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Utilisation of goals of care discussions and palliative care prior to image-guided procedures near the end of life. Clin Radiol 2022; 77:345-351. [PMID: 35177227 DOI: 10.1016/j.crad.2022.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/19/2022] [Indexed: 11/03/2022]
Abstract
AIM To characterise image-guided procedures performed near the end of life and the use of goals of care discussions (GOC) and palliative care consultation (PCC) prior to these procedures. MATERIALS AND METHODS Retrospective chart review of 3,714 consecutive inpatient procedures performed for 2,351 patients and 8,206 outpatient procedures performed for 5,225 patients within a suburban medical system. Data were collected on demographics, procedures performed, mortality, and use of GOC or PCC prior to the procedures. Procedures near the end of life were classified as emergent, elective, or palliative. Logistic regression was used to assess for demographic disparities in care. RESULTS Nine percent of inpatients died within 30 days of their procedure, 57% of which were within the same hospitalisation. Of these patients, 59% had a documented GOC and 35% had a PCC. Similarly, 7% of outpatients died within 6 months of their procedure. A minority of these patients had a documented GOC (37%) or PCC (13%). There were few statistically significant demographic disparities in this care and the associated odds ratios were small. CONCLUSION A wide array of image-guided procedures is performed near the end of life. GOC and PCC are underutilised prior to these procedures. Few demographic disparities exist in this care.
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Soliman IW, Leaver S, Flaatten H, Fjølner J, Wernly B, Bruno RR, Artigas A, Bollen Pinto B, Schefold JC, Beil M, Sviri S, van Heerden PV, Szczeklik W, Elhadi M, Joannidis M, Oeyen S, Zafeiridis T, Wollborn J, Banzo MJA, Fuest K, Marsh B, Andersen FH, Moreno R, Boumendil A, Guidet B, Jung C, De Lange DW. Health-related quality of life in older patients surviving ICU treatment for COVID-19: results from an international observational study of patients older than 70 years. Age Ageing 2022; 51:6523677. [PMID: 35136896 PMCID: PMC8825757 DOI: 10.1093/ageing/afab278] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/03/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND health-related quality of life (HRQoL) is an important patient-centred outcome in patients surviving ICU admission for COVID-19. It is currently not clear which domains of the HRQoL are most affected. OBJECTIVE to quantify HRQoL in order to identify areas of interventions. DESIGN prospective observation study. SETTING admissions to European ICUs between March 2020 and February 2021. SUBJECTS patients aged 70 years or older admitted with COVID-19 disease. METHODS collected determinants include SOFA-score, Clinical Frailty Scale (CFS), number and timing of ICU procedures and limitation of care, Katz Activities of Daily Living (ADL) dependence score. HRQoL was assessed at 3 months after ICU admission with the Euro-QoL-5D-5L questionnaire. An outcome of ≥4 on any of Euro-QoL-5D-5L domains was considered unfavourable. RESULTS in total 3,140 patients from 14 European countries were included in this study. Three months after inclusion, 1,224 patients (39.0%) were alive and the EQ-5D-5L from was obtained. The CFS was associated with an increased odds ratio for an unfavourable HRQoL outcome after 3 months; OR 1.15 (95% confidence interval (CI): 0.71-1.87) for CFS 2 to OR 4.33 (95% CI: 1.57-11.9) for CFS ≧ 7. The Katz ADL was not statistically significantly associated with HRQoL after 3 months. CONCLUSIONS in critically ill old intensive care patients suffering from COVID-19, the CFS is associated with the subjectively perceived quality of life. The CFS on admission can be used to inform patients and relatives on the risk of an unfavourable qualitative outcome if such patients survive.
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Affiliation(s)
- Ivo W Soliman
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, the Netherlands
| | - Susannah Leaver
- General Intensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Department of Anaestesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Bernhard Wernly
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Raphael R Bruno
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | | | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | | | - Jakob Wollborn
- Department of Anesthesiolgy, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Havard Medical School, Boston, MA, USA
| | - Maria Jose Arche Banzo
- Servicio de Medicina Intensiva, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Kristina Fuest
- Department of Anesthesiology and Intensive Care, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Brian Marsh
- Department of Anesthesia and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocríticos e Trauma. Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
| | - Ariane Boumendil
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, F-75012 Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, F-75012 Paris, France
| | - Bertrand Guidet
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, F-75012 Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, F-75012 Paris, France
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Dylan W De Lange
- Address correspondence to: D. W. de Lange, Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. Tel: +31 88 75 585 61; Fax: +31 88 75 556 77.
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Bauck P. Practicing Neighbor Love: Empathy, Religion, and Clinical Ethics. HEC Forum 2022:10.1007/s10730-021-09466-4. [PMID: 35031900 DOI: 10.1007/s10730-021-09466-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
The role of religion in clinical ethics consultations is contested. The religion of the ethics consultant can be an important part of the consultation process and improve the quality of a consultation. Practicing neighbor love leads to empathy, which not only can improve the quality of ethics consultations but also creates a space for religion to be part of, but not imposed on, the consultation. The practice of empathy will build trust, rapport, and an intersubjective connection that improves the quality of the consultation. (The views expressed are the author's and not representative of any institution or employer).
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Nortje M, Haque S, Nortje N. The Benefits of Informed Non-Dissent when Families have Difficulty Making a Decision. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1094702ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Zink M, Horvath A, Stadlbauer V. When is it considered reasonable to start a risky and uncomfortable treatment in critically ill patients? A random sample online questionnaire study. BMC Med Ethics 2021; 22:146. [PMID: 34732195 PMCID: PMC8564596 DOI: 10.1186/s12910-021-00705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 09/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment. Methods We performed an anonymous online survey in a random sample of 1,052 participants recruited via email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%. Results Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival (0–33% survival) when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients. Conclusion No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00705-4.
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Affiliation(s)
- M Zink
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of the Brothers of St. John of God, St. Veit an Der Glan, Austria and Hospital of the Elisabethinen Klagenfurt, Klagenfurt, Austria
| | - A Horvath
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria.,Center for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - V Stadlbauer
- Department of Internal Medicine, Research Unit "Transplantation Research", Medical University of Graz, Graz, Austria. .,Center for Biomarker Research in Medicine (CBmed), Graz, Austria. .,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Auenbruggerplatz 15, 8036, Graz, Austria.
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57
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Lemmon ME, Wusthoff CJ, Boss RD, Rasmussen LA. Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101258. [PMID: 34176763 PMCID: PMC8627487 DOI: 10.1016/j.siny.2021.101258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Engaging with ethical issues is central to the management of neonatal encephalopathy (NE). As treatment for these neonates evolves, new ethical issues will arise and many existing challenges will remain. We highlight three key ethical issues that arise in the care of neonates with NE treated with therapeutic hypothermia: facilitating shared decision making, understanding futility, and defining the boundaries between standard of care and research. Awareness of these issues will help clinicians counsel families in light of evolving treatments and outcomes.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham, NC, 27710, USA,Corresponding author. (M.E. Lemmon)
| | - Courtney J. Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Stanford, 750 Welch Road, Suite 317, Palo Alto, CA, 94304, USA
| | - Renee D. Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 N. Wolfe St, Suite 2019, Baltimore, MD, 21287, United States
| | - Lisa Anne Rasmussen
- Division of Palliative Care, Department of Family Medicine, Department of Neurology, Department of Pediatrics, Larner College of Medicine, University of Vermont, UVM Medical Center Palliative Care, 111 Colchester Avenue, Main Campus, Smith 262, Burlington, VT, 05401-1473, USA.
