When Resources Are Not Scarce������������������������������������������ 159
16.3.2 When Resources Are Scarce and Cannot Meet
the Demand�������������������������������������������������������������������������� 159
xiv Contents

16.4 Ethical Values for Alloting Scarce Healthcare Resources���������������� 159


16.5 Time and Decision-Making Process of Prioritization���������������������� 160
16.6 Recommendations for Fair Allocation of Scare
Medical Resources in Critical Care During the
COVID-19 Pandemic������������������������������������������������������������������������ 161
16.7 Conclusion���������������������������������������������������������������������������������������� 164
References���������������������������������������������������������������������������������������������������� 164
Index�������������������������������������������������������������������������������������������������������������������� 167
About the Editors

Andrej Michalsen, MD, MPH was born in 1957 in


Überlingen, Germany. He received his medical train-
ing at Kiel, Freiburg, and Tübingen Universities as
well as at the University of Texas School of Public
Health in Houston, TX, USA, and he has worked at the
academic hospitals of Mainz, Germany, and Utrecht,
the Netherlands. He is currently a consultant in
Anaesthesiology and Critical Care at Tettnang
Hospital, Germany, and the chair of the Ethics
Committee there. He is a member of the Section on
Ethics of the European Society of Intensive Care
Medicine (which he chaired from 2013 to 2016), a
member of the Ethics Section of the German
Interdisciplinary Association of Intensive Care and
Emergency Medicine, and a member of the Ethics and
Conflict of Interest Committee of the American
Thoracic Society. He also chaired the Subcommittee
on Ethics of the Annual German Anaesthesiology
Congress from 2017 to 2020. His main areas of interest
are focused on ethical issues in health care delivery and
end-­of-­life care.

Nicholas Sadovnikoff, MD obtained his medical


degree from Brown University in 1984. He has been on
the Critical Care Anesthesia and Thoracic Anesthesia
faculty at Brigham and Women’s Hospital (BWH) and
Harvard Medical School since 1998. He is board-certi-
fied in Internal Medicine, Critical Care Medicine and
Anesthesiology, and is the Co-Director of the Surgical
Intensive Care Units as well as program director of the
BWH Fellowship in Anesthesiology Critical Care. He
was inducted as a fellow in the American College of
Critical Care Medicine (FCCM) in 2008. In 2008–2009,
he completed the Fellowship in Medical Ethics at

xv
xvi About the Editors

Harvard Medical School and is the faculty of the


Harvard Center of Bioethics. He currently serves as
Co-Chair of the BWH Ethics Committee, is an active
member of the BWH Ethics Consultation Service, and
has achieved certification in Healthcare Ethics
Consultation (HEC-C). His major areas of interest
include advance care planning and end-of-life care,
ethics of organ donation and transplantation, and
informed consent and surrogate decision-making.
Contributors

Elie Azoulay MD, PhD Service de Médecine Intensive et Réanimation, Hôpital


Saint-Louis, AP-HP, Université Paris Diderot, Paris, France
Jan Bakker, MD, PhD, FCCM, FCCP Department of Pulmonology, Sleep
Medicine and Critical Care, New York University School of Medicine, New
York, NY, USA
Department of Intensive Care (Adults), Erasmus University Medical Center,
Rotterdam, The Netherlands
Julie Benbenishty, RN, PhD Department of Nursing Administration, Hadassah
Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
Dominique Benoit, MD, PhD Department of Intensive Care Medicine, Ghent
University Hospital and Ghent University Faculty of Medicine and Health Sciences,
Ghent, Belgium
Carole Boulanger, RN, MSc, FFICM Intensive Care Unit, Royal Devon and
Exeter NHS Foundation Trust, Exeter, UK
Chris Danbury, MB BS, M.Phil, FRCP, FRCA, FFICM Department of Intensive
Care Medicine, Royal Berkshire Hospital, Berkshire, UK
School of Law, University of Reading, Reading, UK
E. Wesley Ely, MD, MPH Center for Critical Illness, Brain Dysfunction and
Survivorship, Vanderbilt University, Nashville, TN, USA
Veterans Affairs Geriatric Research Education Clinical Center (GRECC),
Nashville, TN, USA
Dale Gardiner, MBBS, MBioEth Department of Adult Intensive Care, Nottingham
University Hospitals NHS Trust, Nottingham, UK
Armand R. J. Girbes, MD, PhD, EDIC Department of Intensive Care, Amsterdam
University Medical Centers, Location VUmc, Amsterdam, The Netherlands
Alice Hutin, MD, PhD SAMU de Paris, Hôpital Universitaire Necker-Enfants
Malades, Paris, France

