July 14, 2009 | In: HEALTH CARE
102 ETHICS IN THE SURGICAL INTENSIVE CARE UNIT
Ricardo J. Gonzalez M.D.
1. What are the four principles of medical ethics?
1. Beneficence describes the active role of doing good by intervention.
2. Nonmaleficence is equivalent to saying, “First do no harm.”
3. Autonomy accounts for informed consent, competence, and the patient’s right to refuse treatment and to know what’s going on.
4. Justice means that all patients should receive fair and equal care but that one patient’s care should not squander limited resources for others.
2. What is a do-not-resuscitate (DNR) order?
Show answer
A DNR order instructs the surgeon not to resuscitate the patient if cardiopulmonary arrest occurs; however, a DNR order is much more involved and complicated than the acronym would have you believe. DNR is not absolute.
The Joint Commission for the Accreditation of Healthcare Organizations mandates that hospitals have written guidelines that promote accountability for DNR orders. All DNR orders must be documented in writing, similar to all other orders, in the appropriate section of the patient’s chart. They should specify the treatments to be withheld and treatments that the patient wishes to have implemented. Patients and families must participate in the DNR decision. Moreover, the DNR status should be discussed and reviewed with the other members of the health care team. Finally, a DNR order does not mean that the patient should be medically abandoned.
3. What is the difference between withdrawing and withholding support?
Show answer
A decision to withdraw should not be more problematic than a decision to withhold, because one cannot be sure that an intervention will work until you try it. There is no moral or ethical distinction between withdrawal and withholding of support. Either of the two allows natural progression of disease without the interface of medical technology. The decision to withdraw or withhold support does not equate with patient death, although the probability of death may be greater. After the decision has been made, appropriate management should focus on the patient’s comfort and psychosocial support.
4. What is an advance directive?
Show answer
An advance directive is a method of delineating a competent patient’s wishes for application at a time when he or she is no longer competent. Medical management or the lack thereof can be based on the patient’s wishes rather than a perceived sense of what is best for the patient. Advance directives may be an informal document, such as a living will, or a formal legal document, such as medical durable power of attorney.
5. What is durable power of attorney?
Show answer
A durable power of attorney is a patient-appointed proxy decision maker. The proxy decision maker becomes active as soon as the patient is no longer able to make competent medical decisions. Hence, the durable power of attorney must have been established in advance of the cognitive decline of the patient.
6. What is a living will?
Show answer
A living will, much like a durable power of attorney, is a formal advanced directive in which a competent patient produces a pre-illness guideline for future care in accordance with his or her wishes.
7. What is included in informed consent?
Show answer
Information about the patient’s condition as well as risks and benefits of the recommended treatment are included. Moreover, the operative and nonoperative alternatives (including no treatment) should be discussed with the patient. The patient’s understanding of the information and alternatives should be assessed as part of the informed consent. Finally, informed consent is a voluntary decision made by the patient or on behalf of the patient by a proxy decision maker.
8. What are futile care and medical futility?
Show answer
Ultimately, old age and disease will conquer us all. The definition of medically futile or inappropriate treatment is still debated. Nonetheless, there are four main concepts of medical futility:
1. Health care professionals are not required to provide physiologically futile treatment.
2. Imminent demise argues against treatment if the patient has no likelihood of survival to discharge.
3. Under the concept of lethal condition, medical care is considered futile if the patient will survive temporarily but ultimately expire as a result of the ongoing disease process.
4. Quality of life or qualitative futility argues against treatment if the patient’s quality of life is so poor that it would be unreasonable to prolong life.
Care must be taken, however, in making medical decisions based on futility because these decisions may lead to self-fulfilling prophecies.