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Maciel CB. Neurologic Outcome Prediction in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1405-1429. [PMID: 34618766 DOI: 10.1212/con.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW The burden of severe and disabling neurologic injury on survivors, families, and society can be profound. Neurologic outcome prediction, or neuroprognostication, is a complex undertaking with many important ramifications. It allows patients with good prognoses to be supported aggressively, survive, and recover; conversely, it avoids inappropriate prolonged and costly care in those with devastating injuries. RECENT FINDINGS Striving to maintain a high prediction performance during prognostic assessments encompasses acknowledging the shortcomings of this task and the challenges created by advances in medicine, which constantly shift the natural history of neurologic conditions. Embracing the unknowns of outcome prediction and the boundaries of knowledge surrounding neurologic recovery and plasticity is a necessary step toward refining neuroprognostication practices and improving the accuracy of prognostic impressions. The pillars of modern neuroprognostication include comprehensive characterization of neurologic injury burden (primary and secondary injuries), gauging cerebral resilience and estimated neurologic reserve, and tying it all together with individual values surrounding the acceptable extent of disability and the difficulties of an arduous convalescence journey. SUMMARY Comprehensive multimodal frameworks of neuroprognostication using different prognostic tools to portray the burden of neurologic injury coupled with the characterization of individual values and the degree of cerebral reserve and resilience are the cornerstone of modern outcome prediction.
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Garg T, Shnayder-Adams MM, Keller EJ, Makary MS. Ethical Issuing Arising Around Biliary Interventions. Semin Intervent Radiol 2021; 38:388-392. [PMID: 34393351 DOI: 10.1055/s-0041-1731407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tushar Garg
- Division of Vascular and Interventional Radiology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Eric J Keller
- Division of Vascular and Interventional Radiology, Stanford University, Stanford, California
| | - Mina S Makary
- Division of Vascular and Interventional Radiology, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Anstey MH, Mitchell IA, Corke C, Murray L, Mitchell M, Udy A, Sarode V, Nguyen N, Flower O, Ho KM, Litton E, Wibrow B, Norman R. Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:287. [PMID: 34376239 PMCID: PMC8353726 DOI: 10.1186/s13054-021-03712-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/28/2021] [Indexed: 11/11/2022]
Abstract
Background To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. Methods Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. Results A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. Conclusion The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03712-4.
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Affiliation(s)
- Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia. .,School of Population Health, Curtin University, Bentley, Australia. .,School of Medicine, University of Western Australia, Crawley, Australia.
| | - Imogen A Mitchell
- Australian National University, Canberra, Australia.,Canberra Hospital, Canberra, Australia
| | | | - Lauren Murray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Marion Mitchell
- Griffith University, Griffith, QLD, Australia.,Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - Vineet Sarode
- Monash University, Melbourne, Australia.,Cabrini Hospital, Melbourne, Australia
| | - Nhi Nguyen
- Nepean Hospital, Kingswood, NSW, Australia
| | | | - Kwok M Ho
- School of Medicine, University of Western Australia, Crawley, Australia.,Royal Perth Hospital, Perth, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
| | - Edward Litton
- School of Medicine, University of Western Australia, Crawley, Australia.,Fiona Stanley Hospital, Perth, Australia
| | - Bradley Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia.,School of Medicine, University of Western Australia, Crawley, Australia
| | - Richard Norman
- School of Population Health, Curtin University, Bentley, Australia
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Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma. Am J Surg 2021; 223:998-1003. [PMID: 34384589 PMCID: PMC8818056 DOI: 10.1016/j.amjsurg.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about potential disparities in end-of-life care in trauma. We examined racial/ethnic differences in withdrawal of life-sustaining treatment (WLST) in non-head injury trauma. METHODS We retrospectively analyzed the National Trauma Databank (2017-2018), including patients ≥ 18 years without head injury. We performed a bivariate analysis by WLST status and used logistic regression to estimate adjusted odds of WLST by racial/ethnic group. RESULTS Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41-0.57) and Hispanics (OR 0.71, 95% CI 0.57-0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days. CONCLUSIONS Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.
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Silberstein S, Shnayder-Adams MM, Keller EJ, Makary MS. Ethics in Interventional Radiology: A Case-Based Primer. Cardiovasc Intervent Radiol 2021; 44:1510-1517. [PMID: 34231013 DOI: 10.1007/s00270-021-02894-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
As the field of interventional radiology assumes a larger role in patient care, the specialty has a growing responsibility to recognize and understand ethical dilemmas within the field. We present a case-based primer on common ethical issues in IR, including requests for potentially inappropriate procedures, surrogate decision making, informed consent, and managing conflicts of interest and procedural complications. This primer is intended to be used as a guide for discussion-based training in ethics in IR while inspiring further research in applied ethics in IR.
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Affiliation(s)
- Sara Silberstein
- Albany Medical College, 75 New Scotland Avenue, Albany, NY, 12208, USA.
| | - Michelle M Shnayder-Adams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Eric J Keller
- Division of Vascular and Interventional Radiology, Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Mina S Makary
- Division of Vascular and Interventional Radiology, Department of Radiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Brummett AL. Defending, Improving, Expanding, and Applying a Moral-Metaphysical Proceduralism for Secular Clinical Ethics. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:W6-W9. [PMID: 34152902 DOI: 10.1080/15265161.2021.1926593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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Abstract
Rationale: Medical interventions that prolong life without achieving an effect that the patient can appreciate as a benefit are often considered futile or inappropriate by healthcare providers. In recent years, a multicenter guideline has been released with recommendations on how to resolve conflicts between families and clinicians in these situations and to increase public engagement. Although laypeople are acknowledged as important stakeholders, their perceptions and understanding of the terms "potentially inappropriate" or "futile" treatment have received little formal evaluation.Objectives: To evaluate the community perspective about the meaning of futile treatment.Methods: Six focus groups (two groups each of ages <65, 65-75, and >75 yr) were convened to explore what constitutes futile treatment and who should decide in situations of conflict between doctors and families. Focus group discussions were analyzed using grounded theory.Results: There were 39 participants aged 18 or older with at least one previous hospitalization (personal or by immediate relative). When asked to describe futile or inappropriate treatment, community members found the concept difficult to understand and the terminology inadequate, though when presented with a case describing inappropriate treatment, most participants recognized it as the provision of inappropriate treatment. Several themes emerged regarding participant difficulty with the concept, including inadequate physician-patient communication, lack of public emphasis on end-of-life issues, skepticism that medical treatment can be completely inappropriate, and doubts and fears that medical futility could undermine patient and/or family autonomy. Participants also firmly believed that in situations of conflict families should be the ultimate decision-makers.Conclusions: Public engagement in policy development and discourse around medical futility will first require intense education to familiarize the lay public about use of inappropriate treatment at the end of life.
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Hsieh LJ, Keller EJ, Shnayder-Adams MM, Salamo RM, Vairavamurthy JP. The Ethics of Trauma Care: What Interventional Radiologists Should Know. Semin Intervent Radiol 2021; 38:239-242. [PMID: 34108812 DOI: 10.1055/s-0041-1729154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Lee J Hsieh
- School of Medicine, University of California San Diego, La Jolla, California
| | - Eric J Keller
- Division of Interventional Radiology, Stanford University, Stanford, California
| | | | - Russell M Salamo
- Division of Interventional Radiology, University of Southern California, Los Angeles, California
| | - Jenanan P Vairavamurthy
- Division of Interventional Radiology, University of Southern California, Los Angeles, California
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Brummett A. What is the appropriate role of reason in secular clinical ethics? An argument for a compatibilist view of public reason. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:281-290. [PMID: 33475924 DOI: 10.1007/s11019-021-10004-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
This article describes and rejects three standard views of reason in secular clinical ethics. The first, instrumental reason view, affirms that reason may be used to draw conceptual distinctions, map moral geography, and identify invalid forms of argumentation, but prohibits recommendations because reason cannot justify any content-full moral or metaphysical commitments. The second, public reason view, affirms instrumental reason, and claims ethicists may make recommendations grounded in the moral and metaphysical commitments of bioethical consensus. The third, comprehensive reason view, also affirms instrumental reason, but encourages ethicists to make recommendations grounded in the moral and metaphysical commitments of their private worldviews. A compatibilist view of public reason is then defended, which holds that each standard view captures an important role for reason in different aspects of secular clinical ethics. The article ends by identifying three implications for enduring theoretical debates in clinical ethics.