xvii
1 How Ethics Can Support Clinicians Caring for Critically Ill Patients 11

31. Long AC, Brumback LC, Curtis JR, et al. Agreement with consensus statements on end-of-life
care. Crit Care Med. 2019;47:1396–401.
32. Lo B, Ruston D, Kates L, et al. Discussing religious and spiritual issues at the end of life: a
practical guide for physicians. JAMA. 2002;287:749–54.
33. Davidson JE, Aslakson RA, Long AC, et al. Guidelines for family-centered care in the neona-
tal, pediatric, and adult ICU. Crit Care Med. 2017;45:103–28.
34. Reeves S, Perrier L, Goldman J, et al. Interprofessional education: effects on professional
practice and healthcare outcomes (update). Cochrane Database Syst Rev. 2013;(3):CD002213.
35. Epstein EG, Whitehead PB, Prompahakul C, et al. Enhancing understanding of moral dis-
tress: the measure of moral distress for health care professionals. AJOB Empir Bioeth.
2019;10:113–24.
36. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to
medical mishaps. Acad Med. 2004;79:186–94.
37. Pavlish BCL, Brown-Saltzman K, Raho JA, et al. A national survey on moral obligations in
critical care. Am J Crit Care. 2019;28:183–92.
38. Michalsen A, Long AC, DeKeyser GF, et al. Interprofessional shared decision-making in
the ICU: a systematic review and recommendations from an expert panel. Crit Care Med.
2019;47:1258–66.
39. Hamric AB, Wocial LD. Institutional ethics resources: creating moral spaces. Hast Cent Rep.
2016;46:S22–7.
40. Walker MU. Keeping moral space open: new images of ethics consulting. Hast Cent Rep.
1993;23:33–40.
Another random document with
no related content on Scribd:
“Where are you going, Robin Redbreast?”

Then off flew the wee, wee Robin until he came to a wall of turf
and there he saw a greedy Hawk sitting and watching to see what
small birds passed by. And the greedy Hawk called to him and said,
“Where are you going, Robin Redbreast, this frosty Yuletide
weather?”
Then the wee, wee Robin said to the Hawk, “I am going to the
King to sing him a song this good Yule morning.”
And the greedy Hawk replied, “Go not yet. Come here, Robin
Redbreast, and I’ll let you see a bonny green feather that I wear in
my wing.”
But the wee, wee Robin said, “No, no, greedy Hawk. You have
pecked all the tiny birds but you’ll not peck me.”
Then off flew the wee, wee Robin until he came to a hollow in the
hillside and there he saw a sly Fox sitting. The sly Fox saw Robin
and called to him, “Where are you going, Robin Redbreast, this
frosty Yuletide weather?”
Then the wee, wee Robin said to the Fox, “I am going to the King
to sing him a song this good Yule morning.”
And the sly Fox replied, “Go not yet. Come here, Robin Redbreast,
and I will show you a bonny spot on the tip of my tail.”
But the wee, wee Robin said, “No, no, sly Fox. You may show the
bonny spot on the tip of your tail to the lambs but not to me.”
Then off flew the wee, wee Robin until he came to a little shepherd
Lad sitting beside his cot. The little shepherd Lad saw Robin and
called to him, “Where are you going, Robin Redbreast, this frosty
Yuletide weather?”
Then the wee, wee Robin said to the shepherd Lad, “I am going to
the King to sing him a song this good Yule morning.”
And the shepherd Lad replied, “Go not yet. Come here and I will
give you some crumbs from my pouch.”
But the wee, wee Robin said, “No, no, little shepherd Lad. You
caught the goldfinch but you’ll not catch me.”
Then off flew the wee, wee Robin until he came to the King, and
he sat down upon a plowshare just outside of the King’s window, and
he sang him a pretty song because it was such a good Yule morning.
The King was very much pleased indeed and he said to the Queen,
“What shall we give the wee, wee Robin Redbreast for singing us
such a pretty song?”
The Queen thought and thought and at last she decided. “I think
we will give the wee, wee Robin Redbreast a wee Wren to be his
wife,” the Queen said to the King.
So the wee, wee Robin Redbreast and the wee Wren were
married and the King, and the Queen, and all the court, and the
whole countryside danced at their wedding. And after the wedding
the two flew home to the Robin’s own waterside.
THE STORY OF
IBBITY.

