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Georgakis S, Dragioti E, Gouva M, Papathanakos G, Koulouras V. The Complex Dynamics of Decision-Making at the End of Life in the Intensive Care Unit: A Systematic Review of Stakeholders' Views and Influential Factors. Cureus 2024; 16:e52912. [PMID: 38406151 PMCID: PMC10893775 DOI: 10.7759/cureus.52912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
A lack of consensus resulting in severe conflicts is often observed between the stakeholders regarding their respective roles in end-of-life (EOL) decision-making in the ICU. Since the burden of these decisions lies upon the individuals, their opinions must be known by medical, judicial, legislative, and governmental authorities. Part of the solution to the issues that arise would be to examine and understand the views of the people in different societies. Hence, in this systematic review, we assessed the attitudes of the physicians, nurses, families, and the general public toward who should be involved in decision-making and influencing factors. Toward this, we searched three electronic databases, i.e., PubMed, CINAHL (Cumulative Index to Nursing & Allied Health), and Embase. A matrix was developed, discussed, accepted, and used for data extraction by two independent investigators. Study quality was evaluated using the Newcastle-Ottawa Scale. Data were extracted by one researcher and double-checked by a second one, and any discrepancies were discussed with a third researcher. The data were analyzed descriptively and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-three studies met our inclusion criteria. Most involved healthcare professionals and reported geographic variations in different timeframes. While paternalistic features have been observed, physicians overall showed an inclination toward collaborative decision-making. Correspondingly, the nursing staff, families, and the public are aligned toward patient and relatives' participation, with nurses expressing their own involvement as well. Six categories of influencing factors were identified, with high-impact factors, including demographics, fear of litigation, and regulation-related ones. Findings delineate three key points. Firstly, overall stakeholders' perspectives toward EOL decision-making in the ICU seem to be leaning toward a more collaborative decision-making direction. Secondly, to reduce conflicts and reach a consensus, multifaceted efforts are needed by both healthcare professionals and governmental/regulatory authorities. Finally, due to the multifactorial complexity of the subject, directly related to demographic and regulatory factors, these efforts should be more extensively sought at a regional level.
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Affiliation(s)
- Spiros Georgakis
- Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, GRC
| | - Elena Dragioti
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
| | - Mary Gouva
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
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Wikstøl D, Horn MA, Pedersen R, Magelssen M. Citizen attitudes to non-treatment decision making: a Norwegian survey. BMC Med Ethics 2023; 24:20. [PMID: 36890542 PMCID: PMC9993678 DOI: 10.1186/s12910-023-00900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/03/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Decisions about appropriate treatment at the end of life are common in modern healthcare. Non-treatment decisions (NTDs), comprising both withdrawal and withholding of (potentially) life-prolonging treatment are in principle accepted in Norway. However, in practice they may give rise to significant moral problems for health professionals, patients and next of kin. Here, patient values must be considered. It is relevant to study the moral views and intuitions of the general population on NTDs and special areas of contention such as the role of next of kin in decision-making. METHODS Electronic survey to members of a nationally representative panel of Norwegian adults. Respondents were presented with vignettes describing patients with disorders of consciousness, dementia, and cancer where patient preferences varied. Respondents answered ten questions about the acceptability of non-treatment decision making and the role of next of kin. RESULTS We received 1035 complete responses (response rate 40.7%). A large majority, 88%, supported the right of competent patients to refuse treatment in general. When an NTD was in line with the patient's previously expressed preferences, more respondents tended to find NTDs acceptable. More respondents would accept NTDs for themselves than for the vignette patients. In a scenario with an incompetent patient, clear majorities wanted the views of next of kin to be given some but not decisive weight, and more weight if concordant with the patient's wishes. There were, however, large variations in the respondents' views. CONCLUSION This survey of a representative sample of the Norwegian adult population indicates that attitudes to NTDs are often in line with national laws and guidelines. However, the high variance among the respondents and relatively large weight given to next of kin's views, indicate a need for appropriate dialogue among all stakeholders to prevent conflicts and extra burdens. Furthermore, the emphasis given to previously expressed opinions indicates that advance care planning may increase the legitimacy of NTDs and prevent challenging decision-making processes.
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Affiliation(s)
- David Wikstøl
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | | | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway. .,MF Norwegian School of Theology, Religion and Society, Oslo, Norway.
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Muacevic A, Adler JR, Khalayla M, Lazraq M, Miloudi Y, Bensaid A, El Harrar N. Moroccans' Views on Resuscitation According to Presumed Degree of Disability: A Cross-Sectional Study. Cureus 2023; 15:e33460. [PMID: 36628402 PMCID: PMC9822531 DOI: 10.7759/cureus.33460] [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: 01/06/2023] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION According to the World Health Organization (WHO), disability is a public health problem that can be difficult to manage medically and financially. Disability can either be innate or develop after resuscitation. Therefore, the decision regarding whether to resuscitate a patient or not raises certain ethical questions, especially in the context of a Muslim country such as Morocco. AIM The main aim of this study is to survey the public's opinions regarding their willingness to be resuscitated or have their relatives be resuscitated based on their foreseeable degree of disability. METHODS This cross-sectional study was conducted over a 10-month period and employed a self-administered questionnaire. The participants included were all adult (i.e., over 18 years of age) Moroccan nationals, and they were selected regardless of their religious identity. Moreover, the modified Rankin Scale (mRS) was used to measure the participants' foreseeable degree of handicap. The participants were divided into two groups: healthcare workers and non-healthcare workers. RESULTS In total, 1083 questionnaires were retained. The average age of the participants was 30 (± 8) years, with the male-to-female sex ratio being 0.78. Moreover, 39.6% of the participants were healthcare workers. It was found that compared to the non healthcare workers, the healthcare professionals were more willing to be resuscitated themselves and have resuscitation performed on their relatives, but only when the degree of foreseeable disability was estimated to be absent or insignificant, whereas they were less willing to be resuscitated and have resuscitation performed on their relatives when the degree of foreseeable disability was estimated to be mild or higher. CONCLUSION In conclusion, there should be a pre-established procedure, along with a legislative and multidisciplinary framework, within the hospital structures in order to help in the decision-making process regarding whether to resuscitate a patient or not.
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Mentzelopoulos SD, Chen S, Nates JL, Kruser JM, Hartog C, Michalsen A, Efstathiou N, Joynt GM, Lobo S, Avidan A, Sprung CL. Derivation and performance of an end-of-life practice score aimed at interpreting worldwide treatment-limiting decisions in the critically ill. Crit Care 2022; 26:106. [PMID: 35418103 PMCID: PMC9009016 DOI: 10.1186/s13054-022-03971-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Limitations of life-sustaining interventions in intensive care units (ICUs) exhibit substantial changes over time, and large, contemporary variation across world regions. We sought to determine whether a weighted end-of-life practice score can explain a large, contemporary, worldwide variation in limitation decisions.
Methods The 2015–2016 (Ethicus-2) vs. 1999–2000 (Ethicus-1) comparison study was a two-period, prospective observational study assessing the frequency of limitation decisions in 4952 patients from 22 European ICUs. The worldwide Ethicus-2 study was a single-period prospective observational study assessing the frequency of limitation decisions in 12,200 patients from 199 ICUs situated in 8 world regions. Binary end-of-life practice variable data (1 = presence; 0 = absence) were collected post hoc (comparison study, 22/22 ICUs, n = 4592; worldwide study, 186/199 ICUs, n = 11,574) for family meetings, daily deliberation for appropriate level of care, end-of-life discussions during weekly meetings, written triggers for limitations, written ICU end-of-life guidelines and protocols, palliative care and ethics consultations, ICU-staff taking communication or bioethics courses, and national end-of-life guidelines and legislation. Regarding the comparison study, generalized estimating equations (GEE) analysis was used to determine associations between the 12 end-of-life practice variables and treatment limitations. The weighted end-of-life practice score was then calculated using GEE-derived coefficients of the end-of-life practice variables. Subsequently, the weighted end-of-life practice score was validated in GEE analysis using the worldwide study dataset. Results In comparison study GEE analyses, end-of-life discussions during weekly meetings [odds ratio (OR) 0.55, 95% confidence interval (CI) 0.30–0.99], end-of-life guidelines [OR 0.52, (0.31–0.87)] and protocols [OR 15.08, (3.88–58.59)], palliative care consultations [OR 2.63, (1.23–5.60)] and end-of-life legislation [OR 3.24, 1.60–6.55)] were significantly associated with limitation decisions (all P < 0.05). In worldwide GEE analyses, the weighted end-of-life practice score was significantly associated with limitation decisions [OR 1.12 (1.03–1.22); P = 0.008]. Conclusions Comparison study-derived, weighted end-of-life practice score partly explained the worldwide study’s variation in treatment limitations. The most important components of the weighted end-of-life practice score were ICU end-of-life protocols, palliative care consultations, and country end-of-life legislation.
Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03971-9.
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Affiliation(s)
- Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, 45-47 Ipsilandou Street, 10675, Athens, Greece.
| | - Su Chen
- D2, K Lab, Department of Electrical and Computer Engineering, Rice University, Houston, TX, USA
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jacqueline M Kruser
- Division of Allergy, Pulmonary, and Critical Care Medicine, The University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Christiane Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité University Medicine Berlin, Berlin, Germany.,Klinik Bavaria, Kreischa, Germany
| | - Andrej Michalsen
- Department of Anesthesiology, Critical Care, Emergency Medicine, and Pain Therapy, Konstanz Hospital, Konstanz, Germany
| | - Nikolaos Efstathiou
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | - Suzana Lobo
- Critical Care Division - Faculty of Medicine São José do Rio Preto, São Paulo, Brazil
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Kink E. Therapiebegrenzung in der Intensivmedizin. WIENER KLINISCHES MAGAZIN 2022; 25:48-53. [PMID: 35308833 PMCID: PMC8916694 DOI: 10.1007/s00740-022-00437-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/24/2022]
Abstract
Eine der wesentlichen Aufgaben der Intensivmedizin ist die tägliche Überprüfung der getroffenen diagnostischen oder therapeutischen Maßnahmen nach Sinnhaftigkeit. Ist der Sinn nicht gegeben, so müssen nach unseren ethischen Grundsätzen diese unterlassen bzw. beendet und dem Menschen ein Sterben in Würde ermöglicht werden. Die Entscheidungen am Lebensende unterliegen diversen Einflussfaktoren, sodass die Therapiebegrenzung nationalen Richtlinien folgt. Das ethische Klima hat nicht nur Auswirkungen auf den Patienten und seine Familie, sondern auch Burnout-Rate, Personalzufriedenheit und Personalfluktuation stehen in einem direkten Zusammenhang mit den getroffenen Entscheidungen am Lebensende.
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Affiliation(s)
- Eveline Kink
- Abteilung für Innere Medizin und Pneumologie, LKH Graz II, Standort Enzenbach, Hörgas 30, 8112 Gratwein-Straßengel, Österreich
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Appelros P, Svensson E, Heidenreich K, Svantesson M. Ethical issues in stroke thrombolysis revisited. Acta Neurol Scand 2021; 144:611-615. [PMID: 34725820 DOI: 10.1111/ane.13530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Peter Appelros
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Elisabeth Svensson
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Kaja Heidenreich
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
| | - Mia Svantesson
- Faculty of Medicine and Health University Health Care Research CenterÖrebro University Örebro Sweden
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Bužgová R, Kozáková R, Bar M, Škutová M, Ressner P, Bártová P. The Attitudes of Progressive Neurological Disease Patients and Their Family Members to End of Life Care: A Cross-Sectional Study. OMEGA-JOURNAL OF DEATH AND DYING 2020; 85:4-22. [PMID: 32571138 DOI: 10.1177/0030222820936922] [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] [Indexed: 12/14/2022]
Abstract
The objective was to identify the attitudes of progressive neurological disease (PND) patients and their family members regarding end-of-life care, and their worries about dying. The sample included 327 participants. The Attitudes of Patients with PND to End-of-Life Care questionnaire was used to collect the data. Statistically significant differences in the assessment of attitudes towards end-of-life care between patients and family members were identified (p < 0.001). Family members more frequently favored patients being kept alive at any cost; patients more commonly wished to have their end of life under control. Respondents most frequently deferred to doctors when it came to decisions on treatment to keep patients alive. However, both patients and family members wanted patients to be able to decide on their treatment by leaving a written record of their previously stated wishes. The demands of patients and their families regarding end-of-life care should be documented in individual care plans.
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Affiliation(s)
- Radka Bužgová
- Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Radka Kozáková
- Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Michal Bar
- Neurology Clinic, University Hospital Ostrava, Ostrava, Czech Republic
| | - Monika Škutová
- Department of Nursing and Midwifery, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Neurology Clinic, University Hospital Ostrava, Ostrava, Czech Republic
| | - Pavel Ressner
- Neurology Clinic, University Hospital Ostrava, Ostrava, Czech Republic
| | - Petra Bártová
- Neurology Clinic, University Hospital Ostrava, Ostrava, Czech Republic
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Ay E, Weigand MA, Röhrig R, Gruss M. Dying in the Intensive Care Unit (ICU): A Retrospective Descriptive Analysis of Deaths in the ICU in a Communal Tertiary Hospital in Germany. Anesthesiol Res Pract 2020; 2020:2356019. [PMID: 32190047 PMCID: PMC7068140 DOI: 10.1155/2020/2356019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Modern intensive care methods led to an increased survival of critically ill patients over the last decades. But an unreflected application of modern intensive care measures might lead to prolonged treatment for incurable diseases, and an inadaequate or too aggressive therapy can prolong the dying process of patients. In this study, we analysed end-of-life decisions regarding withholding and withdrawal of intensive care measures in a German intensive care unit (ICU) of a communal tertiary hospital. METHODS Patient datasets of all adult patients dying in an ICU or an intermediate care unit (IMC) in a tertiary communal hospital (Klinikum Hanau, Germany) between 01.01.2011 and 31.12.2012 were analysed for withholding and withdrawal of intensive care measures. RESULTS During the two-year period, 1317 adult patients died in Klinikum Hanau. Of these, 489 (37%) died either in an ICU/IMC unit. The majority of those deceased patients (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (. CONCLUSIONS About one-third of patients dying in the hospital died in ICU/IMC. At least one life-sustaining therapy was limited/withdrawn in more than 60% of those patients. Withholding of a therapy was more common than active therapy withdrawal. Ventilation and renal replacement therapy were withdrawn in less than 5% of patients, respectively.
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Affiliation(s)
- Esma Ay
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
| | - Markus. A. Weigand
- Department of Anaesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 110, Heidelberg D-69120, Germany
| | - Rainer Röhrig
- Department of Medical Informatics, University Hospital RWTH Aachen, Aachen, Germany
| | - Marco Gruss
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Klinikum Hanau GmbH, Leimenstrasse 20, Hanau D-63450, Germany
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Demir Kureci H, Tanriverdi O, Ozcan M. Attitudes towards and experiences of ethical dilemmas in treatment decision-making process among medical oncologists. J Eval Clin Pract 2020; 26:209-215. [PMID: 30912249 DOI: 10.1111/jep.13127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to evaluate the attitudes towards and experiences of ethical dilemmas in the treatment decision-making process among medical oncologists who are the members of the Turkish Society of Medical Oncology. MATERIALS AND METHODS A questionnaire was developed based on related literature. Between April 1 and May 1, 2016, questionnaires were electronically sent to 412 medical oncologists who were the members of the Turkish Society of Medical Oncology. Overall, 125 of 412 medical oncologists (30.33%) filled the questionnaire. RESULTS Most medical oncologists encountered dilemmas, such as a lack of comprehension among the patients and family members regarding the information provided, a lack of clarity regarding the identity and role of individuals in the decision-making process, and demands for futile treatment. The most common problem (70.4%) was the lack of available clinical ethics consultancy services to guide medical oncologists when facing an ethical dilemma. Legal concerns regarding withholding or withdrawing futile treatments were high. More than half of the medical oncologists (56.8%) reported the preservation of the quality of life as their primary professional duty. CONCLUSION Our results demonstrate that medical oncologists tend to adopt an approach that respects patient autonomy and that adheres to the principle of proportionality rather than a paternalistic approach when facing ethical dilemmas. Within this context, we suggest an increased use of a multidisciplinary team approach, ethics consultancy services, and training programmes as well as the publication of ethical guidelines tailored to the oncology field.
