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Gotanda H, Ikesu R, Walling AM, Zhang JJ, Xu H, Reuben DB, Wenger NS, Damberg CL, Zingmond DS, Jena AB, Gross N, Tsugawa Y. Association between physician age and patterns of end-of-life care among older Americans. J Am Geriatr Soc 2024; 72:2070-2081. [PMID: 38721884 PMCID: PMC11226372 DOI: 10.1111/jgs.18939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.
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Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ryo Ikesu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jessica J. Zhang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - David S. Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Karwa ML, Naqvi AA, Betchen M, Puri AK. In-Hospital Triage. Crit Care Clin 2024; 40:533-548. [PMID: 38796226 DOI: 10.1016/j.ccc.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.
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Affiliation(s)
- Manoj L Karwa
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Weiler Hospital, 4th Floor, 1825 Eastchester Road, Bronx, NY 10461, USA.
| | - Ali Abbas Naqvi
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Melanie Betchen
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
| | - Ajay Kumar Puri
- Division of Critical Care Medicine, Albert Einstein College of Medicine / Montefiore Medical Center, Moses Division, 111 East 210th Street, Gold Zone (Main Floor), Bronx, NY 10467, USA
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Jucker JA, Cannizzaro V, Kirsch RE, Streuli JC, De Clercq E. Between hope and disillusionment: ECMO seen through the lens of nurses working in a neonatal and paediatric intensive care unit. Nurs Crit Care 2024; 29:765-776. [PMID: 38511290 DOI: 10.1111/nicc.13051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 12/06/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Using extracorporeal membrane oxygenation (ECMO) in paediatric and neonatal intensive care units (PICU/NICU) creates ethical challenges and carries a high risk for moral distress, burn out and team conflicts. AIM The study aimed to gain a more comprehensive understanding of the underlying factors affecting moral distress when using ECMO for infants and children by examining the attitudes of ECMO nurses. METHODS Four focus groups discussions were conducted with 21 critical care nurses working in a Swiss University Children's Hospital. Purposive sampling was adopted to identify research participants. The data were analysed using reflexive thematic analysis. RESULTS Unlike "miracle machine" stories in online media reports, specialized nurses working in PICU/NICU expressed both their hopes and fears towards this technology. Their accounts also contained references to events and factors that triggered experiences of moral distress: the unspeakable nature of the death of a child or infant; the seemingly lack of honest and transparent communication with parents; the apparent loss of situational awareness among doctors; the perceived lack of recognition for the role of nurses and the variability in end-of-life decision-making; the length of time it takes doctors to take important treatment decisions; and the resource intensity of an ECMO treatment. CONCLUSION The creation of a multidisciplinary moral community with transparent information among all involved health care professionals and the definition of clear treatment goals as well as the implementation of paediatric palliative care for all paediatric ECMO patients should become a priority if we want to alleviate situations of moral distress. RELEVANCE FOR CLINICAL PRACTICE The creation of a multidisciplinary moral community, clear treatment goals and the implementation of palliative care for all paediatric ECMO patients are crucial to alleviate situations of moral distress for nurses, and thus to improve provider well-being and the quality of patient care in PICU/NICU.
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Affiliation(s)
- Jovana A Jucker
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital Zurich, Zürich, Switzerland
- Department of Neonatology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, Zürich, Switzerland
| | - Roxanne E Kirsch
- Department of Bioethics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jürg C Streuli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, Zürich, Switzerland
- Stiftung Dialog Ethik, Zürich, Switzerland
| | - Eva De Clercq
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zürich, Switzerland
- Stiftung Dialog Ethik, Zürich, Switzerland
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4
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Lyons B, Donnelly M. Consent to testing for brain death. JOURNAL OF MEDICAL ETHICS 2024; 50:442-446. [PMID: 37879900 PMCID: PMC11228188 DOI: 10.1136/jme-2023-109425] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/16/2023] [Indexed: 10/27/2023]
Abstract
Canada has recently published a new Clinical Practice Guideline on the diagnosis and management of brain death. It states that consent is not necessary to carry out the interventions required to make the diagnosis. A supporting article not only sets out the arguments for this but also contends that 'UK laws similarly carve out an exception, excusing clinicians from a prima facie duty to get consent'. This is supplemented by the claim that recent court decisions in the UK similarly confirm that consent is not required, referencing two judgements in Battersbee We disagree with the authors' interpretation of the law on consent in the UK and argue that there is nothing in Battersbee to support the conclusion that consent to testing is not necessary. Where there is a disagreement about testing for brain death in the UK, court authorisation is required.