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Affiliation(s)
- Abram Brummett
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA.
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Chang DW, Neville TH, Parrish J, Ewing L, Rico C, Jara L, Sim D, Tseng CH, van Zyl C, Storms AD, Kamangar N, Liebler JM, Lee MM, Yee HF. Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments. JAMA Intern Med 2021; 181:786-794. [PMID: 33843946 PMCID: PMC8042568 DOI: 10.1001/jamainternmed.2021.1000] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 02/19/2021] [Indexed: 11/14/2022]
Abstract
Importance For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit. Objective To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care. Design, Setting, and Participants This prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage. Interventions Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers. Main Outcomes and Measures Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure). Results A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P < .01). Key components of family meetings, such as discussions of risks and benefits of ICU treatments (preintervention, 15 [34.9%] vs postintervention, 56 [94.9%]; P < .01), eliciting values and preferences of patients (20 [46.5%] vs 58 [98.3%]; P < .01), and identifying clinical markers of improvement (9 [20.9%] vs 52 [88.1%]; P < .01), were discussed more frequently after intervention. Median ICU length of stay was significantly reduced between preintervention and postintervention periods (8.7 [interquartile range (IQR), 5.7-18.3] days vs 7.4 [IQR, 5.2-11.5] days; P = .02). Hospital mortality was similar between the preintervention and postintervention periods (66 of 113 [58.4%] vs 56 of 96 [58.3%], respectively; P = .99). Invasive ICU procedures were used less frequently in the postintervention period (eg, mechanical ventilation preintervention, 97 [85.8%] vs postintervention, 70 [72.9%]; P = .02). Conclusions and Relevance In this study, a quality improvement intervention that trained physicians to communicate and plan ICU care with family members of critically ill patients in the ICU using TLTs was associated with improved quality of family meetings and a reduced intensity and duration of ICU treatments. This study highlights a patient-centered approach for treating critically ill patients that may reduce nonbeneficial ICU care. Trial Registration ClinicalTrials.gov Identifier: NCT04181294.
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Affiliation(s)
- Dong W. Chang
- Division of Pulmonary and Critical Care Medicine, Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
- Los Angeles County Department of Health Services, Los Angeles, California
| | - Thanh H. Neville
- Division of Pulmonary and Critical Care Medicine, Ronald Reagan University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer Parrish
- Division of Pulmonary and Critical Care Medicine, Lundquist Institute at Harbor-University of California, Los Angeles Medical Center, David Geffen School of Medicine at UCLA, Torrance, California
| | - Lian Ewing
- Los Angeles County Department of Health Services, Los Angeles, California
- Division of Pulmonary and Critical Care Medicine, Olive View Medical Center, David Geffen School of Medicine at UCLA, Sylmar, California
| | - Christy Rico
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Liliacna Jara
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Danielle Sim
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Chi-hong Tseng
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Carin van Zyl
- Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Aaron D. Storms
- Division of Geriatric, Hospital, Palliative, and General Internal Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Nader Kamangar
- Los Angeles County Department of Health Services, Los Angeles, California
- Division of Pulmonary and Critical Care Medicine, Olive View Medical Center, David Geffen School of Medicine at UCLA, Sylmar, California
| | - Janice M. Liebler
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - May M. Lee
- Division of Pulmonary and Critical Care Medicine, Los Angeles County-University of Southern California Medical Center, Keck School of Medicine of University of Southern California, Los Angeles
| | - Hal F. Yee
- Los Angeles County Department of Health Services, Los Angeles, California
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Anstey MH, Mitchell IA, Corke C, Norman R. Population Preferences for Treatments When Critically Ill: A Discrete Choice Experiment. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2021; 13:339-346. [PMID: 32009209 DOI: 10.1007/s40271-020-00410-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Many patients in the intensive care unit are too unwell to participate in shared decision making or have not previously documented their wishes. In these situations, understanding the values of the general population could help doctors provide appropriate guidance to surrogate decision makers. METHODS Using a discrete choice experiment design, we conducted an online survey using an Australian panel. Participants were asked about their willingness to accept treatments, faced with a variety of possible outcomes and probabilities (low, moderate or high). The outcomes were across four domains: loss of functional autonomy, pain, cognitive disability and degree of burden on others. Demographic details, prior experience of intensive care unit and current health conditions were also collected. Data were analysed using logistic regression, predicting whether respondents choose to continue active treatment or not. RESULTS Nine hundred and eighty-four respondents, representative of age and sex completed the web-based survey. With the increasing likelihood of negative post-intensive care unit sequelae, there was a higher probability of the respondent preferring to stop ongoing active treatment, with the largest coefficients being on caring assistance and the need for full-time residential care. Those who identified as very religious, were younger or who had children under 5 years of age were more likely to choose to continue active treatment. CONCLUSIONS Respondents valued their independence as the most important factor in deciding whether to receive ongoing medical treatments in the intensive care unit. When clinicians are unable to obtain specific patient information, they should consider framing their decision making around the likelihood of the patient achieving functional independence rather than survival.
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Affiliation(s)
- Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia. .,School of Public Health, Curtin University, Perth, WA, Australia.
| | - Imogen A Mitchell
- Australian National University, Canberra, ACT, Australia.,Canberra Hospital, Canberra, ACT, Australia
| | - Charlie Corke
- University Hospital Geelong, Geelong, VIC, Australia
| | - Richard Norman
- School of Public Health, Curtin University, Perth, WA, Australia
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Escher M, Nendaz MR, Cullati S, Hudelson P. Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study. BMJ Open 2021; 11:e046268. [PMID: 34020978 PMCID: PMC8144032 DOI: 10.1136/bmjopen-2020-046268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care. DESIGN This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis. SETTING Data were collected in a Swiss tertiary care centre between March and June 2013. PARTICIPANTS 12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions. RESULTS Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need. CONCLUSIONS In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.
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Affiliation(s)
- Monica Escher
- Division of Palliative Medicine, University Hospitals of Geneva, Geneva, Switzerland
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Mathieu R Nendaz
- Unit for Development and Research in Medical Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Stéphane Cullati
- Quality of Care Service, University Hospitals of Geneva, Geneva, Switzerland
- Population Health Laboratory, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Patricia Hudelson
- Department of Primary Care, University Hospitals of Geneva, Geneva, Switzerland
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Dagla M, Petousi V, Poulios A. Neonatal End-of-Life Decision Making: The Possible Behavior of Greek Physicians, Midwives, and Nurses in Clinical Scenarios. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18083938. [PMID: 33918554 PMCID: PMC8069263 DOI: 10.3390/ijerph18083938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/16/2022]
Abstract
Background: This study investigates the acceptability, bioethical justification, and determinants of the provision of intensive care to extremely preterm or ill neonates among healthcare professionals serving in NICUs in Greek hospitals. Methods: Healthcare professionals (71 physicians, 98 midwives, and 82 nurses) employed full-time at all public Neonatal Intensive Care Units (NICUs) (n = 17) in Greece were asked to report their potential behavior in three clinical scenarios. Results: The majority of healthcare professionals would start and continue intensive care to (a) an extremely preterm neonate, (b) a full-term neonate with an unfavorable prognosis, and (c) a neonate with complete phocomelia. In cases (a) and (b), midwives and nurses compared to physicians (p = 0.009 and p = 0.004 in scenarios (a) and (b), respectively) and health professionals ascribing to the quality-of-life principle compared to those ascribing to the intrinsic value of life (p = 0.001 and p = 0.01 scenarios (a) and (b) respectively), tend towards withholding or withdrawing care. Religion plays an important role in all three scenarios (p = 0.005, p = 0.017 and p = 0.043, respectively). Conclusions: Understanding healthcare professionals’ therapeutic intensiveness in the face of NICU ethical dilemmas can improve NICU policies, support strategies, and, consequently, the quality of neonatal intensive care.