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Affiliation(s)
- Hatice Demir Kureci
- Department of Medical History and Ethics, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Ozgur Tanriverdi
- Department of Internal Medicine and Medical Oncology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Muesser Ozcan
- Department of Medical History and Ethics, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
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Culture and personal influences on cardiopulmonary resuscitation- results of international survey. BMC Med Ethics 2019; 20:102. [PMID: 31878920 PMCID: PMC6933623 DOI: 10.1186/s12910-019-0439-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/13/2019] [Indexed: 11/16/2022] Open
Abstract
Background The ethical principle of justice demands that resources be distributed equally and based on evidence. Guidelines regarding forgoing of CPR are unavailable and there is large variance in the reported rates of attempted CPR in in-hospital cardiac arrest. The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest. Methods Cross sectional questionnaire survey conducted among a convenience sample of physicians that likely comprise code team members in their country (Indonesia, Israel and Mexico). The questionnaire included details regarding respondent demographics and training, personal value judgments and preferences as well as professional experience regarding CPR and forgoing of resuscitation. Results Of the 675 questionnaires distributed, 617 (91.4%) were completed and returned. Country of practice and level of knowledge about resuscitation were strongly associated with avoiding CPR performance. Mexican physicians were almost twicemore likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84 (95% CI 1.03, 3.26), p = 0.038]. Mexican responders also placed greater emphasison personal and patient quality of life (p < 0.001). In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for apatient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12 (95%CI 1.30, 3.46), p = 0.003]. Conclusions In unexpected in-hospital cardiac arrest the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences. Physician CPR training should include information regarding predictors of patient outcome at as well as emphasis on differentiating between patient and personal preferences in an emergency.
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Ethical challenges faced by healthcare professionals who care for suicidal patients: a scoping review. Monash Bioeth Rev 2019; 35:50-79. [PMID: 29667145 DOI: 10.1007/s40592-018-0076-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
For each one of the approximately 800,000 people who die from suicide every year, an additional twenty people attempt suicide. Many of these attempts result in hospitalization or in contact with other healthcare services. However, many personal, educational, and institutional barriers make it difficult for healthcare professionals to care for suicidal individuals. We reviewed literature that discusses suicidal patients in healthcare settings in order to highlight common ethical issues and to identify knowledge gaps. A sample was generated via PubMed using keywords "[(ethics OR *ethic*) AND suicid*] AND [English (Language) OR French (Language)]" (final N = 52), ethics content was extracted according to scoping review methodology, and categorized thematically. We identified three main areas posing ethical challenges for health professionals caring for suicidal individuals and their families. These were: (1) making clinical decisions for patients in acute care or when presented with specific circumstances; (2) issues arising from therapeutic relationships in chronic care, and (3) organizational factors. There is considerable uncertainty about how to resolve ethical issues when caring for someone who is suicidal. The stigma associated with suicide and mental illness, problems associated with risk-benefit assessments, and the fear of being held liable for malpractice should a patient die by suicide were overarching themes present across these three categories. Caring for suicidal patients is clinically and ethically challenging. The current literature highlights the complexity and range of decisions that need to be made. More attention should be paid to the difficulties faced by healthcare professionals and the development of solutions.
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Gäbler M, Ohrenberger G, Funk GC. Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties. ERJ Open Res 2019; 5:00163-2018. [PMID: 31544110 PMCID: PMC6745412 DOI: 10.1183/23120541.00163-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 06/20/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction End-stage chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure are often treated by representatives from different medical specialties. This study investigates if the choice of treatment is influenced by the medical specialty. Methods An online cross-sectional survey among four Austrian medical societies was performed, accompanied by a case vignette of a geriatric end-stage COPD patient with acute respiratory failure. Respondents had to choose between noninvasive ventilation (NIV), a conservative treatment attempt (without NIV) and a palliative approach. Ethical considerations and their impact on decision making were also assessed. Results Responses of 162 physicians (67 from intensive care units (ICUs), 51 from pulmonology or internal departments and 44 from geriatric or palliative care) were included. The decision for NIV (instead of a conservative or palliative approach) was associated with working in an ICU (OR 14.9, 95% CI 1.87-118.8) and in a pulmonology or internal department (OR 9.4, 95% CI 1.14-78.42) compared with working in geriatric or palliative care (Model 1). The decision for palliative care was negatively associated with working in a pulmonology or internal department (OR 0.16, 95% CI 0.05-0.47) and (nonsignificantly) in an ICU (OR 0.41, 95% CI 0.15-1.12) (Model 2). Conclusions Department association was shown to be an independent predictor for treatment decisions in end-stage COPD with acute respiratory failure. Further research on these differences and influential factors is necessary.
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Affiliation(s)
- Martin Gäbler
- Institute of Preventive and Applied Sports Medicine, Krems University Hospital, Karl Landsteiner University of Health Sciences, Krems, Austria.,Dept of Respiratory and Critical Care Medicine, Otto-Wagner-Hospital, Vienna, Austria
| | | | - Georg-Christian Funk
- Medical Dept II and Karl-Landsteiner Institute für Lungenforschung und Pneumologische Onkologie Wilheminenspital, Vienna, Austria
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Kink E, Erler L, Fritz W, Funk GC, Gäbler M, Krenn F, Kühteubl G, Schindler O, Wanke T. Beatmung bei COPD: von der Präklinik bis zur außerklinischen Beatmung. Eine Übersicht des Arbeitskreises für Beatmung und Intensivmedizin der österreichischen Gesellschaft für Pneumologie. Wien Klin Wochenschr 2019; 131:417-427. [PMID: 31111203 DOI: 10.1007/s00508-019-1515-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This paper was created by the Austrian Society of Pneumology (Working group Ventilation and Intensive Care) to summarize the specific characteristics of mechanical ventilation in patients presenting with chronic obstructive pulmonary disease (COPD). The main differences in pathophysiology and mechanical ventilation are shown, including acute respiratory failure and out-of-hospital mechanical ventilation.
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Affiliation(s)
- Eveline Kink
- Abteilung für Innere Medizin und Pneumologie, LKH Graz II, Standort Enzenbach, Hörgas 30, 8112, Gratwein-Straßengel, Österreich
| | - Lorenz Erler
- Abteilung für Lungenkrankheiten, Leoben, Österreich
| | - Wilfried Fritz
- Klinische Abteilung für Lungenkrankheiten, Universitätsklinikum für Innere Medizin, LKH.-Univ. Klinikum Graz, Graz, Österreich
| | | | - Martin Gäbler
- Institut für Präventiv- und Angewandte Sportmedizin, Universitätsklinikum Krems, Karl Landsteiner Privatuniversität für Gesundheitswissenschaften, Mitterweg 10, 3500, Krems an der Donau, Österreich
| | | | | | - Otmar Schindler
- Abteilung für Innere Medizin und Pneumologie, LKH Graz II, Standort Enzenbach, Hörgas 30, 8112, Gratwein-Straßengel, Österreich
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Abstract
PURPOSE OF REVIEW End-of-life (EOL) care can be stressful for clinicians as well as patients and their relatives. Decisions to withhold or withdraw life-sustaining therapy vary widely depending on culture, beliefs and organizational norms. The following review will describe the current understanding of the problem and give an overview over interventional studies. RECENT FINDINGS EOL care is a risk factor for clinician burnout; poor work conditions contribute to emotional exhaustion and intent to leave. The impact of EOL care on families is part of the acute Family Intensive Care Unit Syndrome (FICUS) and the Post Intensive Care Syndrome-Family (PICS-F). Family-centered care (FCC) acknowledges the importance of relatives in the ICU. Several interventions have been evaluated, but evidence for their effectiveness is at best moderate. Some interventions even increased family stress. Interventional studies, which address clinician burnout are rare. SUMMARY EOL care is associated with negative outcomes for ICU clinicians and relatives, but strength of evidence for interventions is weak because we lack understanding of associated factors like work conditions, organizational issues or individual attitudes. In order to develop complex interventions that can successfully mitigate stress related to EOL care, more research is necessary, which takes into account all potential determinants.