Once upon a time there was a little brown boy named Ibbity. He
lived in a warm country where there are jungles and tigers and sandy
deserts. Now Ibbity was always wondering about things, and one
day he said to his mother:
“I wonder, oh, I do wonder what is the strongest thing in the world.”
But his mother could not tell him, so Ibbity started off by himself to
find out.
He went a long, long way, and at last he came to a tree. Up the
tree climbed Ibbity and looked abroad over the jungle and the desert
for something very big and strong. But just then the top of the tree
broke. Bump, down fell little Ibbity to the ground.
“Oh, Tree, you are the strongest thing, are you not?” cried Ibbity,
sitting up and rubbing his head. “You are able to throw Ibbity to the
ground.”
“No, I am not as strong as the wind,” sighed the tree, “it was the
wind that broke my branch.”
Then Ibbity ran far away to the place where the wind was blowing
the sand in the desert, and he said:
“Oh, Wind, the tree threw Ibbity, but you broke the tree. Are you
not the strongest one?”
“No, I am not the strongest one,” said the wind, “the hill is able to
stop my blowing.”
So Ibbity ran on and on, until he came to a high hill, and to the hill
he said:
“Oh, Hill, the tree threw Ibbity, and the wind broke the tree, but you
are able to stop the wind. Are you not the strongest one?”
“Not I,” said the hill. “At my feet lives a small mouse. She is cutting
a tunnel straight through me.”
So Ibbity went down the hill, and looked around in the bushes until
he found a small brown mouse. To the mouse he said:
“O Mouse, the tree threw Ibbity, the wind broke the tree, and the
hill can stop the wind, but you have dug a tunnel through the hill. Are
you not the strongest one?”
“No,” said the mouse. “Cannot the tiger catch me?”
So Ibbity traveled to the jungle, where the tiger lives, and he said:
“Oh, Tiger, the tree threw Ibbity, the wind broke the tree, the hill is
able to stop the wind, and the mouse has dug a tunnel through the
hill, but you can catch the mouse. Are you not the strongest one?”
But the tiger was caught fast in a net, and he said to Ibbity:
“No, this rope is stronger than I.”
And Ibbity said to the rope:
“Oh, Rope, the tree threw Ibbity, the wind broke the tree, the hill
can stop the wind, the mouse has dug a tunnel under the hill, the
tiger is able to catch the mouse, but you have caught the tiger. Are
you not the strongest one?”
“No,” said the rope, “for the fire burns me.”
So Ibbity ran and ran until he came to a fire, and to the fire he
said:
“Oh, Fire, the tree threw Ibbity, the wind broke the tree, the hill
stops the wind, the mouse tunnels the hill, the tiger catches the
mouse, the rope catches the tiger, but you are able to burn the rope.
Are you not the strongest one?”
“No,” said the fire, “my heat is less than that of the great sun.”
Then Ibbity looked up at the sky, and he called loudly to the sun:
“Oh, great Sun, the tree threw Ibbity, the wind broke the tree, the
hill stops the wind, the mouse tunnels the hill, the tiger catches the
mouse, the rope catches the tiger, the fire burns the rope, but your
heat is greater than that of the fire. Are you not the strongest one?”
Then the sun winked its large yellow eye at Ibbity, and never a
word did it say, for it was too far off to hear Ibbity’s little voice.
So Ibbity clapped his hands and cried, “I have found the strongest
one. It is the sun.”
And little Ibbity went home again to tell his mother.
THE CHIPMUNK
WHO CHATTERED
TOO MUCH.