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Affiliation(s)
- Maria Dagla
- Department of Midwifery, University of West Attica, 12243 Athens, Greece
- Correspondence: (M.D.); (V.P.)
| | - Vasiliki Petousi
- Department of Sociology, University of Crete, 74100 Crete, Greece
- Correspondence: (M.D.); (V.P.)
| | - Antonios Poulios
- Department of Psychology, National Kapodestrian University, 10679 Athens, Greece;
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Smithard DG, Abdelhameed N, Han T, Pieris A. Age, Frailty, Resuscitation and Intensive Care: With Reference to COVID-19. Geriatrics (Basel) 2021; 6:36. [PMID: 33916039 PMCID: PMC8167565 DOI: 10.3390/geriatrics6020036] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 11/16/2022] Open
Abstract
Discussion regarding cardiopulmonary resuscitation and admission to an intensive care unit is frequently fraught in the context of older age. It is complicated by the fact that the presence of multiple comorbidities and frailty adversely impact on prognosis. Cardiopulmonary resuscitation and mechanical ventilation are not appropriate for all. Who decides and how? This paper discusses the issues, biases, and potential harms involved in decision-making. The basis of decision making requires fairness in the distribution of resources/healthcare (distributive justice), yet much of the printed guidance has taken a utilitarian approach (getting the most from the resource provided). The challenge is to provide a balance between justice for the individual and population justice.
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Affiliation(s)
- David G Smithard
- Department Geriatric Medicine, Lewisham and Greenwich NHS Trust, London SE13 6LH, UK
- School of Health Science, University of Greenwich, London SE9 2UG, UK
| | - Nadir Abdelhameed
- Geriatric Medicinet, King’s College Hospital, London SE5 9RS, UK; (N.A.); (T.H.)
| | - Thwe Han
- Geriatric Medicinet, King’s College Hospital, London SE5 9RS, UK; (N.A.); (T.H.)
| | - Angelo Pieris
- Geriatric Medicine, St Thomas’ Hospital, London SE1 7EH, UK;
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Abstract
PURPOSE OF REVIEW The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events. RECENT FINDINGS In the 21st century, there have already been several outbreaks of infectious diseases that have led to mass casualties creating ICU strain, providing multiple opportunities for hospitals and hospital systems to prepare their ICUs for future events. Unfortunately, the sheer scale and rapidity of the SARS-CoV-2 pandemic led to overwhelming strain on every aspect of ICU disaster preparedness. Yet, by analyzing experiences of hospitals throughout the first 7 months of the current pandemic in the areas of infection control, equipment preparedness, staffing strategies, ICU spatial logistics as well as acute and postacute treatment, various important lessons have already emerged that will prove critical for successful future ICU preparedness. SUMMARY Preemptive planning, beginning with the early identification of staffing resources, supply chains and alternative equipment sources, coupled with strong infection control practices that also provide for the flexibility for evolving evidence is of utmost importance. However, there is no single approach that can be applied to every health system.
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Affiliation(s)
- Gavin Harris
- Divisions of Pulmonary Allergy and Critical Care Medicine and Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Amesh Adalja
- Johns Hopkins Center for Health Security, Bloomberg School of Public Health, Baltimore, Maryland, USA
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Kaps B, Chen HA, Kopf GS, Encandela J. Perspectives on the Effectiveness of a Medical Futility Policy. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021321048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bible KC, Kebebew E, Brierley J, Brito JP, Cabanillas ME, Clark TJ, Di Cristofano A, Foote R, Giordano T, Kasperbauer J, Newbold K, Nikiforov YE, Randolph G, Rosenthal MS, Sawka AM, Shah M, Shaha A, Smallridge R, Wong-Clark CK. 2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer. Thyroid 2021; 31:337-386. [PMID: 33728999 PMCID: PMC8349723 DOI: 10.1089/thy.2020.0944] [Citation(s) in RCA: 282] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Since the guidelines for the management of ATC by the American Thyroid Association were first published in 2012, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, and researchers on published evidence relating to the diagnosis and management of ATC. Methods: The specific clinical questions and topics addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of the Task Force members (authors of the guideline). Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. Results: The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, targeted/systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues, including end of life. The guidelines include 31 recommendations and 16 good practice statements. Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the management of ATC. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with ATC.
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Affiliation(s)
- Keith C. Bible
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Electron Kebebew
- Stanford University, School of Medicine, Stanford, California, USA
| | - James Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Juan P. Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria E. Cabanillas
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Antonio Di Cristofano
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Thomas Giordano
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jan Kasperbauer
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kate Newbold
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, United Kingdom
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - M. Sara Rosenthal
- Program for Bioethics and Markey Cancer Center Oncology Ethics Program, Departments Internal Medicine, Pediatrics and Behavioral Science, University of Kentucky, Lexington, Kentucky, USA
| | - Anna M. Sawka
- Division of Endocrinology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Manisha Shah
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashok Shaha
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Domínguez-Gil B, Ascher N, Capron AM, Gardiner D, Manara AR, Bernat JL, Miñambres E, Singh JM, Porte RJ, Markmann JF, Dhital K, Ledoux D, Fondevila C, Hosgood S, Van Raemdonck D, Keshavjee S, Dubois J, McGee A, Henderson GV, Glazier AK, Tullius SG, Shemie SD, Delmonico FL. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med 2021; 47:265-281. [PMID: 33635355 PMCID: PMC7907666 DOI: 10.1007/s00134-020-06341-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Abstract
A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.
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Affiliation(s)
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Alexander M Capron
- Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Department of Medicine and Law, University of Southern California, Los Angeles, CA, USA
| | - Dale Gardiner
- Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander R Manara
- Consultant in Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James L Bernat
- Department of Neurology and Medicine, Active Emeritus, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Jeffrey M Singh
- University of Toronto, and Trillium Gift of Life Network, Toronto, Canada
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, Sant Vincent'S Hospital, Sidney, Australia
| | - Didier Ledoux
- Department of Anesthesia and Intensive Care, University of Liège, Liège, Belgium
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Sarah Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Dirk Van Raemdonck
- University Hospitals Leuven and Catholic University Leuven, Leuven, Belgium
| | - Shaf Keshavjee
- Toronto General Hospital, University of Toronto, Toronto, Canada
| | - James Dubois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, Australia
| | - Galen V Henderson
- Director of Neurocritical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam D Shemie
- Pediatric Intensive Care, Montreal Children's Hospital, McGill University, Medical Advisor, Deceased Donation, Canadian Blood Services, Montreal, Canada
| | - Francis L Delmonico
- Chief Medical Officer, New England Donor Services, 60 1st Ave, Waltham, MA, 02451, USA.
- Department of Surgery, Harvard Medical School at Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Miles AH, Rushton CH, Wise BM, Moore A, Boss RD. Pediatric Chronic Critical Illness, Prolonged ICU Admissions, and Clinician Distress. J Pediatr Intensive Care 2021; 11:275-281. [DOI: 10.1055/s-0041-1724098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/12/2021] [Indexed: 10/22/2022] Open
Abstract
AbstractTo gain an in-depth understanding of the experience of pediatric intensive care unit (PICU) clinicians caring for children with chronic critical illness (CCI), we conducted, audiotaped, and transcribed in-person interviews with PICU clinicians. We used purposive sampling to identify five PICU patients who died following long admissions, whose care generated substantial staff distress. We recruited four to six interdisciplinary clinicians per patient who had frequent clinical interactions with the patient/family for interviews. Conventional content analysis was applied to the transcripts resulting in the emergence of five themes: nonbeneficial treatment; who is driving care? Elusive goals of care, compromised personhood, and suffering. Interventions directed at increasing consensus, clarifying goals of care, developing systems allowing children with CCI to be cared for outside of the ICU, and improving communication may help to ameliorate this distress.