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Hernández-Marrero P, Fradique E, Pereira SM. Palliative care nursing involvement in end-of-life decision-making: Qualitative secondary analysis. Nurs Ethics 2018; 26:1680-1695. [PMID: 29807491 DOI: 10.1177/0969733018774610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nurses are the largest professional group in healthcare and those who make more decisions. In 2014, the Committee on Bioethics of the Council of Europe launched the "Guide on the decision-making process regarding medical treatment in end-of-life situations" (hereinafter, Guide), aiming at improving decision-making processes and empowering professionals in making end-of-life decisions. The Guide does not mention nurses explicitly. OBJECTIVES To analyze the ethical principles most valued by nurses working in palliative care when making end-of-life decisions and investigate if they are consistent with the framework and recommendations of the Guide; to identify what disputed/controversial issues are more frequent in these nurses' current end-of-life care practices. DESIGN Qualitative secondary analysis. PARTICIPANTS/CONTEXT Three qualitative datasets including 32 interviews from previous studies with nurses working in palliative care in Portugal. ETHICAL CONSIDERATION Ethical approval was obtained from the Ethics Research Lab of the Instituto de Bioética (Ethics Research Lab of the Institute of Bioethics) (Ref.04.2015). Ethical procedures are thoroughly described. FINDINGS All participant nurses referred to autonomy as an ethical principle paramount in end-of-life decision-making. They were commonly involved in end-of-life decision-making. Palliative sedation and communication were the most mentioned disputed/controversial issues. DISCUSSION Autonomy was highly valued in end-of-life care and decision-making. Nurses expressed major concerns in assessing patients' preferences, wishes, and promoting advance care planning. Nurses working in palliative care in Portugal were highly involved in end-of-life decision-making. These processes embraced a collective, inclusive approach. Palliative sedation was the most mentioned disputed issue, which is aligned with previous findings. Communication also emerged as a sensitive ethical issue; it is surprising, however, that only three nurses referred to it. CONCLUSION While the Guide does not explicitly mention nurses in its content, this study shows that nurses working in palliative care in Portugal are involved in these processes. Further research is needed on nurses' involvement and practices in end-of-life decision-making.
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Affiliation(s)
| | - Emília Fradique
- Hospital de Santa Maria, Portugal; Instituto S. João de Deus, Portugal
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Blazquez V, Rodríguez A, Sandiumenge A, Oliver E, Cancio B, Ibañez M, Miró G, Navas E, Badía M, Bosque MD, Jurado MT, López M, Llauradó M, Masnou N, Pont T, Bodí M. Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study. Med Intensiva 2018; 43:352-361. [PMID: 29747939 DOI: 10.1016/j.medin.2018.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/09/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN Prospective multicenter study. SETTING Eleven ICUs. PATIENTS All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.
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Affiliation(s)
- V Blazquez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain
| | - A Sandiumenge
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - E Oliver
- Transplant Coordination, University Hospital Bellvitge, Barcelona, Spain
| | - B Cancio
- Intensive Care Unit, University Hospital Moises Broggi, Barcelona, Spain
| | - M Ibañez
- Intensive Care Unit, University Hospital Verge de la Cinta de Tortosa, Tortosa, Spain
| | - G Miró
- Intensive Care Unit, Consorci Sanitari del Maresme, Mataró, Spain
| | - E Navas
- Intensive Care Unit, University Hospital Mutua de Terrassa, Terrassa, Spain
| | - M Badía
- Intensive Care Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - M D Bosque
- Intensive Care Unit, University Hospital General de Catalunya, Barcelona, Spain
| | - M T Jurado
- Intensive Care Unit, Hospital de Terrassa, Terrassa, Spain
| | - M López
- Intensive Care Unit, University Hospital de Vic, Vic, Spain
| | - M Llauradó
- International University of Catalunya, Barcelona, Spain
| | - N Masnou
- Transplant Coordination, University Hospital Dr. Trueta, Girona, Spain
| | - T Pont
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - M Bodí
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain.
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Gouda A, Alrasheed N, Ali A, Allaf A, Almudaiheem N, Ali Y, Alghabban A, Alsalolami S. Knowledge and Attitude of ER and Intensive Care Unit Physicians toward Do-Not-Resuscitate in a Tertiary Care Center in Saudi Arabia: A Survey Study. Indian J Crit Care Med 2018; 22:214-222. [PMID: 29743759 PMCID: PMC5930524 DOI: 10.4103/ijccm.ijccm_523_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Only a few studies from Arab Muslim countries address do-not-resuscitate (DNR) practice. The knowledge of physicians about the existing policy and the attitude towards DNR were surveyed. Objective The objective of this study is to identify the knowledge of the participants of the local DNR policy and barriers of addressing DNR including religious background. Methods A questionnaire has been distributed to Emergency Room (ER) and Intensive Care Unit (ICU) physicians. Results A total of 112 physicians mostly Muslims (97.3%). About 108 (96.4%) were aware about the existence of DNR policy in our institute. 107 (95.5%) stated that DNR is not against Islamic. Only (13.4%) of the physicians have advance directives and (90.2%) answered they will request to be DNR if they have terminal illness. Lack of patients and families understanding (51.8%) and inadequate training (35.7%) were the two most important barriers for effective DNR discussion. Patients and families level of education (58.0%) and cultural factors (52.7%) were the main obstacles in initiating a DNR order. Conclusions There is a lack of knowledge about DNR policy which makes the optimization of DNR process difficult. Most physicians wish DNR for themselves and their patients at the end of life, but only a few of them have advance directives. The most important barriers for initializing and discussing DNR were lack of patient understanding, level of education, and the culture of patients. Most of the Muslim physicians believe that DNR is not against Islamic rules. We suggest that the DNR concept should be a part of any training program.
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Affiliation(s)
- Alaa Gouda
- Department of Intensive Care, King Abdulaziz Medical City, Riyadh, KSA
| | - Norah Alrasheed
- Department of Emergency Care, King Abdulaziz Medical City, Riyadh, KSA
| | - Alaa Ali
- Alfaisal University, College of Medicine, Riyadh, KSA
| | - Ahmad Allaf
- Alfaisal University, College of Medicine, Riyadh, KSA
| | - Najd Almudaiheem
- Princess Nourah Bint Abdulrahman University, College of Medicine, Riyadh, KSA
| | - Youssuf Ali
- Alfaisal University, College of Medicine, Riyadh, KSA
| | - Ahmad Alghabban
- Department of Emergency Care, King Abdulaziz Medical City, Riyadh, KSA
| | - Sami Alsalolami
- Department of Emergency Care, King Abdulaziz Medical City, Riyadh, KSA
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Tang ST, Wen FH, Chang WC, Hsieh CH, Chou WC, Chen JS, Hou MM. Preferences for Life-Sustaining Treatments Examined by Hidden Markov Modeling Are Mostly Stable in Terminally Ill Cancer Patients' Last Six Months of Life. J Pain Symptom Manage 2017; 54:628-636.e2. [PMID: 28782702 DOI: 10.1016/j.jpainsymman.2017.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Stability of life-sustaining treatment (LST) preferences at end of life (EOL) has not been well established for terminally ill cancer patients nor have transition probabilities been explored between different types of preferences. OBJECTIVE We assessed the stability of cancer patients' LST preferences at EOL by identifying distinct LST preference states and examining the probability of each state transitioning to other states between consecutive time points. METHODS Stability of LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, cardiac massage, intubation with mechanical ventilation, intravenous nutrition support, and nasogastric tube feeding) was examined among 303 cancer patients in their last six months by hidden Markov modeling. RESULTS Six distinct LST preference states (initial size) were identified: uniformly preferring (8.3%), uniformly rejecting (33.8%), and uniformly uncertain about (20.5%) LST, favoring intravenous nutrition support but rejecting other treatments (19.9%), and favoring (3.6%) or uncertain about (14.0%) nutrition support and ICU care while rejecting other treatments. Shifts between LST preference states were relatively small between any two time points (transition probability of staying at the same state was 92.1% to 97.5%), except for the state characterized by uncertainty about nutrition support and ICU care while rejecting other treatments, in which 8.3% of patients shifted LST preferences toward uniform uncertainty at a subsequent assessment. CONCLUSIONS Our patients' LST preferences remained stable without prominent shifts toward preferring less aggressive LSTs even when death approached. Clarifying patients' understanding and expectations about LST efficacy and tailoring interventions to the unique needs of patients in each state may provide personalized EOL care.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, ROC
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
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Tsai HB, Chao CT, Huang JW, Chang RE, Hung KY. A nationwide survey of healthcare personnel's attitude, knowledge, and interest toward renal supportive care in Taiwan. PeerJ 2017; 5:e3540. [PMID: 28698823 PMCID: PMC5502085 DOI: 10.7717/peerj.3540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 06/14/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Renal supportive care (RSC) is an important option for elderly individuals reaching end-stage renal disease; however, the frequency of RSC practice is very low among Asian countries. We evaluated the attitude, the knowledge, and the preference for specific topics concerning RSC among participants who worked in different medical professions in Taiwan. METHODS A cross-sectional questionnaire-based survey was employed. Healthcare personnel (N = 598) who were involved in caring for end-stage renal disease patients at more than 40 facilities in Taiwan participated in this study. Participants were asked about their motivation for learning about RSC, the topics of RSC they were most and least interested in, their willingness to provide RSC, and to rate their knowledge and perceived importance of different topics. RESULTS The vast majority of respondents (81.9%) were self-motivated about RSC, among whom nephrologists (96.8%) and care facilitators (administrators/volunteers) (45%) exhibited the highest and the least motivation, respectively (p < 0.01). Overall, respondents indicated that they had adequate knowledge about the five pre-specified RSC topics between medical professions (p = 0.04). Medical professions and institutional size exerted significant influence on the willingness to provide RSC. CONCLUSIONS Our results facilitate the understanding of the knowledge and attitude toward different RSC topics among varied medical professions, and can guide the design of RSC education content for healthcare personnel.
