Biologic control of the introduced and invasive, woody plant tamarisk (Tamarix spp, saltcedar) in south-western states is controversial because it affects habitat of the federally endangered South-western Willow Flycatcher (Empidonax traillii extimus). These songbirds sometimes nest in tamarisk where floodplain-level invasion replaces native habitats. Biologic control, with the saltcedar leaf beetle (Diorhabda elongate), began along the Virgin River, Utah, in 2006, enhancing the need for comprehensive understanding of the tamarisk-flycatcher relationship. We used maximum entropy (Maxent) modeling to separately quantify the current extent of dense tamarisk habitat ( > 50% cover) and the potential extent of habitat available for E. traillii extimus within the studied watersheds. We used transformations of 2008 Landsat Thematic Mapper images and a digital elevation model as environmental input variables. Maxent models performed well for the flycatcher and tamarisk with Area Under the ROC Curve (AUC) values of 0.960 and 0.982, respectively. Classification of thresholds and comparison of the two Maxent outputs indicated moderate spatial overlap between predicted suitable habitat for E. traillii extimus and predicted locations with dense tamarisk stands, where flycatcher habitat will potentially change flycatcher habitats. Dense tamarisk habitat comprised 500 km 2 within the study area, of which 11.4% was also modeled as potential habitat for E. traillii extimus. Potential habitat modeled for the flycatcher constituted 190 km 2 , of which 30.7% also contained dense tamarisk habitat. Results showed that both native vegetation and dense tamarisk habitats exist in the study area and that most tamarisk infestations do not contain characteristics that satisfy the habitat requirements of E. traillii extimus. Based on this study, effective biologic control of Tamarix spp. may, in the short term, reduce suitable habitat available to E. traillii extimus, but also has the potential in the long term to increase suitable habitat if appropriate mixes of native woody vegetation replace tamarisk in biocontrol areas.

AJ is a 59-year-old male with a history of poorly controlled diabetes mellitus (type 2), cardiovascular disease, multiple strokes, and end-stage renal failure (dialysis dependent). Patient states he was previously very active, but after his stroke he has been cared for in an intermediate care facility. His course has been complicated by multiple decubitus ulcers, immobility, aspiration pneumonia, and urinary tract infections, resulting in multiple hospital admissions. On this admission, AJ was diagnosed with vancomycin-resistant enterococcal sepsis. When transport arrived to take him to dialysis, he refused, stating "I no longer want to live like this." The attending physician consulted psychiatry who diagnosed major depression and felt patient did not have the capacity to make the decision to withhold treatment. The nephrology team refused to dialyze the patient "against his will." Palliative medicine was consulted to determine surrogacy and to evaluate capacity. AJ expressed understanding of his situation and the consequences of his action stating "I don't want to kill myself, but if I stop dialysis I'll die and that is my wish." AJ also stated "who wouldn't be depressed in my situation?" AJ has no identified surrogate, being estranged from his spouse who was reportedly abusive, and lacked other relatives or friends. The attending physician was assigned surrogate and immediately ordered an ethics consult.

No abstract

JD is a 48-year-old male patient of the outpatient cancer center affiliated with the local not-for-profit hospital-based health system. He has hemophilia A (congenital Factor VIII deficiency) and was started on an a recombinant DNAderived, antihemophilic factor for on-demand treatment and control of bleeding episodes and routine prophylaxis to reduce the frequency of bleeding episodes. JD has no insurance and was given several doses of medication after he told the cancer center that he had government insurance but lost his card. Routine investigation showed JD had no insurance. He admitted prevarication, stating "I was afraid you wouldn't treat me." Over the next several months, JD, who has a history of intravenous (IV) drug abuse, refused to allow social work to help him apply for financial assistance. He refused to sign Medicaid applications and would not produce the documents required to qualify for free care from the health system. In addition, he missed several appointments and became known for showing up at the cancer center at random times demanding treatment and being disruptive in the waiting room. He missed 90% of his follow-up appointments. A social worker on multiple occasions sat down with him to complete his paper work, but he either refused to cooperate or left the center in anger. One of the hematologists wants to refuse treatment due to the cost (over US$17 000/month) and JD's refusal to fill out financial aid forms. The other hematologist in the clinic has resisted dismissal, stating that it is their duty to treat this patient on his terms. The practice administrator requests an ethics consultation to resolve this dilemma.

GJ is a 63-year-old male with a-1 antitrypsin deficiency (a-1) and a new lung mass. He presented to the emergency department (ED) complaining of dyspnea at rest and on exertion, with profound weakness. He was admitted for chronic obstructive pulmonary disease (COPD) exacerbation. GJ has been nonadherent with a-1 antitrypsin replacement therapy and is the primary caregiver for his wife who is disabled and diabetic. Staff was alerted when his continuous oxygen saturation monitor showed an oxygen saturation of 70% on high-flow nasal oxygen. When staff entered the room, patient was out of bed, with oxygen on, stating he wanted to leave the hospital immediately. The attending physician was called and GJ told her that he was worried about his wife, who had no one to administer her insulin. The attending told GJ that leaving the hospital would be against medical advice (AMA), and he responded "I don't care, I'm leaving and I'm driving home." During this exchange, GJ's oxygen saturation dropped to 69% and he had to sit down because he "felt faint." Blood pressure was 90/60 and heart rate was 114. The attending feels leaving the hospital would be harmful to GJ but wants to respect his autonomy. GJ has no one to provide transportation and the attending feels allowing him to drive would be a danger to the community. She does not want to restrain GJ against his will but also does not want to allow him to leave, specifically to drive. The attending asks for an emergency ethics consult.