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Affiliation(s)
- Alison H. Miles
- Division of Pediatric Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Cynda H. Rushton
- Department of Pediatrics, Berman Institute of Bioethics, School of Nursing, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
| | - Brian M. Wise
- Department of Nursing, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Aka Moore
- Department of Nursing, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Renee D. Boss
- Division of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States
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Tang ST, Huang CC, Hu TH, Lo ML, Chou WC, Chuang LP, Chiang MC. End-of-Life-Care Quality in ICUs Is Associated With Family Surrogates' Severe Anxiety and Depressive Symptoms During Their First 6 Months of Bereavement. Crit Care Med 2021; 49:27-37. [PMID: 33116053 DOI: 10.1097/ccm.0000000000004703] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Evidence linking end-of-life-care quality in ICUs to bereaved family members' psychologic distress remains limited by methodological insufficiencies of the few studies on this topic. To examine comprehensively the associations of family surrogates' severe anxiety and depressive symptoms with end-of-life-care quality in ICUs over their first 6 months of bereavement. DESIGN Prospective, longitudinal, observational study. SETTING/PARTICIPANTS Family surrogates (n = 278) were consecutively recruited from seven medical ICUs at two academically affiliated medical centers in Taiwan. MEASUREMENTS AND STATISTICAL ANALYSIS Family surrogates' anxiety and depressive symptoms were assessed 1, 3, and 6 months postloss using the Hospital Anxiety and Depression Scale. Family satisfaction with end-of-life care in ICUs was assessed 1-month postloss by the Family Satisfaction in the ICU questionnaire. Patients' end-of-life care was documented over the patient's ICU stay. Associations of severe anxiety and depressive symptoms (scores ≥ 8 for each subscale) with end-of-life-care quality in ICUs (documented by patient care received and family satisfaction with end-of-life care in ICUs) were examined by multivariate logistic regression models with generalized estimating equation. MAIN RESULTS Prevalence of severe anxiety and depressive symptoms decreased significantly over time. Surrogates' lower likelihood of severe anxiety or depressive symptoms 3-6 month postloss was associated with death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and higher family satisfaction with end-of-life care in ICUs. Bereaved surrogates' higher likelihood of these symptoms was associated with physician-surrogate prognostic communication and conducting family meetings before patients died. CONCLUSIONS End-of-life-care quality in ICUs is associated with bereaved surrogates' psychologic well-being. Enhancing end-of-life-care quality in ICUs by improving the process of end-of-life care, for example, promoting death without cardiopulmonary resuscitation, withdrawing life-sustaining treatments, and increasing family satisfaction with end-of-life care, can lighten bereaved family surrogates' severe anxiety symptoms and severe depressive symptoms.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, R.O.C
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Tsung-Hui Hu
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
| | - Mei-Ling Lo
- School of Nursing, Medical College, Chang Gung University, Taoyuan, Taiwan, Republic of China
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
- College of Medicine, Chang Gung University, Taoyuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, Republic of China
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Lo ML, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC, Wen FH, Tang ST. Quality Assessments of End-of-Life Care by Medical Record Review for Patients Dying in Intensive Care Units in Taiwan. J Pain Symptom Manage 2020; 60:1092-1099.e1. [PMID: 32650138 DOI: 10.1016/j.jpainsymman.2020.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT/OBJECTIVE Essential indicators of high-quality end-of-life care in intensive care units (ICUs) have been established but examined inconsistently and predominantly with small samples, mostly from Western countries. Our study goal was to comprehensively measure end-of-life-care quality delivered in ICUs using chart-derived process-based quality measures for a large cohort of critically ill Taiwanese patients. METHODS For this observational study, patients with APACHE II score ≥20 or goal of palliative care and with ICU stay exceeding three days (N = 326) were consecutively recruited and followed until death. RESULTS Documentation of process-based indicators for Taiwanese patients dying in ICUs was variable (8.9%-96.3%), but high for physician communication of the patient's poor prognosis to his/her family members (93.0%), providing specialty palliative-care consultations (73.3%), a do-not-resuscitate order in place at death (96.3%), death without cardiopulmonary resuscitation (93.5%), and family presence at patient death (76.1%). Documentation was infrequent for social-worker involvement (8.9%) and interdisciplinary family meetings to discuss goals of care (22.4%). Patients predominantly (79.8%) continued life-sustaining treatments (LSTs) until death and died with full life support, with 88.3% and 58.9% of patients dying with mechanical ventilation support and vasopressors, respectively. CONCLUSIONS Taiwanese patients dying in ICUs heavily used LSTs until death despite high prevalences of documented prognostic communication, providing specialty palliative-care consultations, having a do-not-resuscitate order in place, and death without cardiopulmonary resuscitation. Family meetings should be actively promoted to facilitate appropriate end-of-life-care decisions to avoid unnecessary suffering from potentially inappropriate LSTs during the last days of life.
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Affiliation(s)
- Mei-Ling Lo
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, R.O.C
| | - Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C.
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Cacic K, Bonomo J. NeuroEthics and End of Life Care. Emerg Med Clin North Am 2020; 39:217-225. [PMID: 33218659 DOI: 10.1016/j.emc.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.
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Affiliation(s)
- Kelsey Cacic
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Mail Location 0525, Stetson Building, 260 Stetson Street, Suite 2300, Cincinnati, OH 45267-0525, USA.
| | - Jordan Bonomo
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA; Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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Courtwright AM, Rubin E, Erler KS, Bandini JI, Zwirner M, Cremens MC, McCoy TH, Robinson EM. Experience with a Revised Hospital Policy on Not Offering Cardiopulmonary Resuscitation. HEC Forum 2020; 34:73-88. [PMID: 33136221 DOI: 10.1007/s10730-020-09429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
Critical care society guidelines recommend that ethics committees mediate intractable conflict over potentially inappropriate treatment, including Do Not Resuscitate (DNR) status. There are, however, limited data on cases and circumstances in which ethics consultants recommend not offering cardiopulmonary resuscitation (CPR) despite patient or surrogate requests and whether physicians follow these recommendations. This was a retrospective cohort of all adult patients at a large academic medical center for whom an ethics consult was requested for disagreement over DNR status. Patient demographic predictors of ethics consult outcomes were analyzed. In 42 of the 116 cases (36.2%), the patient or surrogate agreed to the clinician recommended DNR order following ethics consultation. In 72 of 74 (97.3%) of the remaining cases, ethics consultants recommended not offering CPR. Physicians went on to write a DNR order without patient/surrogate consent in 57 (79.2%) of those cases. There were no significant differences in age, race/ethnicity, country of origin, or functional status between patients where a DNR order was and was not placed without consent. Physicians were more likely to place a DNR order for patients believed to be imminently dying (p = 0.007). The median time from DNR order to death was 4 days with a 90-day mortality of 88.2%. In this single-center cohort study, there was no evidence that patient demographic factors affected ethics consultants' recommendation to withhold CPR despite patient/surrogate requests. Physicians were most likely to place a DNR order without consent for imminently dying patients.
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Affiliation(s)
- Andrew M Courtwright
- Department of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.,Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
| | - Emily Rubin
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly S Erler
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
| | | | - Mary Zwirner
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Social Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Departments of Psychiatry and Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Ellen M Robinson
- Edwin H. Cassem Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA. .,Patient Care Services, Massachusetts General Hospital, Boston, MA, 02114, USA.
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Keller EJ, Rabei R, Heller M, Kothary N. Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis. Cardiovasc Intervent Radiol 2020; 44:127-133. [PMID: 33078233 DOI: 10.1007/s00270-020-02675-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement. METHODS Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1-39 years of experience) and 7 referring physicians (3 males, 4 females, 6-14 years of experience) were analyzed. RESULTS Many IRs (75%) perceived futility as an important issue. Years of experience (r = 0.60, p = 0.03) and being in academics (r = 0.62, p = 0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility. CONCLUSION This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.