9. What are the clinical determinants of brain death?
Show answer
Many of the current concepts of brain death are based on the 1968 report from the ad hoc committee at Harvard Medical School, which called for a new neurologic definition of brain death. But it was not until 1981 that BEMAT justified the neurologic criteria of brain death by stressing the need for intact brainstem integrative function in order for a person to function as a whole. By definition, brain death requires loss of brainstem reflexes in an irreversibly comatose patient. Brain death includes loss of the pupillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and respiratory reflexes for ≥ 6 hours. The patient also should undergo an apnea test, in which the pCO2 is allowed to rise to at least 60 mmHg without coexistent hypoxia. The patient should be observed for the absence of spontaneous breathing. Other ancillary tests are not essential; for example, it is not necessary to perform an intravenous radioisotope cerebral angiogram or a four-vessel contrast cerebral angiogram or to document an isoelectric (”flat”) electroencephalogram.
Of note, all of the above criteria for brain death require the absence of central nervous system depression caused by barbiturates, narcotics, or hypothermia.
10. What is a persistent vegetative state?
Show answer
In a persistent vegetative state, typically seen after improvement of a comatose state, the patient lies motionless and without activity. The patient appears to be awake but does not have awareness of his or her surroundings or higher mental activity. Other names for this entity are coma vigil and akinetic mutism.
11. What is euthanasia?
Show answer
Euthanasia requires that the physician play an active role in assisting in the death of the patient. The concepts of physician-assisted suicide and active and passive euthanasia are highly controversial. In 1992, the Society of Critical Care Medicine published the results of a survey of critical care specialists; 87% had withdrawn life-prolonging support from patients. In addition, the most recent U.S. law pertaining to assisted suicide was passed in Oregon in 1994. This law makes it legal for a physician to prescribe medication to terminally ill patients for the purpose of committing suicide.
12. Who should approach patients’ families about organ donation?
Show answer
Some claim that the physician who has established good rapport with the patient’s family should raise the issue of organ donation. Others believe that the local organ procurement personnel should approach the family because they have greater interest and training in the process. The best approach is probably a combined one.
13. What should patients’ families be told when organ donation is feasible?
Show answer
The surgeon should stress that the patient has died despite an actively beating heart. The family should be questioned about the patient’s wishes regarding organ donation. All topics should be based on the concepts of informed consent. The family should be informed of the likelihood that several patients will benefit from the donated organs. The family needs to understand that there is no guarantee that the organs will be suitable for donation. They should be assured that they are not responsible for the cost of care provided after brain death is determined and that they may refuse organ donation without fear of prejudice.
14. What is the role of the hospital ethics committee?
Show answer
The hospital ethics committee educates hospital staff members, creates policy, and provides a source of consultation.
The function of education is accomplished through grand rounds, seminars, special lectures, and journal clubs. The hospital ethics committee should be viewed as an intrinsic part of the hospital community. Developed policies should be reviewed by other committees and divisions of the hospital to foster a better sense of cohesiveness when ethical and moral dilemmas arise. The consultative function of the ethics committee produces the greatest amount of controversy. In fact, many hospitals negate this function by stating that it interferes with the physician-patient relationship. The hospital ethics committee can and should provide an arena for collaboration and general ethical education within the hospital.
References
BIBLIOGRAPHY
1. Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death: A definition of irreversible coma. JAMA 205:337-340, 1968.
2. Aminoff MJ: The central nervous system. In Medical Diagnosis and Treatment. Norwalk, CT, Appleton & Lange, 1996.
3. Arnold RM, Siminoff LA, Frader JE: Ethical issues in organ procurement: A review for intensivists. Crit Care Med 12:29-48, 1996. Full article
4. Bernat JL, Culver CM, Gert B: On the definition and criterion of death. Ann Intern Med 94:389-394, 1981. Medline Similar articles Full article
5. Harken AH: Enough is enough. Arch Surg 10:1061-1063, 1999. Full article
6. Kelley DF, Hoyt JW: Ethics consultation. Crit Care Med 12:49-70, 1996.
7. McCollough L, Jones J, Brody B: Surgical Ethics. Oxford, Oxford University Press, 1998.
8. Nyman DJ, Eidelman AL, Sprung CL: Euthanasia. Crit Care Clin 12:85-96, 1996. Medline Similar articles
9. Society of Critical Care Ethics Committee: Attitudes of critical care medicine professionals concerning foregoing life-sustaining treatments. Crit Care Med 20:320-326, 1992.