Once upon a time, when Indians and animals lived together in the
same forest and animals could speak, the Chipmunk was the
greatest talker of them all.
He lived in a lodge in the middle of the woods with his grandfather
who was very old and wise as well. But the Chipmunk was young,
and very daring. He was able to run so fast and climb trees, and
jump from one branch to another that he thought nothing in the world
could harm him. He had a louder voice then than he has now. He
chattered all day long, boasting about himself. At last he became
very tiresome to the other animals.
They came at last and spoke to the Chipmunk’s grandfather about
him.
“Your grandson chatters so loudly,” scolded the Blue Jay, “that the
birds are not able to hear me when I warn them of danger in the
forest.”
And the Frog came to the Chipmunk’s grandfather with tears in his
eyes. “Your grandson chatters so loudly,” croaked the Frog, “that no
one can hear me when I sing on the edge of the stream in the
evening.”
It was quite true. The Chipmunk talked and boasted all the time.
He chattered as he started out from his lodge in the morning and all
the way down the path to let every one know that he was on his way.
He chattered when he came to a nut tree and when he picked up
some nuts. He had pockets in his cheeks, so he could chatter even
when he came home with a mouthful of nuts. There seemed to be no
way of keeping this young Chipmunk quiet, and at last his
grandfather decided to speak to him about it.
“You are not using your voice as it was meant that you should, my
son,” said the Chipmunk’s grandfather. “All the creatures in feathers
and fur in the forest speak for a reason. The Ground Hog whistles to
call his young, and the Frog croaks when wild beasts creep toward
the lodges, and the Robin sings of rain. But you, my son, chatter for
no reason except your foolish pride. Beware! the Great Chief will
hear you and catch you some day if you do not stop!”
The Chipmunk thought that night of what his grandfather had said.
But when morning came, he forgot all about it and took his noisy way
through the woods again. He made just as much noise as he could,
even after he had reached a hickory-nut tree, and climbed up among
the branches.
Suddenly, though, he was still. He heard the leaves on the ground
rustle and the twigs crackle with heavy footsteps. Peering down
between the branches, the Chipmunk saw the Great Chief of whom
his grandfather had warned him. He looked as tall as a young tree
and as dark as a thunder cloud. He carried a long bow and a quiver
of arrows. He had come for the Chipmunk, and he waited under the
tree, looking up among the branches to see when he should come
down.
But the leaves on the branches hid the Chipmunk. He gathered a
handful of nuts and tossed them down. The Great Chief was thrown
off his guard by the trick. He jumped, thinking it was the Chipmunk,
but the little fellow scampered down the other side of the tree. He got
home to his lodge in safety.
The next day the Chipmunk was even more noisy than ever as he
started out. He reached a tree, climbed up in it, and again the Great
Chief came with his bow and arrows to kill the chattering little pest.
But the Chipmunk gathered a handful of twigs which he threw down
at the feet of the Great Chief.
“Here I come,” the Chipmunk chattered. As the Great Chief
watched to see him follow the twigs he dropped down on the other
side of the tree and once more reached home safe.
When the Chipmunk started out the third morning he had a great
piece of news to tell the whole world. He told it just as loudly as he
could.
“The Great Chief can’t catch me. He can’t catch me,” boasted the
Chipmunk.
He kept on chattering this after he had scampered up a tree, and a
very bold plan entered his head.
The Great Chief came at last. He strode angrily until he came to
the tree where the Chipmunk sat looking down at him.
“Come down! Come down from this tree!” called the Great Chief in
a loud voice.
That was just what the Chipmunk planned to do. He was going to
come down and dare the Great Chief to catch him. He felt that he
would be safe in doing this. So the Chipmunk came down and stood
a second, chattering to the Great Chief, who was so surprised that
he did not move at first.
Then the Chipmunk ran and the Great Chief ran after him. It was a
race for life, the Chipmunk soon found out, for the Great Chief
gained at every step. The Chipmunk leaped and jumped, and panted
for breath. On, and on they went, in and out among the trees. The
Chipmunk lost his loud voice in fear and no other member of the
family has had such a loud one since that day. He could see his
lodge with his grandfather waiting for him in the door, but it did not
seem possible that he could reach it.
Oh, there he was at the door; but just as he went inside the Great
Chief took hold of the Chipmunk with his strong fingers. Although the
Chipmunk pulled himself loose, he had a row of long white stripes on
his back where the Great Chief had clutched him.
And every other Chipmunk, since then, has had white stripes on
his back, because of the first Chipmunk who chattered too much.
HOW THE SQUIRREL
GOT WINGS.