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Affiliation(s)
- Eric J Keller
- Department of Radiology, Stanford University, Stanford, 300 Pasteur Drive, H3630, Stanford, CA, 94305, USA.
| | - Rana Rabei
- Department of Radiology and Biomedical Imaging, UCSF, 505 Parnassus Avenue, M-391, San Francisco, CA, 94143, USA
| | - Michael Heller
- Department of Radiology and Biomedical Imaging, UCSF, 505 Parnassus Avenue, M-391, San Francisco, CA, 94143, USA
| | - Nishita Kothary
- Department of Radiology, Stanford University, Stanford, 300 Pasteur Drive, H3630, Stanford, CA, 94305, USA
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Accini Mendoza JL, Beltrán N, Nieto Estrada VH, Ramos Bolaños E, Pizarro Gómez C, Rebolledo CE, Duran Pérez JC, Dueñas Castell C, Arias A, Barciela E, Camargo R, Rojas JA, Zabaleta Polo Y, Florian Pérez MC, Torres V. Declaración de consenso en medicina crítica para la atención multidisciplinaria del paciente con sospecha o confirmación diagnóstica de COVID-19. ACTA ACUST UNITED AC 2020. [PMCID: PMC7164846 DOI: 10.1016/j.acci.2020.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
El comportamiento de la infección por SARS-CoV-2 obligó a la Organización Mundial de la Salud a emitir una convocatoria global de activación de mecanismos de emergencia para atender la crisis de salud pública latente. Las unidades de cuidados intensivos son uno de los principales recursos de los sistemas sanitarios dada la tasa de neumonías complicadas que presentan los pacientes infectados. En respuesta a los distintos lineamientos y diferentes niveles de evidencia de la información disponible, la Asociación Colombiana de Medicina Crítica y Cuidados Intensivos (AMCI) convocó un equipo multidisciplinario de expertos en medicina crítica para establecer una declaratoria de consenso de buena práctica clínica para la atención de pacientes con COVID-19. Su objetivo es facilitar y estandarizar la toma de decisiones en los aspectos más relevantes desde la organización administrativa de las áreas de atención hasta el abordaje clínico del paciente, teniendo en cuenta la seguridad del personal sanitario, la infraestructura y los recursos con los que cuenta el país para responder a la emergencia. Este documento está sujeto a la evolución del conocimiento y a los resultados de investigaciones en curso.
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Abstract
INTRODUCTION Studies have suggested 5-20% of paediatric ICU patients may receive care felt to be futile. No data exists on the prevalence and impact of futile care in the Paediatric Cardiac ICU. The aim is to determine the prevalence and economic impact of futile care. MATERIALS AND METHOD Retrospective cohort of patients with congenital cardiac disease 0-21 years old, with length of stay >30 days and died (2015-2018). Documentation of futility by the medical team was retrospectively and independently reviewed. RESULTS Of the 127 deaths during the study period, 51 (40%) had hospitalisation >30 days, 13 (25%) had received futile care and 26 (51%) withdrew life-sustaining treatment. Futile care comprised 0.69% of total patient days with no difference in charges from patients not receiving futile care. There was no difference in insurance, single motherhood, education, income, poverty, or unemployment in families continuing futile care or electing withdrawal of life-sustaining treatment. Black families were less likely than White families to elect for withdrawal (p = 0.01), and Hispanic families were more likely to continue futile care than non-Hispanics (p = 0.044). CONCLUSIONS This is the first study to examine the impact of futile care and characteristics in the paediatric cardiac ICU. Black families were less likely to elect for withdrawal, while Hispanic families more likely to continue futile care. Futile care comprised 0.69% of bed days and little burden on resources. Cultural factors should be investigated to better support families through end-of-life decisions.
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84
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Wycech J, Fokin AA, Katz JK, Tymchak A, Teitzman RL, Koff S, Puente I. Reduction in Potentially Inappropriate Interventions in Trauma Patients following a Palliative Care Consultation. J Palliat Med 2020; 24:705-711. [PMID: 32975481 DOI: 10.1089/jpm.2020.0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Palliative care is expanding as part of treatment, but remains underutilized in trauma settings. Palliative care consultations (PCC) have shown to reduce nonbeneficial, potentially inappropriate interventions (PII), as decision for their use should always be made in the context of both the patient's prognosis and the patient's goals of care. Objective: To characterize trauma patients who received PCC and to analyze the effect of PCC and do-not-resuscitate (DNR) orders on PII in severely injured patients. Setting/Subjects: Retrospective cohort study of 864 patients admitted to two level 1 trauma centers: 432 patients who received PCC (PCC group) were compared with 432 propensity score match-controlled (MC group) patients who did not receive PCC. Measurements: PCC in a consultative palliative care model, PII (including tracheostomy and percutaneous endoscopic gastrostomy) rate and timing, DNR orders. Results: PCC rate in trauma patients was 4.3%, with a 5.3-day average time to PCC. PII were done in 9.0% of PCC and 6.0% of MC patients (p = 0.09). In the PCC group, 74.1% of PII were done before PCC, and 25.9% after. PCC compared with MC patients had significantly higher mechanical ventilation (60.4% vs. 18.1%, p < 0.001) and assisted feeding requirements (14.1% vs. 6.7%, p < 0.001). We observed a statistically significant reduction in PII after PCC (p = 0.002). Significantly less PCC than MC patients had PII following DNR (26.3% vs. 100.0%, p = 0.035). Conclusions: PCC reduced PII in severely injured trauma patients by factor of two. Since the majority of PII in PCC patients occurred before PCC, a more timely administration of PCC is recommended. To streamline goals of care, PCC should supplement or precede a DNR discussion.
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Affiliation(s)
- Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | - Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Jeffrey K Katz
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Alexander Tymchak
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, USA
| | | | - Susan Koff
- TrustBridge Health, West Palm Beach, Florida, USA
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida, USA.,Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida, USA.,Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida, USA
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85
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Neville TH, Wiley JF, Kardouh M, Curtis JR, Yamamoto MC, Wenger NS. Change in inappropriate critical care over time. J Crit Care 2020; 60:267-272. [PMID: 32932112 DOI: 10.1016/j.jcrc.2020.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 08/09/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Intensive care interventions that prolong life without achieving meaningful benefit are considered clinically "inappropriate". In 2012, the frequency of perceived-inappropriate critical care was 10.8% at one academic health system; and we aimed to re-evaluate this frequency. METHODS For 4 months in 2017, we surveyed critical care physicians daily and asked whether each patient was receiving appropriate, probably inappropriate, or inappropriate critical care. Patients were categorized into three groups: 1) patients for whom treatment was never inappropriate, 2) patients with at least one assessment that treatment was probably inappropriate, but no inappropriate treatment assessments, and 3) patients who had at least one assessment of inappropriate treatment. RESULTS Fifty-five physicians made 10,105 assessments on 1424 patients. Of these, 94 (6.6%) patients received at least one assessment of inappropriate critical care, which is lower than 2012 (10.8% (p < 0.01)). Comparing 2017 and 2012, patient age, MS-DRG, length of stay, and hospital mortality were not significantly different (p > 0.05). Inpatient mortality in 2017 was 73% for patients receiving inappropriate critical care. CONCLUSIONS Over five years the proportion of patients perceived to be receiving inappropriate critical care dropped by 40%. Understanding the reasons for such change might elucidate how to continue to reduce inappropriate critical care.
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Affiliation(s)
- Thanh H Neville
- UCLA, Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, USA.
| | - Joshua F Wiley
- Turner Institute for Brain and Mental Health and School of Psychological Sciences, Monash University, Australia
| | - Miramar Kardouh
- UCLA, Department of Medicine, David Geffen School of Medicine, USA
| | - J Randall Curtis
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Myrtle C Yamamoto
- UCLA, Department of Medicine, Quality Improvement, David Geffen School of Medicine, USA
| | - Neil S Wenger
- UCLA, Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, USA
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Andersen SK, Montgomery CL, Bagshaw SM. Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission. J Crit Care 2020; 60:279-284. [PMID: 32942163 DOI: 10.1016/j.jcrc.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe patients who die within 24 h of ICU admission in order to better optimize care delivery. METHODS This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression. RESULTS Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6). CONCLUSION Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.