10. State of Oregon: ORS.251.215, The Oregon Death with Dignity Act. Official 1994 Oregon General Election Handbook, 1994, pp 121-124.
11. Younger SJ: Medical futility. Crit Care Clin 12:165-178, 1996.
213 Responses to Ethics In The Surgical Intensive Care Unit
Habez
January 21st, 2012 at 3:42 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
best supplements for muscle gain
January 24th, 2012 at 6:08 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Dallas Video Production
January 25th, 2012 at 3:02 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Dallas Website Design
January 25th, 2012 at 3:56 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Dallas Senior Portrait Photographer
January 25th, 2012 at 5:53 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Dallas Wedding Photographers
January 25th, 2012 at 5:56 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
liberar moviles valencia
January 25th, 2012 at 8:03 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
pre workout supplements
January 25th, 2012 at 11:15 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
best bcaa supplements
January 26th, 2012 at 12:15 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
webcam chat
January 26th, 2012 at 6:01 pm
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
simran possessed
January 26th, 2012 at 7:39 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
Phil Cannella
January 26th, 2012 at 8:55 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
cheap hotel
January 26th, 2012 at 9:55 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
Pizza Hut vouchers
January 26th, 2012 at 9:59 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Cheap Cruises
January 26th, 2012 at 11:01 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
flights to pakistan
January 26th, 2012 at 11:06 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
SATNAV
January 27th, 2012 at 3:17 am
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Dr.Shams Eye Care Clinic
January 27th, 2012 at 3:29 am
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
muay thai Thailand
January 27th, 2012 at 4:52 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
florida unemployment benefits
January 27th, 2012 at 5:24 am
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
Dallas Pet Photographer
January 27th, 2012 at 5:44 am
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
Dallas Headshot Photographers
January 27th, 2012 at 6:36 am
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
Great logos
January 27th, 2012 at 6:55 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Swedish Meatballs
January 27th, 2012 at 9:52 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
diet plan
January 27th, 2012 at 10:34 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
watch free movies online
January 27th, 2012 at 10:53 am
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
lol
January 27th, 2012 at 12:04 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
solihull dental treatment
January 27th, 2012 at 12:33 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
Legal Herbal Potpourri
January 27th, 2012 at 4:17 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
inkjet cartridges
January 27th, 2012 at 5:34 pm
Links…
[...]Sites of interest we have a link to[...]……
cash advance
January 27th, 2012 at 5:39 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
Smoking Incense
January 27th, 2012 at 6:31 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
Smoke Herbal
January 27th, 2012 at 6:50 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
now habit
January 27th, 2012 at 7:14 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
uzaktan egitim
January 27th, 2012 at 9:11 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
free ipad 3
January 27th, 2012 at 9:24 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
encryption
January 27th, 2012 at 10:16 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Search Inmates
January 27th, 2012 at 10:42 pm
Links…
[...]Sites of interest we have a link to[...]……
orange county ca escorts
January 27th, 2012 at 11:03 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
best over the counter sleep aid
January 27th, 2012 at 11:28 pm
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
scalp psoriasis
January 28th, 2012 at 12:04 am
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
grievance procedure
January 28th, 2012 at 12:09 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
best shampoo for oily hair
January 28th, 2012 at 8:27 am
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Himalaya holidays
January 28th, 2012 at 9:39 am
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
Mats
January 28th, 2012 at 9:41 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
buy facebook
January 28th, 2012 at 1:22 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
European casino hotels
January 28th, 2012 at 2:43 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
personal ads
January 28th, 2012 at 2:44 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Mobile Money Bandit scam
January 28th, 2012 at 3:21 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
how to avoid work at home scams
January 28th, 2012 at 3:22 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
nikon coolpix
January 28th, 2012 at 4:57 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
wedding rings
January 28th, 2012 at 5:23 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