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Affiliation(s)
- Hung-Bin Tsai
- Division of Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chia-Ter Chao
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medicine, National Taiwan University Hospital Jinshan Branch, New Taipei City, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jenq-Wen Huang
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ray-E Chang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kuan-Yu Hung
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu County, Taiwan
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Gerritsen RT, Koopmans M, Hofhuis JG, Curtis JR, Jensen HI, Zijlstra JG, Engelberg RA, Spronk PE. Comparing Quality of Dying and Death Perceived by Family Members and Nurses for Patients Dying in US and Dutch ICUs. Chest 2017; 151:298-307. [DOI: 10.1016/j.chest.2016.09.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/05/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022] Open
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Bein T. Understanding intercultural competence in intensive care medicine. Intensive Care Med 2016; 43:229-231. [PMID: 27379795 DOI: 10.1007/s00134-016-4432-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Thomas Bein
- Department of Anesthesia and Operative Intensive Care, University Hospital Regensburg, 93042, Regensburg, Germany.
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22
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Perceptions of a good death: A qualitative study in intensive care units in England and Israel. Intensive Crit Care Nurs 2016; 36:8-16. [PMID: 27283117 DOI: 10.1016/j.iccn.2016.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 04/19/2016] [Accepted: 04/24/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To explore factors perceived to contribute to 'a good death' and the quality of end of life care in two countries with differing legal and cultural contexts. DESIGN AND METHODS Multi-centre study consisting of focus group and individual interviews with intensive care nurses. Data were analysed using qualitative thematic analysis; emotional content was analysed using specialist linguistic software. SETTINGS/PARTICIPANTS Fifty five Registered Nurses in intensive care units in Israel (n=4) and England (n=3), purposively sampled across age, ICU experience and seniority. FINDINGS Four themes and eleven sub-themes were identified that were similar in both countries. Participants identified themes of: (i) timing of communication, (ii) accommodating individual behaviours, (iii) appropriate care environment and (iv) achieving closure, which they perceive prevent, and contribute to, a good death and good quality of end of life care. Emotional content showed significant amount of 'sadness talk' and 'discrepancy talk', using words such as 'could and 'should' when participants were talking about the actions of clinicians. CONCLUSIONS The qualities of a good death were more similar than different across cultures and legal systems. Themes identified by participants may provide a framework for guiding end of life discussions in the intensive care unit.
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Graw JA, Spies CD, Wernecke KD, Braun JP. End-of-life decisions in surgical intensive care medicine - the relevance of blood transfusions. Transfus Apher Sci 2016; 54:416-20. [PMID: 27068352 DOI: 10.1016/j.transci.2016.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/21/2016] [Accepted: 03/22/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND End-of-life decisions (EOLDs) are common in the intensive care unit (ICU). EOLDs underlie a dynamic process and limitation of ICU-therapies is often done sequentially. Questionnaire-based and observational studies on medical ICUs and in palliative care reveal blood transfusions as the first therapy physicians withhold as an EOLD. METHODS To test whether this practice also applies to surgical ICU-patients, in an observational study, all deceased patients (n = 303) admitted to an academic surgical ICU in a three-year period were analyzed for the process of limiting ICU-therapies. RESULTS Restriction of further surgery (85.4%) and limiting doses of vasopressors (75.8%) were the most frequent forms of limitations in surgical ICU therapies. Surgical patients, who had blood transfusions withheld (44.6%), had more ICU-therapies withheld or withdrawn simultaneously than patients who had transfusions maintained (5 ± 2 vs. 2 ± 1, p < 0.001). Secondary EOLDs and subsequent limitations occurred less frequently in patients who had transfusions withheld with their first EOLD (17.1% vs. 35.6%, p < 0.05). CONCLUSION Limitation orders for blood transfusions are not a prioritized decision in EOLDs of surgical ICU patients. Withholding blood transfusions correlates with discontinuation of further significant life-support therapies. This suggests that EOLDs to withhold blood transfusions are part of the most advanced limitations of therapy on the surgical ICU.
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Affiliation(s)
- Jan A Graw
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany.
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany
| | - Klaus-D Wernecke
- Charité - Universitätsmedizin Berlin and SOSTANA GmbH, Berlin, Germany
| | - Jan-P Braun
- Department of Anesthesiology and Intensive Care Medicine, HELIOS Klinikum Hildesheim, Germany
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Szawarski P. Classic cases revisited: Mr David James, futile interventions and conflict in the ICU. J Intensive Care Soc 2016; 17:244-251. [PMID: 28979498 DOI: 10.1177/1751143716628885] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The technology so prevalent in the modern healthcare setting often creates an illusion that the biological certainty of death can somehow be evaded. Increasing number of deaths worldwide occurs in hospitals, and doctors by necessity inherit the role traditionally owned by priests, in overseeing the dying process. Unrealistic expectations concerning cure or indeed different perceptions of patient's interests on a background of deficient communication can lead to conflict. The case of David James illustrates conflict arising in the context of critical illness where further life-sustaining interventions were deemed to be futile. Futility and conflict in context of critical illness are discussed along with the legal judgements pertaining to the case of David James.
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Affiliation(s)
- Piotr Szawarski
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
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25
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Approaches to patients and families with strong religious beliefs regarding end-of-life care. Curr Opin Crit Care 2015; 20:668-72. [PMID: 25215868 DOI: 10.1097/mcc.0000000000000148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW End-of-life (EOL) decisions with limitations are made daily in ICUs around the world and may involve between 2 and 22% of patients admitted to an ICU. EOL decisions may be affected by numerous factors, including location and religion. This review aims to determine an approach to patients and families with strong religious views. RECENT FINDINGS Different religions have different approaches and beliefs regarding EOL care. Religious people choose more active life-sustaining measures than would nonreligious people. The patient's views on EOL care should be understood, although this is often not possible and the family members' or surrogates' understanding of the patient's wishes is relied upon. This is problematic as the family's wishes may differ from those of the patient. Family members may also have different religious beliefs or have different expressions of their beliefs. Through an open communication with the patient and/or family members, an understanding of the patient's views can be obtained and decisions regarding their involvement in decision making can be taken. Conflicts can be resolved by an interdisciplinary team approach including religious leaders. SUMMARY Through proper open communication and understanding of the patient's and/or family's views on EOL care and involvement of religious leaders, decisions can be made regarding how to further care for the patient.
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Lesieur O, Leloup M, Gonzalez F, Mamzer MF. Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units. Ann Intensive Care 2015; 5:56. [PMID: 26092498 PMCID: PMC4486647 DOI: 10.1186/s13613-015-0056-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/28/2015] [Indexed: 01/24/2023] Open
Abstract
Background In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law. Methods The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013. Results During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal). Conclusions More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.
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Park JH, Koh SO, Cho JS, Na S. Evaluation of Informed Consent for Withholding and Withdrawal of Life Support in Korean Intensive Care Units. Korean J Crit Care Med 2015. [DOI: 10.4266/kjccm.2015.30.2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Sprung CL, Rusinova K, Ranzani OT. Variability in forgoing life-sustaining treatments: reasons and recommendations. Intensive Care Med 2015; 41:1679-81. [PMID: 26077065 DOI: 10.1007/s00134-015-3868-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 05/05/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Charles L Sprung
- General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel,
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Szawarski P. Classic cases revisited: Mrs Janet Tracey, resuscitation and the importance of good communication. J Intensive Care Soc 2015; 16:142-146. [PMID: 28979396 PMCID: PMC5606485 DOI: 10.1177/1751143715569020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The prevalence of inappropriate care, defined as actions contrary to personal and professional beliefs, is high. This is a reflection of the reluctance of the society at large to acknowledge the biological certainty that is death. The case of Mrs Janet Tracey illustrates importance of good communication at the end of life, and the difficulties associated with making of DNACPR decisions. The case brings together two bioethical perspectives on the relationship between the patient and the physician namely the rights based approach, as emphasised by the Article 8 of the European Convention on Human Rights and the bioethical principles approach ephasising autonomy. In doing so it creates a medico-legal landmark for all those involved in management of the end of life.