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Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
| | - Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada; Alberta Health Services Critical Care Strategic Clinical Network, Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
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Abstract
Rationale: National guidelines have laid out a process to conflict resolution in cases of potentially inappropriate medical interventions. Objectives: To determine the association between information about a process-based approach and lay public perceptions of the appropriateness of withholding medically inappropriate interventions. Methods: Respondents from a nationwide sample completed a survey with two adult intensive care unit-based vignettes: one about advanced cancer where doctors told the family that additional chemotherapy would not be offered, and a second case of multiorgan failure after brain hemorrhage where dialysis would not be offered. Participants were randomly assigned to see or not see information about a detailed process for the determination to withhold (second opinion, ethics consultation, exploring transfer to another institution). The primary outcome was the perceived appropriateness of not providing the treatment (four-point scale, dichotomized for analysis, modified Poisson regression), and the secondary outcome was the negative emotional reaction to the case (positive and negative affect schedule, range 1-5, higher is greater negative emotional response, linear regression). Results: A total of 1,191 respondents were included. Providing detailed process information increased the perceived appropriateness of withholding treatment by approximately 10 percentage points in each vignette: (chemotherapy, 75.7-85.4%; dialysis, 68.0-79.3%). Process information remained associated with perceived appropriateness of withholding treatment after adjustment for order effects and prespecified respondent characteristics (chemotherapy: prevalence ratio, 1.13; 95% confidence interval [CI], 1.07-1.19) (dialysis: prevalence ratio, 1.17; 95% CI, 1.10-1.25). Process information was not associated with emotional response to the cases (chemotherapy: β = -0.04; 95% CI, -0.16 to 0.09) (dialysis: β = -0.02; 95% CI, -0.14 to 0.10; both adjusted for order effects). Conclusions: Providing process-based conflict resolution information increased public acceptance of determinations of medical futility, supporting the practice outlined in national consensus statements.
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Johal HK, Danbury C. Conflict before the courtroom: challenging cognitive biases in critical decision-making. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106177. [PMID: 32631970 PMCID: PMC8639943 DOI: 10.1136/medethics-2020-106177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 05/31/2023]
Abstract
Conflict is an important consideration in the intensive care unit (ICU). In this setting, conflict most commonly occurs over the 'best interests' of the incapacitated adult patient; for instance, when families seek aggressive life-sustaining treatments, which are thought by the medical team to be potentially inappropriate. Indeed, indecision on futility of treatment and the initiation of end-of-life discussions are recognised to be among the greatest challenges of working in the ICU, leading to emotional and psychological 'burnout' in ICU teams. When these disagreements occur, they may be within the clinical team or among those close to the patient, or between the clinical team and those close to the patient. It is, therefore, crucial to have a theoretical understanding of decision-making itself, as unpicking misalignments in the family's and clinical team's decision-making processes may offer strategies to resolve conflict. Here, we relate Kahneman and Tversky's work on cognitive biases and behavioural economics to the ICU environment, arguing that these biases could partly explain disparities in the decision-making processes for the two conflicting parties. We suggest that through the establishment of common ground, challenging of cognitive biases and formulation of mutually agreeable solutions, mediation may offer a pragmatic and cost-effective solution to conflict resolution. The litigation process is intrinsically adversarial and strains the doctor-patient-relative relationship. Thus an alternative external party should be considered, however mediation is not frequently used and more research is needed into its effectiveness in resolving conflicts in the ICU.
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Affiliation(s)
| | - Christopher Danbury
- Adult Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
- School of Law, University of Reading, Reading, UK
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McCullough LB. In Response to COVID-19 Pandemic Physicians Already Know What to Do. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:9-12. [PMID: 32323624 DOI: 10.1080/15265161.2020.1754100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
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90
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Anderson M, Youngner S, Smith RD, Nandyal RR, Orlowski JP, Jessie Hill B, Barsman SG. Neonatal Organ and Tissue Donation for Research: Options Following Death by Natural Causes. Cell Tissue Bank 2020; 21:289-302. [PMID: 32166424 PMCID: PMC7223177 DOI: 10.1007/s10561-020-09822-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/02/2020] [Indexed: 12/11/2022]
Abstract
The donation of organs and tissues from neonates (birth to 28 days) for transplantation has been a relatively infrequent occurrence. Less common has been the use of neonatal organs and tissues for research. Specific ethical and legal questions beg for rational and transparent guidelines with which to evaluate referrals of potential donors. Donation of organs and tissues from a neonate can play a key role in the care and support provided to families by health care professionals around the time of a neonate's death. We report on the recovery of neonatal organs and tissues for research. A working group made up of bioethicists, neonatologists, lawyers, obstetric practioners as well as organ procurement and tissue banking professionals evaluated legal, ethical and medical issues. Neonatal donor family members were also consulted. Our primary goals were (a) to ensure that referrals were made in compliance with all applicable federal and state laws, regulations and institutional protocols, and (b) to follow acceptable ethical standards. Algorithms and policies designed to assist in the evaluation of potential neonatal donors were developed. Neonatal donation is proving increasingly valuable for research into areas including diabetes, pulmonary, gastrointestinal, genitourinary and neurological development, rheumatoid arthritis, autism, childhood psychiatric and neurologic disorders, treatment of MRSA infection and pediatric emergency resuscitation. The development of policies and procedures will assist medical professionals who wish to offer the option of donation to family members anticipating the death of a neonate.
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Affiliation(s)
| | - Stuart Youngner
- Department of Bioethics, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-4976 USA
| | - Regina Dunne Smith
- International Institute for Advancement of Medicine, Romansville, PA USA
| | - Raja R. Nandyal
- Department of Neonatology, Oklahoma University Health Sciences Center, Oklahoma City, OK USA
| | | | - B. Jessie Hill
- School of Law, Case Western Reserve University, Cleveland, OH USA
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91
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Kon AA. Shared Decision-Making in the Determination of Death by Neurologic Criteria. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:30-32. [PMID: 32618503 DOI: 10.1080/15265161.2020.1754507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Alexander A Kon
- University of California San Diego School of Medicine
- University of Washington School of Medicine
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92
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Prognosis and futility in neurosurgical emergencies: A review. Clin Neurol Neurosurg 2020; 195:105851. [PMID: 32422469 DOI: 10.1016/j.clineuro.2020.105851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 11/22/2022]
Abstract
A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.
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93
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Wocial LD, Slaven JE, Montz K, Monahan PO, Hickman SE, Callahan CM, Helft PR, Sachs GA, Inger L, Burke ES, Torke AM. Factors Associated with Physician Moral Distress Caring for Hospitalized Elderly Patients Needing a Surrogate Decision-maker: a Prospective Study. J Gen Intern Med 2020; 35:1405-1412. [PMID: 32096085 PMCID: PMC7210358 DOI: 10.1007/s11606-020-05652-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 07/11/2019] [Accepted: 12/10/2019] [Indexed: 10/24/2022]
Abstract
BACKGROUND When working with surrogate decision-makers, physicians often encounter ethical challenges that may cause moral distress which can have negative consequences for physicians. OBJECTIVE To determine frequency of and factors associated with physicians' moral distress caring for patients requiring a surrogate. DESIGN Prospective survey. PARTICIPANTS Physicians (n = 154) caring for patients aged 65 years and older and their surrogate decision-makers (n = 362 patient/surrogate dyads). Patients were admitted to medicine or medical intensive care services, lacked decisional capacity and had an identified surrogate. MAIN MEASURES Moral distress thermometer. KEY RESULTS Physicians experienced moral distress in the care of 152 of 362 patients (42.0%). In analyses adjusted for physician, patient, and surrogate characteristics, physician/surrogate discordance in preferences for the plan of care was not significantly associated with moral distress. Physicians were more likely to experience moral distress when caring for older patients (1.06, 1.02-1.10), and facing a decision about life-sustaining treatment (3.58, 1.54-8.32). Physicians were less likely to experience moral distress when caring for patients residing in a nursing home (0.40, 0.23-0.69), patients who previously discussed care preferences (0.56, 0.35-0.90), and higher surrogate ratings of emotional support from clinicians (0.94, 0.89-0.99). Physicians' internal discordance when they prefer a more comfort-focused plan than the patient is receiving was associated with significantly higher moral distress (2.22, 1.33-3.70) after adjusting for patient, surrogate, and physician characteristics. CONCLUSIONS Physician moral distress occurs more frequently when the physician is male, the patient is older or requires decisions about life-sustaining treatments. These findings may help target interventions to support physicians. Prior discussions about patient wishes is associated with lower distress and may be a target for patient-centered interventions.