why should we hire you
January 28th, 2012 at 5:52 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
scansnap S1500
January 28th, 2012 at 6:20 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
residential heating and air salt lake
January 28th, 2012 at 6:22 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
voodoo doughnuts
January 28th, 2012 at 8:35 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
Compare car hire and save
January 28th, 2012 at 9:37 pm
Links…
[...]Sites of interest we have a link to[...]……
Lady Silence by Celeste Hall
January 28th, 2012 at 10:00 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
wedding photography Oxfordshire
January 28th, 2012 at 10:18 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
acne
January 28th, 2012 at 11:19 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
hotel linen supplier
January 28th, 2012 at 11:22 pm
Links…
[...]Sites of interest we have a link to[...]……
selling gold jewelry
January 28th, 2012 at 11:45 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
dental gold
January 28th, 2012 at 11:47 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
Alin Ophy
January 29th, 2012 at 12:24 am
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
travel bug
January 29th, 2012 at 1:51 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
watch myp2p
January 29th, 2012 at 1:54 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
hcg recipes
January 29th, 2012 at 2:28 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
hardship letter
January 29th, 2012 at 2:30 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
property investment
January 29th, 2012 at 2:54 pm
Links…
[...]Sites of interest we have a link to[...]……
luxury villa rental st lucia
January 29th, 2012 at 4:07 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Tribos que Lideramos
January 29th, 2012 at 4:09 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
iphone
January 29th, 2012 at 5:43 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
Best Treatment For Eczema
January 29th, 2012 at 5:50 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Escort girl Paris
January 29th, 2012 at 7:04 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
Holton Buggs
January 29th, 2012 at 7:06 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
High Risk Credit Card Processing
January 29th, 2012 at 7:11 pm
Links…
[...]Sites of interest we have a link to[...]……
project payday review
January 29th, 2012 at 8:52 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
best wefted Indian hair
January 29th, 2012 at 8:53 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
bingo game cage
January 29th, 2012 at 10:08 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
cheap office chairs
January 29th, 2012 at 10:13 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
como puedo quedar embarazada
January 29th, 2012 at 11:14 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
hypnosis for weight loss
January 29th, 2012 at 11:36 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
leather loveseat
January 29th, 2012 at 11:38 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
tetris
January 30th, 2012 at 12:07 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
DSW printable coupons
January 30th, 2012 at 12:43 am
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
luxury comforter sets
January 30th, 2012 at 1:02 am
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
LED Tester
January 30th, 2012 at 7:14 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
roller shutters
January 30th, 2012 at 7:21 am
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
sports action photography
January 30th, 2012 at 9:01 am
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
how to make money online
January 30th, 2012 at 9:11 am
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
Flower delivery in Sri Lanka
January 30th, 2012 at 10:19 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Jennifer Ellison wallpapers
January 30th, 2012 at 11:20 am
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Gatwick Parking
January 30th, 2012 at 11:37 am
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
Cheap Payday Loans
January 30th, 2012 at 1:28 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
Wholesale Clothing
January 30th, 2012 at 1:35 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
online casino uk
January 30th, 2012 at 2:34 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
indoor bootcamp
January 30th, 2012 at 6:37 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
weight loss boot camp
January 30th, 2012 at 6:55 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Tattoo
January 30th, 2012 at 8:58 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
chest coach system
January 30th, 2012 at 9:04 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
what is serotonin
January 30th, 2012 at 9:09 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
bathroom tile ideas
January 30th, 2012 at 10:26 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
Trading Systems
January 30th, 2012 at 10:44 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
mma tampa
January 30th, 2012 at 10:47 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
hotels near uk cities
January 30th, 2012 at 11:07 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
buy neopoints
January 30th, 2012 at 11:09 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
marijuana addiction