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Affiliation(s)
- Piotr Szawarski
- Consultant in Intensive Care Medicine and Anaesthesia, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Wexham, UK
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Determinants of care outcomes for patients who die in hospital in Ireland: a retrospective study. BMC Palliat Care 2015; 14:11. [PMID: 25927310 PMCID: PMC4422526 DOI: 10.1186/s12904-015-0014-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/24/2015] [Indexed: 12/02/2022] Open
Abstract
Background More people die in hospital than in any other setting which is why it is important to study the outcomes of hospital care at end of life. This study analyses what influenced outcomes in a sample of patients who died in hospital in Ireland in 2008/9. The study was undertaken as part of the Irish Hospice Foundation’s Hospice Friendly Hospitals Programme (2007–2012). Methods Outcomes of care were assessed by nurses, doctors and relatives who cared for the patient during the last week of life. Multi-level modelling was used to analyse how care outcomes were influenced by care inputs. Results The sample of 999 patients represents 10% of acute hospital deaths and 29% of community hospital deaths in Ireland in 2008/9. Five care outcomes were assessed for each patient: symptom experience, symptom management, patient care, acceptability of the way patient died, family support. Care outcomes during the last week of life tended to be better when: the patient had cancer; admission to hospital was planned rather than emergency; death occurred in a single room or where privacy, dignity and environment of the ward was better; team meetings were held; there was good communication with patients and relatives; relatives were facilitated to stay overnight and were present at the time of death; nursing staff were experienced and had training in end-of-life care; the hospital had specific objectives for developing end-of-life care in its service plan. Conclusions The study shows significant differences in how care outcomes, including pain, were assessed by nurses, doctors and relatives. Care inputs operate in a mutually reinforcing manner to generate care outcomes which implies that improvements in one area are likely to have spill-over effects in others. Building on these findings, the Irish Hospice Foundation has developed an audit and review system to support quality improvement in all care settings where people die. Electronic supplementary material The online version of this article (doi:10.1186/s12904-015-0014-2) contains supplementary material, which is available to authorized users.
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Nelson JE, Mathews KS, Weissman DE, Brasel KJ, Campbell M, Curtis JR, Frontera JA, Gabriel M, Hays RM, Mosenthal AC, Mulkerin C, Puntillo KA, Ray DE, Weiss SP, Bassett R, Boss RD, Lustbader DR. Integration of palliative care in the context of rapid response: a report from the Improving Palliative Care in the ICU advisory board. Chest 2015; 147:560-569. [PMID: 25644909 PMCID: PMC4314822 DOI: 10.1378/chest.14-0993] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/01/2014] [Indexed: 01/24/2023] Open
Abstract
Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ross M Hays
- University of Washington School of Medicine, Seattle, WA
| | | | | | | | - Daniel E Ray
- University of California, San Francisco, San Francisco, CA
| | | | - Rick Bassett
- Lehigh Valley Health Network, Allentown, PA; Johns Hopkins University School of Medicine, Baltimore, MD
| | - Renee D Boss
- Icahn School of Medicine at Mount Sinai, New York, NY; St. Luke's Hospital, Boise, ID
| | - Dana R Lustbader
- Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead, NY
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Evolution and prognosis of long intensive care unit stay patients suffering a deterioration: A multicenter study. J Crit Care 2015; 30:654.e1-7. [PMID: 25656920 DOI: 10.1016/j.jcrc.2015.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 12/31/2014] [Accepted: 01/12/2015] [Indexed: 12/28/2022]
Abstract
PURPOSE The prognosis of a patient who deteriorates during a prolonged intensive care unit (ICU) stay is difficult to predict. We analyze the prognostic value of the serialized Sequential Organ Failure Assessment (SOFA) score and other variables in the early days after a complication and to build a new predictive score. MATERIALS AND METHODS EPIPUSE (Evolución y pronóstico de los pacientes con ingreso prolongado en UCI que sufren un empeoramiento, Evolution and prognosis of long intensive care unit stay patients suffering a deterioration) study is a prospective, observational study during a 3-month recruitment period in 75 Spanish ICUs. We focused on patients admitted in the ICU for 7 days or more with complications of adverse events that involve organ dysfunction impairment. Demographics, clinical variables, and serialized SOFA after a supervening clinical deterioration were recorded. Univariate and multivariate analyses were performed, and a predictive model was created with the most discriminating variables. RESULTS We included 589 patients who experienced 777 cases of severe complication or adverse event. The entire sample was randomly divided into 2 subsamples, one for development purposes (528 cases) and the other for validation (249 cases). The predictive model maximizing specificity is calculated by minimum SOFA + 2 * cardiovascular risk factors + 2 * history of any oncologic disease or immunosuppressive treatment + 3 * dependence for basic activities of daily living. The area under the receiver operating characteristic curve is 0.82. A 14-point cutoff has a positive predictive value of 100% (92.7%-100%) and negative predictive value of 51% (46.4%-55.5%) for death. CONCLUSIONS EPIPUSE model can predict mortality with a specificity and positive predictive value of 99% in some groups of patients.
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Khandelwal N, Engelberg RA, Benkeser DC, Coe NB, Curtis JR. End-of-life expenditure in the ICU and perceived quality of dying. Chest 2014; 146:1594-1603. [PMID: 25451349 PMCID: PMC4251619 DOI: 10.1378/chest.14-0182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 06/02/2014] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Although end-of-life care in the ICU accounts for a large proportion of health-care costs, few studies have examined the association between costs and satisfaction with care. The objective of this study was to investigate the association of ICU costs with family- and nurse-assessed quality of dying and family satisfaction. METHODS This was an observational study surveying families and nurses for patients who died in the ICU or within 30 h of transfer from the ICU. A total of 607 patients from two Seattle hospitals were included in the study. Survey data were linked with administrative records to obtain ICU and hospital costs. Regression analyses assessed the association between costs and outcomes assessing satisfaction with care: nurse- and family-assessed Quality of Death and Dying (QODD-1) and Family Satisfaction in the ICU (FS-ICU). RESULTS For family-reported outcomes, patient insurance status was an important modifier of results. For underinsured patients, higher daily ICU costs were significantly associated with higher FS-ICU and QODD-1 (P < .01 and P = .01, respectively); this association was absent for privately insured or Medicare patients (P = .50 and P = .85, QODD-1 and FS-ICU, respectively). However, higher nurse-assessed QODD-1 was significantly associated with lower average daily ICU cost and total hospital cost (P < .01 and P = .05, respectively). CONCLUSIONS Family-rated satisfaction with care and quality of dying varied depending on insurance status, with underinsured families rating satisfaction with care and quality of dying higher when average daily ICU costs were higher. However, patients with higher costs were assessed by nurses as having a poorer quality of dying. These findings highlight important differences between family and clinician perspectives and the important role of insurance status.
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Affiliation(s)
- Nita Khandelwal
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
| | - Ruth A Engelberg
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; Harborview Medical Center, the Department of Medicine, University of Washington, Seattle, WA
| | - David C Benkeser
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Norma B Coe
- Department of Health Services, University of Washington, Seattle, WA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA; Harborview Medical Center, the Department of Medicine, University of Washington, Seattle, WA
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Two decades of British newspaper coverage regarding do not attempt cardiopulmonary resuscitation decisions: Lessons for clinicians. Resuscitation 2014; 86:31-7. [PMID: 25449344 DOI: 10.1016/j.resuscitation.2014.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/08/2014] [Accepted: 10/05/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review UK newspaper reports relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions in order to identify common themes and encourage dialogue. METHODS An online media database (LexisNexis(®)) was searched for UK Newspaper articles between 1993 and 2013 that referenced DNACPR decisions. Legal cases, concerning resuscitation decisions, were identified using two case law databases (Lexis Law(®) and Westlaw(®)), and referenced back to newspaper publications. All articles were fully reviewed. RESULTS Three hundred and thirty one articles were identified, resulting from 77 identifiable incidents. The periods 2000-01 and 2011-13 encompassed the majority of articles. There were 16 high-profile legal cases, nine of which resulted in newspaper articles. Approximately 35 percent of newspaper reports referred to DNACPR decisions apparently made without adequate patient and/or family consultation. "Ageism" was referred to in 9 percent of articles (mostly printed 2000-02); and "discrimination against the disabled" in 8 percent (mostly from 2010-12). Only five newspaper articles (2 percent) discussed patients receiving CPR against their wishes. Eighteen newspaper reports (5 percent) associated DNACPR decisions with active euthanasia. CONCLUSIONS Regarding DNACPR decision-making, the predominant theme was perceived lack of patient involvement, and, more recently, lack of surrogate involvement. Negative language was common, especially when decisions were presumed unilateral. Increased dialogue, and shared decision-making, is recommended.