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Affiliation(s)
- Lucia D Wocial
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA.
- Indiana University School of Nursing, Indianapolis, IN, USA.
| | | | - Kianna Montz
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | | | - Susan E Hickman
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA
- Indiana University School of Nursing, Indianapolis, IN, USA
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Christopher M Callahan
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
- IU Division of General Internal Medicine and Geriatrics, Indianapolis, IN, USA
| | - Paul R Helft
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA
- IU Melvin and Bren Simon Cancer Center, Indianapolis, IN, USA
| | - Greg A Sachs
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
- IU Division of General Internal Medicine and Geriatrics, Indianapolis, IN, USA
| | - Lev Inger
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Emily S Burke
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Alexia M Torke
- Charles Warren Fairbanks Center for Medical Ethics, IU Health, Indianapolis, IN, USA
- Indiana University (IU) Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA
- IU Division of General Internal Medicine and Geriatrics, Indianapolis, IN, USA
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, Indianapolis, IN, USA
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Morrison W. Goal-Concordant Care Within the Range of the Possible. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:63-65. [PMID: 32116161 DOI: 10.1080/15265161.2020.1714815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Wynne Morrison
- The Children's Hospital of Philadelphia
- University of Pennsylvania
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96
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Abstract
OBJECTIVES To describe the sources of uncertainty in prognosticating devastating brain injury, the role of the intensivist in prognostication, and ethical considerations in prognosticating devastating brain injury in the ICU. DATA SOURCES A PubMed literature review was performed. STUDY SELECTION Articles relevant to prognosis in intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and postcardiac arrest anoxic encephalopathy were selected. DATA EXTRACTION Data regarding definition and prognosis of devastating brain injury were extracted. Themes related to how clinicians perform prognostication and their accuracy were reviewed and extracted. DATA SYNTHESIS Although there are differences in pathophysiology and therefore prognosis in the various etiologies of devastating brain injury, some common themes emerge. Physicians tend to have fairly good prognostic accuracy, especially in severe cases with poor prognosis. Full supportive care is recommended for at least 72 hours from initial presentation to maximize the potential for recovery and minimize secondary injury. However, physician approaches to the timing of and recommendations for withdrawal of life-sustaining therapy have a significant impact on mortality from devastating brain injury. CONCLUSIONS Intensivists should consider the modern literature describing prognosis for devastating brain injury and provide appropriate time for patient recovery and for discussions with the patient's surrogates. Surrogates wish to have a prognosis enumerated even when uncertainty exists. These discussions must be handled with care and include admission of uncertainty when it exists. Respect for patient autonomy remains paramount, although physicians are not required to provide inappropriate medical therapies.
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97
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Damluji AA, Forman DE, van Diepen S, Alexander KP, Page RL, Hummel SL, Menon V, Katz JN, Albert NM, Afilalo J, Cohen MG. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e6-e32. [DOI: 10.1161/cir.0000000000000741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.
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98
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What Does the Word "Treatable" Mean? Implications for Communication and Decision-Making in Critical Illness. Crit Care Med 2020; 47:369-376. [PMID: 30585833 DOI: 10.1097/ccm.0000000000003614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To explore how nonphysicians and physicians interpret the word "treatable" in the context of critical illness. DESIGN Qualitative study using in-depth interviews. SETTING One academic medical center. SUBJECTS Twenty-four nonphysicians (patients and community members) purposively sampled for variation in demographic characteristics and 24 physicians (attending physicians and trainees) purposively sampled from four specialties (critical care, palliative care, oncology, and surgery). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified two distinct concepts that participants used to interpret the word "treatable": 1) a "good news" concept, in which the word "treatable" conveys a positive message about a patient's future, thereby inspiring hope and encouraging further treatment and 2) an "action-oriented" concept, in which the word "treatable" conveys that physicians have an action or intervention available, but does not necessarily imply an improved prognosis or quality of life. The overwhelming majority of nonphysicians adopted the "good news" concept, whereas physicians almost exclusively adopted the "action-oriented" concept. For some nonphysicians, the word "treatable" conveyed a positive message about prognosis and/or further treatment, even when this contradicted previously stated negative information. CONCLUSIONS Physician use of the word "treatable" may lead patients or surrogates to derive unwarranted good news and false encouragement to pursue treatment, even when physicians have explicitly stated information to the contrary. Further work is needed to determine the extent to which the word "treatable" and its cognates contribute to widespread decision-making and communication challenges in critical care, including discordance about prognosis, misconceptions that palliative treatments are curative, and disputes about potentially inappropriate or futile treatment.
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99
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Nurok M, Warsh J, Griner T, Kharabi M, Castongia J, Overbeck C, Krueger L, Coleman B, Ramzy D, Chung J, Chan A, Ley E, Kubendran S, Parrish N, Yu Z, Langberg M, Finder S, Rosen BT, Kaplan RS, Sax H, Arabia F. Extracorporeal Membrane Oxygenation Appropriateness: An Interdisciplinary Consensus-Based Approach. Anesth Analg 2019; 128:e38-e41. [PMID: 29261542 DOI: 10.1213/ane.0000000000002723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe a quality improvement initiative aimed at achieving interdisciplinary consensus about the appropriate delivery of extracorporeal membrane oxygenation (ECMO). Interdisciplinary rounds were implemented for all patients on ECMO and addressed whether care was consistent with a patient's minimally acceptable outcome, maximally acceptable burden, and relative likelihood of achieving either. The rounding process was associated with decreased days on venoarterial ECMO, from a median of 6 days in 2014 (first quartile [Q1]-third quartile [Q3], 3-10) to 5 days in 2015 (Q1-Q3, 2.5-8) and in 2016 (Q1-Q3, 1-8). Our statistical methods do not allow us to conclude that this change was due to our intervention, and it is possible that the observed decreases would have occurred whether or not the rounding process was implemented.
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Affiliation(s)
- Michael Nurok
- From the Department of Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Todd Griner
- Critical Care Nursing, Cedars-Sinai Medical Center, Los Angeles, California
| | - Mayumi Kharabi
- Human Centered Design, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph Castongia
- Human Centered Design, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cali Overbeck
- Human Centered Design, Cedars-Sinai Medical Center, Los Angeles, California
| | - Lisa Krueger
- Department of Social Work, Cedars-Sinai Medical, Los Angeles, California
| | - Bernice Coleman
- Critical Care Nursing, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danny Ramzy
- From the Department of Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Joshua Chung
- From the Department of Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Alice Chan
- Critical Care Nursing, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Ley
- From the Department of Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Sindhu Kubendran
- Department of Clinical Transformation, Cedars-Sinai, Los Angeles, California
| | - Neil Parrish
- Department of Clinical Transformation, Cedars-Sinai, Los Angeles, California
| | - Zhe Yu
- Department of Clinical Transformation, Cedars-Sinai, Los Angeles, California
| | - Michael Langberg
- Department of Medical Affairs, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stuart Finder
- Center for Healthcare Ethics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bradley T Rosen
- Supportive Care Medicine and Physician Alignment & Care Transitions, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Harry Sax
- From the Department of Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Francisco Arabia
- From the Department of Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
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Abstract
Stroke is a sudden, unexpected illness with an uncertain prognosis for functional recovery. Ethical issues in the care of patients with stroke include assessment of decision-making capacity when cognition or communication is impaired, prognostication, evaluation of quality of life, withdrawal or withholding of life-sustaining treatment, and how to optimize surrogate decision making. Skilled communication between clinicians and patients or their surrogates promotes shared decision making and may prevent ethical conflict. Nurses with an understanding of the ethics of stroke care play an important role in the care of patients with stroke and their families.
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