January 31st, 2012 at 12:29 am
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
kataskeyh istoselidon
January 31st, 2012 at 7:46 am
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
hugeyield
January 31st, 2012 at 10:04 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Tisa Whittle
January 31st, 2012 at 11:42 am
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
mma workouts
January 31st, 2012 at 11:58 am
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
giraffe bracing
January 31st, 2012 at 1:14 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
motivation for weight loss
January 31st, 2012 at 2:16 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Personal Injury Lawyer Cleveland
January 31st, 2012 at 2:32 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
female pain during intercourse treatment
January 31st, 2012 at 8:22 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
solar panel electrician
January 31st, 2012 at 9:26 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
wedding bouquets
January 31st, 2012 at 9:38 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
Scleritis symptoms
January 31st, 2012 at 10:02 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
canon ixus 230 hs
January 31st, 2012 at 10:04 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
how to be a respiratory therapist
January 31st, 2012 at 10:15 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Transfer Music from iPhone to Computer
January 31st, 2012 at 10:38 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
qrops
January 31st, 2012 at 10:40 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
fire pit screens
January 31st, 2012 at 11:08 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
play houses
January 31st, 2012 at 11:35 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
Blog filmy porno
February 1st, 2012 at 7:07 am
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Good video camera
February 1st, 2012 at 7:16 am
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
backlinks
February 1st, 2012 at 7:24 am
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Calculators
February 1st, 2012 at 8:39 am
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
commercial inspections
February 1st, 2012 at 8:48 am
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
NYC Hotels
February 1st, 2012 at 9:45 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
How to get toned
February 1st, 2012 at 10:21 am
Links…
[...]Sites of interest we have a link to[...]……
URL
February 1st, 2012 at 11:22 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
Notarztkurs Sylt
February 1st, 2012 at 12:53 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
nikon d5000 review
February 1st, 2012 at 1:07 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Scott Tucker Payday Loans
February 1st, 2012 at 2:38 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
led lighting manufacturer
February 1st, 2012 at 8:18 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
Dove Body Soap
February 1st, 2012 at 8:29 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Husband Pillow
February 1st, 2012 at 9:24 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
teen halloween costumes
February 1st, 2012 at 10:11 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Used Cars Chesterfield
February 1st, 2012 at 11:27 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
medical job search
February 1st, 2012 at 11:59 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
scientific pipettor
February 2nd, 2012 at 12:38 am
Links…
[...]Sites of interest we have a link to[...]……
Scott Tucker Racing
February 2nd, 2012 at 7:19 am
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Scott Tucker CBS
February 2nd, 2012 at 8:45 am
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Scott Tucker Racing
February 2nd, 2012 at 8:48 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Okna Pcv Mogilno
February 2nd, 2012 at 10:34 am
That’s what we need…
…our new additions to the blogroll……
Dynavin Navigation Multimedia
February 3rd, 2012 at 7:11 am
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
the best website on the net
February 3rd, 2012 at 7:56 am
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
BPO Companies
February 3rd, 2012 at 8:00 am
Tough Week…
It was a tough week here this week, so I just took to piddeling around on the internet and realized…
watch super bowl live online
February 3rd, 2012 at 12:57 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
Scott Tucker CBS
February 3rd, 2012 at 9:04 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Appraisal Management Companies
February 4th, 2012 at 2:56 am
Digg suggestion…
While checking out Digg yesterday I noticed this…
reo companies
February 4th, 2012 at 6:33 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]…
lipo 6 hers reviews
February 4th, 2012 at 9:50 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
e-cig reviews
February 4th, 2012 at 11:20 am
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
steven cymbrowitz
February 4th, 2012 at 12:26 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
best payday loan
February 4th, 2012 at 1:30 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
compare prices
February 4th, 2012 at 2:37 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
SWTOR Walkthrough
February 4th, 2012 at 3:03 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
Best wheels for sliding