Once upon a time the Indians tell us that the Manito was the good
spirit of the woods. He taught every wild creature, bird, beast, or fish
its own special work. It was then that the Beaver learned how to be a
mason, and the Oriole to be a weaver. The Mole learned how to dig
long, secret tunnels although he was blind. The Spider was taught to
spin and the Bee to make honey.
Then, too, the Manito made the Squirrel the little harvester of the
woods, gathering nuts in the fall and digging holes in the earth in
which to bury them for the winter. It was planned that the Squirrel
should be an example to man of the wisdom of working while others
feasted. He gathered food for the days when the wind would howl
and the snow drift about his lodge. So the Squirrel spent his days
looking for nuts and laying them away for cold weather. With him
went his friend, the Woodchuck.
In those days, the Woodchuck ate nuts, and as his legs were short
and his feet flat he could not climb trees. His feet were shaped like
shovels. He used them for digging himself a little house in the side of
a hill where he planned to sleep through the winter until spring
should come. But he was very fond of nuts. His friend, the Squirrel,
was good enough to take him about the woods and show him the
places where nuts were scattered on the ground. The Squirrel gave
him half of all the nuts there were. The Woodchuck cracked these
with his sharp teeth and ate them all.
The Manito was apt to walk through the forest at night to see if
everything was safe. He wished, too, to see if his little wild children
had done their work during the day. One evening in the late fall the
Manito went through the forest in the form of a night wind. He looked
in the door of the Woodchuck’s house in the side of the hill. It was
empty!
Taking his way through the trees the Manito saw a little creature in
a gray fur blanket creeping softly along from one spot to another. He
had short legs, and feet shaped like shovels. It was the Woodchuck.
As he came to a place for which he had been looking, the
Woodchuck would dig deep down in the earth with his paws. He
would bring up a store of nuts and carry them back to his hole in the
side of the hill.
“This is not as it should be,” the Manito thought. “I did not plan that
my son, the Woodchuck, should harvest at night. Nor did I decree
that he should gather nuts.”
Then it came to the mind of the Manito what the Woodchuck was
up to!
The next night the Manito had a council fire in the woods and bade
all the wild creatures to come to it. He, himself, dressed in fine
blankets and feathers like an Indian Chief, sat on a rock before the
fire. All his sons, the Squirrel, the Beaver, the Wolf, the Deer, the
Otter, the Fox, and the rest, sat in a circle around the fire. There was
one vacant place, though. The Woodchuck had not yet come.
At the time for the council to open, the Manito stood up and spoke.
“We are gathered here as a court of law,” he said. “I have learned
that my thrifty son, the Squirrel, has been the victim of a thief. He
has been busy and saving, as I have taught him to be. He has done
his harvesting for the winter. But while he slept a friend robbed him
of his nuts. What shall we do to such a false friend?”
“Drown him!” said the Beaver.
“Starve him!” said the Otter.
“Eat him!” barked the Fox and the Wolf.
“Who is he?” asked the gentle Deer.
Just then the Woodchuck tried to slip into his place in the circle
without being seen. He had a nut in his mouth so that every one
knew at once that he was the thief. He was the false friend of the
thrifty Squirrel! The animals rose in a body and would have torn the
Woodchuck to pieces at once, or thrown him into the fire. But the
Manito raised his hand to quiet them. Then he called the Woodchuck
and the Squirrel to come to his side.
“I gave you a place to harvest, in the corn field,” the Manito said to
the Woodchuck. “And I gave you a friend who was good enough to
share his nuts with you because you are so fond of them. You have
disobeyed me, and stolen from your friend. As a punishment I will
take out your sharp teeth so that you can never crack a nutshell
again. You shall have grinding teeth, for eating only corn.”
Then the Manito asked the Squirrel to come closer to him, and he
fitted a pair of wings to his back. “These wings are a reward for your
industry,” he said, “and to help you gather another harvest in place of
that which the Woodchuck stole from you.”
From the night of that council fire to the present time the
Woodchuck has eaten only grains and vegetables. And there have
been flying squirrels because of the first Woodchuck who stole from
his friend.
HOW THEY
BROUGHT HAIRLOCK
HOME.