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Tully RP, Kitchen G, Tufchi A, Saha B, Baker R. Patient Attitudes to Intensive Care and Life-Sustaining Technology. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We used a validated questionnaire to explore the views of patients regarding receiving intensive care and life-sustaining technology. Data was obtained from 38 patients. A score was obtained for ‘general attitude towards use of life-sustaining/prolonging technology’ that varied from 18.9 to 48.5 out of 52, the higher score reflecting a more positive attitude. There was no significant difference between men and women or correlation with age or ASA score. A score for ‘personal desire for life support’ was also obtained, ranging from zero to a maximum possible score of eight, which reflected the most positive view. The median score was 0.5. Women had a significantly lower median score of zero vs 1.5 for men (p=0.022). There was no significant correlation with age or ASA score. There was considerable heterogeneity of views regarding the use of life-sustaining technology. In this study, women were less likely to want intensive medical treatment than men.
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Affiliation(s)
- Redmond P Tully
- Specialty Trainee in Anaesthetics and Intensive Care Medicine, Department of Anaesthesia, Royal Oldham Hospital
| | - Gareth Kitchen
- Specialty Trainee in Anaesthetics, Department of Anaesthesia, Royal Oldham Hospital
| | - Aseem Tufchi
- Consultant Anaesthetist, Department of Anaesthesia, Hull Royal infirmary
| | - Bhaskar Saha
- Consultant in Anaesthetics and Intensive Care Medicine, Department of Anaesthesia, Royal Oldham Hospital
| | - Rose Baker
- Professor of Statistics, University of Salford
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Hurdle V, Ouellet JF, Dixon E, Howard TJ, Lillemoe KD, Vollmer CM, Sutherland FR, Ball CG. Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey. Can J Surg 2014; 57:E69-74. [PMID: 24869619 DOI: 10.1503/cjs.011213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. METHODS We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care. RESULTS A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05). CONCLUSION Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.
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Affiliation(s)
- Valerie Hurdle
- The Department of Surgery, University of Calgary, Calgary, Alta
| | | | - Elijah Dixon
- The Department of Surgery, University of Calgary, Calgary, Alta
| | - Thomas J Howard
- The Department of Surgery, Community Health Network, Indianapolis, Ind
| | - Keith D Lillemoe
- The Department of Surgery, Harvard University, Massachusetts General Hospital, Boston, Mass
| | - Charles M Vollmer
- The Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Chad G Ball
- The Department of Surgery, University of Calgary, Calgary, Alta
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Lam KW, Yeung KWA, Lai KY, Cheng F. Changes in the Attitude and Practice Toward End-of-Life Care: Perspective of Chinese Physicians in Medical Department. Am J Hosp Palliat Care 2014; 32:549-54. [PMID: 24819729 DOI: 10.1177/1049909114531645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION End-of-life care is affected by the attitude and cultural influence of doctors. METHODS To investigate the attitudes and practices of doctors on end-of-life care by questionnaire survey in 2004 and 2008. RESULTS In 2004, 31.7% of the respondents agreed that they "do not attempt resuscitation" (DNAR) form was useful and it rose to 54.4% in 2008. A higher proportion of respondents in 2008 claimed that they signed the DNAR form for documentation and accepted withholding noninvasive life-sustaining treatment compared to 2004. In 2004, 50% of the respondents regarded their training and education on handling DNAR issue as inadequate. CONCLUSION Documentation by DNAR form is gaining wider acceptance. Many doctors are expected to have more training and coaching on communication for handling such sensitive issues.
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Affiliation(s)
- K W Lam
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - K W Au Yeung
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - K Y Lai
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - F Cheng
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Endacott R, Boyer C. Preparing for the unavoidable: public and clinician expectations of death. Nurs Crit Care 2014; 18:112-3. [PMID: 23577944 DOI: 10.1111/nicc.12021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Romain M, Sprung CL. End-of-Life Practices in the Intensive Care Unit: The Importance of Geography, Religion, Religious Affiliation, and Culture. Rambam Maimonides Med J 2014; 5:e0003. [PMID: 24498510 PMCID: PMC3904478 DOI: 10.5041/rmmj.10137] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
End-of-life decisions are made daily in intensive care units worldwide. There are numerous factors affecting these decisions, including geographical location as well as religion and attitudes of caregivers, patients, and families. There is a spectrum of end-of-life care options from full continued care, withholding treatment, withdrawing treatment, and active life-ending procedures.
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Affiliation(s)
- Marc Romain
- To whom correspondence should be addressed. E-mail:
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Vinatier I, Fiancette M, Lebert C, Henry-Lagarrigue M, Martin-Lefèvre L. Collégialité dans les décisions de limitation ou d’arrêt de traitement en réanimation. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13546-013-0811-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ryu HG, Choi JE, Lee S, Koh J, Bae JM, Heo DS. Survey of controversial issues of end-of-life treatment decisions in Korea: similarities and discrepancies between healthcare professionals and the general public. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R221. [PMID: 24093519 PMCID: PMC4056664 DOI: 10.1186/cc13042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 08/07/2013] [Indexed: 11/19/2022]
Abstract
Introduction End-of-life (EOL) treatment issues have recently gained societal attention after the Korean Supreme Court’s ruling that the presumed wishes of an elderly woman in a persistent vegetative state (PVS) should be honored. We tried to evaluate what Koreans thought about controversial issues regarding EOL treatments. Methods We surveyed Koreans with the following questions: 1) are ventilator-dependent PVS patients candidates for end-of life treatment decisions? 2) Is withholding and withdrawing EOL treatment the same thing? 3) In an unconscious, terminally ill patient, whose wishes are unknown, how should EOL decisions be made? 4) How should we settle disagreement amongst medical staff and the patient’s family on EOL decisions? Results One thousand Koreans not working in healthcare and five hundred healthcare professionals responded to the survey. Fifty-seven percent of Koreans not working in healthcare and sixty seven percent of Korean healthcare professionals agreed that ventilator-dependent PVS patients are candidates for EOL treatment decisions. One quarter of all respondents regarded withholding and withdrawing EOL treatment as equal. Over 50% thought that EOL treatment decisions should be made through discussions between the physician and the patient’s family. For conflict resolution, 75% of Koreans not working in healthcare preferred direct settlement between the medical staff and the patient’s family while 55% of healthcare professionals preferred the hospital ethics committee. Conclusions Unsettled issues in Korea regarding EOL treatment decision include whether to include ventilator-dependent PVS patients as candidates of EOL treatment decision and how to sort out disagreements regarding EOL treatment decisions. Koreans viewed withholding and withdrawing EOL treatment issues differently.