February 4th, 2012 at 4:21 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Loaded Balut
February 4th, 2012 at 7:52 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
video sales letter
February 4th, 2012 at 8:30 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
herpes
February 4th, 2012 at 9:02 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
john vespucci
February 4th, 2012 at 9:32 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Eyelash Extension
February 4th, 2012 at 10:00 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
iPhone development
February 4th, 2012 at 11:00 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
performance engines for sale
February 4th, 2012 at 11:20 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
fitness boot camp
February 4th, 2012 at 11:42 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
the power to choose
February 5th, 2012 at 12:52 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
iPhone 4 screen protector
February 5th, 2012 at 1:14 am
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
workout tracker
February 5th, 2012 at 1:39 am
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
ecommerce seo
February 5th, 2012 at 1:57 am
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
hemi power
February 5th, 2012 at 2:59 am
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
betta fish accessories
February 5th, 2012 at 3:29 am
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
natural remedies for cold sores
February 5th, 2012 at 3:34 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
latif thomas
February 5th, 2012 at 1:18 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
football speed
February 5th, 2012 at 2:18 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
Debt Management
February 6th, 2012 at 4:15 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Euro
February 6th, 2012 at 4:28 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Claim Your Free Gifts and Rewards for Every Occasion
February 6th, 2012 at 4:43 am
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
genital warts symptoms
February 6th, 2012 at 8:57 am
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
allevamenti rottweiler
February 6th, 2012 at 10:27 am
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
best car finance deals
February 6th, 2012 at 10:44 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
equity release
February 6th, 2012 at 10:50 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
melatonin kaufen
February 6th, 2012 at 12:41 pm
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
North Myrtle Beach Vacations
February 6th, 2012 at 3:09 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
tarot gratis
February 6th, 2012 at 3:38 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Proactol Diet Pills
February 6th, 2012 at 4:07 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
maryland short sale attorney
February 6th, 2012 at 5:07 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
pawnbroker
February 6th, 2012 at 10:37 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
liver detox diet
February 6th, 2012 at 10:53 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Air Conditioning Repairs
February 7th, 2012 at 1:58 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Robert Shumake
February 7th, 2012 at 9:12 am
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
India Tour Package
February 7th, 2012 at 9:39 am
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
Business Insurance Tampa
February 7th, 2012 at 1:14 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
windows and doors
February 7th, 2012 at 1:19 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
iwatchz sales
February 7th, 2012 at 1:47 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
free cam porn
February 7th, 2012 at 4:15 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
cheap textbooks
February 7th, 2012 at 4:28 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Commercial Pest Control, Integrated Pest Management, London, Herts
February 7th, 2012 at 5:57 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
drum and bass forum
February 7th, 2012 at 6:07 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
noclegi nad morzem
February 7th, 2012 at 9:54 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
fitness business and marketing
February 7th, 2012 at 10:26 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
athena 10x pheromones for men
February 7th, 2012 at 10:33 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
cross country ski poles
February 8th, 2012 at 2:15 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
Tony Ortega
February 8th, 2012 at 2:33 am
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
goal crazy
February 8th, 2012 at 3:08 am
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
Pokrycia Dachowe
February 8th, 2012 at 8:51 am
Pokrycia Dachowe…
… sometimes I can’t resist and link to ……
interpretation
February 8th, 2012 at 1:09 pm
Online Article……
[...]The information mentioned in the article are some of the best available [...]……
psd2html
February 8th, 2012 at 2:19 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Scott Tucker Racing
February 8th, 2012 at 3:55 pm
Links…
[...]Sites of interest we have a link to[...]……
Scott Tucker Racing
February 8th, 2012 at 3:55 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Scott Tucker Racing
February 8th, 2012 at 5:39 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……