Once upon a time, at the foot of a hill, there lived little Boots and
his mother and their nanny goat, who was named Hairlock. Now
Hairlock loved to run away over the hill to the mountain, and she
could never be found when milking time came at night.
One day Boots was ready with his pail and his milking stool, and
he called, “Hairlock, Hairlock, come home to Boots,” but Hairlock did
not come.
Then Boots’s mother climbed to the top of the hill, and she looked,
and she looked, and there she spied Hairlock on the top of a crag, a
long way off.
“Naughty Hairlock,” she cried, “come home to Boots. Boots, run to
Reynard, the fox, and tell him to bite Hairlock.”
So Boots ran to Reynard, the fox, and he said:
“Good Reynard, bite my nanny goat, Hairlock, who stands on the
top of yonder crag, and will not come home to be milked.”
But Reynard said, “Not I, Boots; I’ll not dull my teeth on old
Hairlock’s skin, for I hunt to-night. Another time, Boots, another
time.”
And Boots went back and told his mother what Reynard had said.
“Then go to Greylegs, the wolf, Boots,” said his mother, “and tell
him to bark at naughty Hairlock.”
So Boots ran to Greylegs the wolf, and he said:
“Good Greylegs, bark at my nanny goat, Hairlock, who stands on
the top of yonder crag, and will not come home to be milked.”
But Greylegs said, “Some other time, Boots, some other time. The
night is cold. I must stay at home and sleep and cover my cubs.”
And Boots went back and told his mother what Greylegs had said.
“Then go to Bruin, the bear,” said his mother, “and bid him chase
naughty Hairlock.”
So Boots ran to Bruin, the bear, and he said:
“Good Bruin, chase my nanny goat, Hairlock, who stands on the
top of yonder crag, and will not come home to be milked.”
But Bruin said, “Ah, Boots, I am much too fat to chase Hairlock.
Go to the fir tree and ask him to trap Hairlock.”
So Boots ran to the fir tree, and he said:
“Good Fir Tree, trap my nanny goat, Hairlock, who stands on the
top of yonder crag, and will not come home to be milked.”
But the fir tree only bent and swayed in the wind, and said, “Ask
the woodcutter to fell me, Boots.”
So Boots ran to the woodcutter, and he said:
“Good Woodcutter, fell the fir tree, that he may trap my nanny
goat, Hairlock, who stands at the top of yonder crag, and will not
come home to be milked.”
But the woodcutter said, “Ask the joiner if he will buy my wood,
Boots.”
So Boots went to the joiner, and he said:
“Good Joiner, will you buy wood from the woodcutter, that he may
fell the fir tree? Then the fir tree will trap my nanny goat, Hairlock,
who stands at the top of yonder crag and will not come home to be
milked.”
“That I will, Boots,” said the joiner.
Then the woodcutter felled the fir tree and gave the wood to the
joiner. The joiner took the wood and made a strong yoke, which he
gave to Boots.
Then Boots and his mother ran to the top of the crag and put the
yoke on Hairlock.
And that is how they brought Hairlock home.
THE BEAR WHO
LOST HIS SUPPER.

Once upon a time old Mother Red Cap was out walking in the
forest and she came to a wild cherry tree, the branches of which
hung low with cherries. She climbed up the tree to pick her apron full
of cherries when along came Bruin, the Bear, walking under the tree.
He looked up among the branches and there he saw old Mother Red
Cap.
“Come down, Mother,” he growled, “that I may eat you.” Old
Mother Red Cap did not want to be eaten by Bruin, the Bear, so she
thought, and thought, and then she said:
“You do not want to eat an old woman like me. I will throw you
down my shoe and you may gnaw upon that until I can come down
to the ground and lead you to my house. I have two little kids there
who will make you a savory meal. Have patience, Bruin, until I can
climb down.”
This was what old Mother Red Cap said, and she threw down her
shoe. Bruin gnawed and gnawed upon the shoe, but he found it very
dry eating, so he grew angry. He called up the tree to old Mother
Red Cap:
“Come down, Mother, that I may eat you.”
“Just wait a little longer, Bruin, until I have gathered a few more
cherries,” said she, and she threw down her other shoe. “Gnaw on
this,” she said, “and I will climb down in a few minutes and show you
the way to my house.”
Bruin gnawed upon the second shoe but he found it no better than
the first. But he contented himself with the thought of the two little
kids that he would soon be eating, and he waited beneath the tree
until old Mother Red Cap climbed down.
Down she came, with her apron full of cherries; home she went,
and Bruin tramped along behind her. When they reached her house,
old Mother Red Cap took Bruin, the Bear, out to the barn and
showed him the two little kids. He was in a great hurry to get his
paws around them, but, “Wait,” said Old Mother Red Cap. “First I
must give the two little kids a fine supper that they may be fatter. Go
back to the forest for the night and return in the morning. Then the
two little kids will be fat enough for you to eat.”
So Bruin, the Bear, went back to the forest for the night. Old
Mother Red Cap gave the two little kids a fine, large supper and then
she locked the door of the barn and went to bed. Very early in the
morning she went out to the barn and unlocked the door and let out
the two fat little kids. They scampered off to pasture and were soon
so far away that neither hide nor hoof of them could be seen. Then
old Mother Red Cap locked the door of the barn again.
Almost as soon as the sun was up, Bruin, the Bear, tramped back
from the forest, growling:
“Open the barn door, Mother, that I may eat the two little kids.”
Mother Red Cap stooped down to peep through the key hole of
the barn door. Then she shook her head sadly.
“What a pity it is,” sighed old Mother Red Cap, “that the two little
kids are gone. Can it be that my two mischievous little grandchildren,
Janko and Mirko, unlocked the door and let the kids out?”
At that Bruin, the Bear, was very angry. “Then I must eat your two
little grandchildren, Janko and Mirko,” he growled.
This frightened old Mother Red Cap greatly. She thought and
thought, and then she said: “My two little grandchildren, Janko and
Mirko, are very thin indeed. I must give them three fine meals or they
will not be fat enough for you to eat. In the meantime, do you run
about through the forest to get yourself a better appetite.”
So Bruin, the Bear, went away and ran about in the woods all the
rest of the day. When it was evening he came back with a fine
appetite and rapped at the door of old Mother Red Cap’s house.
“Send out Janko and Mirko,” he growled, “and see what short work
I will make of them.”
“Oho, I’ll not do that,” laughed old Mother Red Cap from inside the
house. “You are too late, Bruin. Janko has just bolted the door so
fast that you will not be able to open it and I have put Mirko to bed,
where he is fast asleep. You must go back to the forest and come
some other day.”
So Bruin, the Bear, saw that old Mother Red Cap had got the best
of him and he went back to the forest, hungry, to look for his supper
there.
THE RABBIT WHO
WAS AFRAID.