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Real de Asúa D, Alcalá-Zamora J, Reyes A. Evolution of End-of-Life Practices in a Spanish Intensive Care Unit between 2002 and 2009. J Palliat Med 2013; 16:1102-7. [DOI: 10.1089/jpm.2013.0136] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Diego Real de Asúa
- Department of Internal Medicine, Fundación de Investigación Biomédica, Hospital Universitario La Princesa, Madrid, Spain
| | - Juan Alcalá-Zamora
- Intensive Care Unit, Fundación de Investigación Biomédica, Hospital Universitario La Princesa, Madrid, Spain
| | - Antonio Reyes
- Intensive Care Unit, Fundación de Investigación Biomédica, Hospital Universitario La Princesa, Madrid, Spain
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Current approach to the haemodynamic management of septic shock patients in European intensive care units: a cross-sectional, self-reported questionnaire-based survey. Eur J Anaesthesiol 2013; 28:284-90. [PMID: 21088597 DOI: 10.1097/eja.0b013e3283405062] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of this survey was to investigate clinicians' current approach to the haemodynamic management and resuscitation endpoints in septic shock. METHODS This cross-sectional, self-reported questionnaire-based survey was sent to the clinical director of selected ICUs in 16 European countries. The questionnaire consisted of two parts and 25 questions. The first part retrieved general information on the hospital and ICU, and the second part of the questionnaire collected detailed information on the approach to haemodynamic management of septic shock. RESULTS Of 481 clinicians invited to participate, 237 (49.3%) responded. Ninety-two questionnaires were excluded because of more than 20% missing responses, rendering 145 (30.1%) for statistical analysis. Administration of albumin (P = 0.007), gelatine preparations (P = 0.002), Ringer's solution (P = 0.02) and isotonic saline (P = 0.001) for fluid resuscitation varied between respondents from different countries. Further differences between respondents from different countries were observed for the choice of the first-line inotropic drug (P < 0.001), use of supplementary vasopressin (P = 0.02), supplementary fludrocortisone (P = 0.05) and measurement of cardiac output with the transpulmonary thermodilution (P = 0.001), lithium dilution (P = 0.004) and oesophageal Doppler (P = 0.005) technique. Mean arterial blood pressure (87%), central venous oxygen saturation (65%), central venous pressure (59%), systolic arterial blood pressure (48%), mixed venous oxygen saturation (42%) and cardiac index (42%) were the six haemodynamic variables most commonly claimed to be used as resuscitation endpoints. CONCLUSION The current approach to the haemodynamic management of septic shock patients in a selected cohort of European ICU clinicians is in agreement with the Surviving Sepsis Campaign guidelines with the exception of the haemodynamic goals.
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Philippart F, Vesin A, Bruel C, Kpodji A, Durand-Gasselin B, Garçon P, Levy-Soussan M, Jagot JL, Calvo-Verjat N, Timsit JF, Misset B, Garrouste-Orgeas M. The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments. Intensive Care Med 2013; 39:1565-73. [PMID: 23765236 DOI: 10.1007/s00134-013-2976-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 05/19/2013] [Indexed: 12/01/2022]
Abstract
PURPOSE To assess preferences among individuals aged ≥80 years for a future hypothetical critical illness requiring life-sustaining treatments. METHODS Observational cohort study of consecutive community-dwelling elderly individuals previously hospitalised in medical or surgical wards and of volunteers residing in nursing homes or assisted-living facilities. The participants were interviewed at their place of residence after viewing films of scenarios involving the use of non-invasive mechanical ventilation (NIV), invasive mechanical ventilation (IMV), and renal replacement therapy after a period of invasive mechanical ventilation (RRT after IMV). Demographic, clinical, and quality-of-life data were collected. Participants chose among four responses regarding life-sustaining treatments: consent, refusal, no opinion, and letting the physicians decide. RESULTS The sample size was 115 and the response rate 87 %. Mean participant age was 84.8 ± 3.5 years, 68 % were female, and 81 % and 71 % were independent for instrumental activities and activities of daily living, respectively. Refusal rates among the elderly were 27 % for NIV, 43 % for IMV, and 63 % for RRT (after IMV). Demographic characteristics associated with refusal were married status for NIV [relative risk (RR), 2.9; 95 % confidence interval (95 %CI), 1.5-5.8; p = 0.002] and female gender for IMV (RR, 2.4; 95 %CI, 1.2-4.5; p = 0.01) and RRT (after IMV) (RR, 2.7; 95 %CI, 1.4-5.2; p = 0.004). Quality of life was associated with choices regarding all three life-sustaining treatments. CONCLUSIONS Independent elderly individuals were rather reluctant to accept life-sustaining treatments, especially IMV and RRT (after IMV). Their quality of life was among the determinants of their choices.
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Affiliation(s)
- F Philippart
- Medical-Surgical, Saint Joseph Hospital Network, 75014, Paris, France
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Hilton AK, Jones D, Bellomo R. Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care. Crit Care 2013; 17:224. [PMID: 23672813 PMCID: PMC3672544 DOI: 10.1186/cc11856] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In-hospital end-of-life care outside the ICU is a new and increasing aspect of practice for intensive care physicians in countries where rapid response teams have been introduced. As more of these patients die from withdrawal or withholding of artificial life support, determining whether a patient is dying or not has become as important to intensivists as the management of organ support therapy itself. Intensivists have now moved to making such decisions in hospital wards outside the boundaries of their usual closely monitored environment. This strategic change may cause concern to some intensivists; however, as custodians of the highest technology area in the hospital, intensivists are by necessity involved in such processes. Now, more than ever before, intensive care clinicians must consider the usefulness of key concepts surrounding nosocomial death and dying and the importance and value of making a formal diagnosis of dying in the wards. In this article, we assess the conceptual background, reference points, challenges and implications of these emerging aspects of intensive care medicine.
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Schwarzkopf D, Behrend S, Skupin H, Westermann I, Riedemann NC, Pfeifer R, Günther A, Witte OW, Reinhart K, Hartog CS. Family satisfaction in the intensive care unit: a quantitative and qualitative analysis. Intensive Care Med 2013; 39:1071-9. [DOI: 10.1007/s00134-013-2862-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 01/27/2013] [Indexed: 01/05/2023]
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Raijmakers NJH, van Zuylen L, Costantini M, Caraceni A, Clark JB, De Simone G, Lundquist G, Voltz R, Ellershaw JE, van der Heide A. Issues and needs in end-of-life decision making: an international modified Delphi study. Palliat Med 2012; 26:947-53. [PMID: 21969309 DOI: 10.1177/0269216311423794] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND end-of-life decision making is an important aspect of end-of-life care that can have a significant impact on the process of dying and patients' comfort in the last days of life. AIM the aim of our study was to identify issues and considerations in end-of-life decision making, and needs for more evidence among palliative care experts, across countries and professions. PARTICIPANTS 90 palliative care experts from nine countries participated in a modified Delphi study. Participants were asked to identify important issues and considerations in end-of-life decision making and to rate the need for more evidence. RESULTS experts mentioned 219 issues in end-of-life decision making related to the medical domain, 122 issues related to the patient wishes and 92 related to relatives' wishes, regardless of profession or country (p > 0.05). In accordance, more than 90% of the experts rated the comfort and wishes of the patient and the potential futility of treatment as important considerations in end-of-life decision making, although some variation was present. When asked about issues that are in need of more evidence, 87% mentioned appropriate indications for using sedatives and effects of artificial hydration at the end of life. A total of 83% mentioned adequate communication approaches. CONCLUSIONS palliative care experts from different professions in different countries encounter similar issues in end-of-life decision making. Adequate communication about these issues is universally experienced as a challenge, which might benefit from increased knowledge. This shared experience enables and emphasizes the need for more international research.
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Kuniavsky M, Ganz FD, Linton DM, Sviri S. The legal guardians' dilemma: Decision making associated with invasive non-life-saving procedures. Isr J Health Policy Res 2012; 1:36. [PMID: 23006738 PMCID: PMC3467171 DOI: 10.1186/2045-4015-1-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 07/17/2012] [Indexed: 11/24/2022] Open
Abstract
Background ICU patients frequently undergo non-life-saving invasive procedures. When patient informed consent cannot be obtained, legal guardianship (LG), often from a close relative, may be required by law. The objective of this cohort study was to investigate the attitudes of LGs of ICU patients regarding the process of decision making for invasive non-life-saving procedures. Methods The study was conducted from May 2009 until June 2010 in general medical/surgical ICUs in two large Israeli medical centers. All 64 LGs who met the study criteria agreed to participate in the study. Three questionnaires were administered: a demographic data questionnaire, the Family Satisfaction with ICU 34 Questionnaire, and the Attitudes towards the LG Decision Making Process questionnaire, developed by the authors. Results The sample consisted of 64 LGs. Most participants were married (n = 56, 87.5%), male (n = 33, 51.6%), who had either a high school (n = 24, 37.5%) or college (n = 19, 29.7%) education, and were at a mean age of 49.2 (±11.22). Almost all of the procedures performed were tracheotomies (n = 63, 98.4%). About two-thirds of the LGs preferred decisions to be made by the medical staff after discussing options with them (n = 42, 65.6%) and about three-fifths stated that decisions could be made without the need for the appointment of an LG (n = 37, 57.8%). Attitudes towards ease of obtaining information and honesty of information were more positive compared to those of consistency and understanding of information. Conclusions The legal guardianship process requires better communication and more understandable information in order to assist LGs in making decisions for others in at times vague and stressful situations.
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Affiliation(s)
- Michael Kuniavsky
- General ICU, Asaf HaRofeh Medical Center, Beer Jaacov 70300, Israel.
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