Once upon a time, a very long way from here, a little wild Rabbit
sat under a tall palm tree. All about him were other tall palm trees
and larger animals than he, and the wild rabbit thought and thought.
And after the Rabbit had thought a while he said to himself, “What if
the earth should crack and swallow me up.”
Just then the wind blew a cocoanut down from a tree and it fell
upon the ground right beside the little wild Rabbit. Up he jumped in
great fear for now he was sure that what he had dreaded was
happening.
“The earth is cracking,” said the Rabbit, and off he hopped as fast
as he could, never stopping to try and find out what it was that had
made the noise.
As he ran he met his Mother and she said to him, “Why do you run
so fast?”
“The earth is cracking,” said the Rabbit, “and I run that I may not
be swallowed up by it.”
On ran the Rabbit, and his Mother ran with him.
As they ran, they met his Father and he said to the Rabbit, “Why
do you run so fast?”
“The earth is cracking,” said the Rabbit, “and we run that we may
not be swallowed up by it.”
On ran the Rabbit and his Mother, and his Father ran with them.
As they ran they met an Elephant, and he said to the Rabbit, “Why
do you run so fast?”
“The earth is cracking,” said the Rabbit, “and we run that we may
not be swallowed up by it.”
On ran the Rabbit and his Mother and his Father, and the Elephant
ran with them.
As they ran they passed a Deer. “Why do you run so fast?” he
asked of the Rabbit.
“The earth is cracking,” said the Rabbit, “and we run that we may
not be swallowed up by it.”
On ran the Rabbit and his Mother and his Father and the
Elephant, and the Deer ran with them.
As they ran they met a Fox. “Why do you run so fast?” the Fox
asked of the Rabbit.
“The earth is cracking,” said the Rabbit, “and we run that we may
not be swallowed up by it.”
On ran the Rabbit and his Mother and his Father and the Elephant
and the Deer, and the Fox ran with them.
As they ran they met all his Relations, and they said to the Rabbit,
“Why do you run so fast?”
“The earth is cracking,” said the Rabbit, “and we run that we may
not be swallowed up by it.”
On ran the Rabbit and his Mother and his Father and the Elephant
and the Deer and the Fox, and a hundred of his Relations ran with
him.
As they ran they came upon the Lion, who is the king of the
beasts, and the Lion said to the Rabbit, “Why do you run so fast?”
“The earth is cracking,” said the Rabbit, “and we run that we may
not be swallowed up by it.”
But the Lion, who is the king of the beasts, did not run. He spoke
again. “Which one of you is it who saw the earth cracking?” he

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