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Asiri A, Alenezi FZ, Tamim H, Sadat M, Bin Humaid F, AlWehaibi W, Al-Dorzi HM, Alzoubi YA, Alanazi SA, Naidu B, Arabi YM. Practice and Predictors of Do-Not-Resuscitate Orders in a Tertiary-Care Intensive Care Unit in Saudi Arabia. Crit Care Res Pract 2024; 2024:5516516. [PMID: 38742230 PMCID: PMC11090671 DOI: 10.1155/2024/5516516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/18/2024] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders. Methods This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999-2017). We compared patients who had DNR orders during the ICU stay with those with "full code." The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital. Results Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with "full code," patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], p < 0.0001), were more likely to be females (43% versus 38%, p < 0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], p < 0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], p < 0.0001) and were more likely to be mechanically ventilated (83% versus 55%, p < 0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, p < 0.0001) and hospital (82.4% versus 18.1%, p < 0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01-1.02), higher APACHE II score (OR 1.09, 95% CI 1.08-1.10), and worse WHO performance status score. Patients admitted in recent years (2012-2017 versus 2002-2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32-0.39, p < 0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with "full code" but they had shorter length of hospital stay. Conclusion In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.
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Affiliation(s)
- Abdulrahman Asiri
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Farhan Zayed Alenezi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hani Tamim
- American University of Beirut Medical Center, Clinical Research Institute, Beirut, Lebanon
- AlFaisal University, College of Medicine, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Felwa Bin Humaid
- King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Wedyan AlWehaibi
- King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hasan M. Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Yasir Adnan Alzoubi
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Samiyah Alrawey Alanazi
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Brintha Naidu
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Yaseen M. Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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Davies B, Parker J. Deference or critical engagement: how should healthcare practitioners use clinical ethics guidance? Monash Bioeth Rev 2024:10.1007/s40592-023-00186-8. [PMID: 38421491 DOI: 10.1007/s40592-023-00186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 03/02/2024]
Abstract
Healthcare practitioners have access to a range of ethical guidance. However, the normative role of this guidance in ethical decision-making is underexplored. This paper considers two ways that healthcare practitioners could approach ethics guidance. We first outline the idea of deference to ethics guidance, showing how an attitude of deference raises three key problems: moral value; moral understanding; and moral error. Drawing on philosophical literature, we then advocate an alternative framing of ethics guidance as a form of moral testimony by colleagues and suggest that a more promising attitude to ethics guidance is to approach it in the spirit of 'critical engagement' rather than deference.
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Affiliation(s)
- Ben Davies
- Department of Philosophy, University of Sheffield, Victoria Street, Sheffield, S3 7QB, UK.
| | - Joshua Parker
- Wythenshawe Hospital, Southmoor Rd. Wythenshawe, Manchester, M23 9LT, UK
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Moynihan KM, Taylor LS, Siegel B, Nassar N, Lelkes E, Morrison W. "Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation. Front Pediatr 2024; 11:1325207. [PMID: 38274466 PMCID: PMC10808631 DOI: 10.3389/fped.2023.1325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO). Analysis Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed. Discussion Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.
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Affiliation(s)
- Katie M. Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lisa S. Taylor
- Office of Ethics, Boston Children’s Hospital, Boston, MA, United States
| | - Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Natasha Nassar
- Clinical and Population Translational Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Efrat Lelkes
- Department of Pediatrics, MaineGeneral Medical Center, Augusta, ME, United States
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Divisions of Critical Care and Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Alizadeh F, Gauvreau K, Mayourian J, Brown E, Barreto JA, Blossom J, Bucholz E, Newburger JW, Kheir J, Vitali S, Thiagarajan RR, Moynihan K. Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes. Pediatrics 2023; 152:e2023061305. [PMID: 37933403 DOI: 10.1542/peds.2023-061305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.
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Affiliation(s)
| | | | | | | | | | - Jeff Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | | | | | - John Kheir
- Departments of Cardiology
- Departments of Pediatrics
| | - Sally Vitali
- Anesthesia, Critical Care, Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | | - Katie Moynihan
- Departments of Cardiology
- Departments of Pediatrics
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Schembs L, Racine E, Shevell M, Jox RJ. Physicians' attitudes towards ethical issues and end-of-life decision-making for pediatric patients with unresponsive wakefulness syndrome: An international survey. Dev Med Child Neurol 2023; 65:1646-1655. [PMID: 36758014 DOI: 10.1111/dmcn.15540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
AIM We examined physicians' perspectives on the mental capabilities of pediatric patients with unresponsive wakefulness syndrome (UWS) and their attitudes towards limiting life-sustaining treatment (LST) in an international context. METHOD A questionnaire survey was conducted among 267 neuropediatricians, practicing in 65 countries. Comparisons were made according to the Human Development Index (HDI) of the countries. The Idler Index of Religiosity was applied to determine religiosity. RESULTS Participants from countries with a very high HDI were generally more favorable to limiting LST (p < 0.001), specifically cardiopulmonary resuscitation (p = 0.021), intubation/ventilation (p = 0.014), hemodialysis/hemofiltration (p < 0.001), and antibiotic therapy (p < 0.001). Treatment costs that were too high had a weaker influence on their decisions (p < 0.001). Participants who found it never ethically justifiable to limit LST had a higher mean Idler Index of private (p = 0.001) and general (p = 0.020) religiosity and were less satisfied with treatment decisions (p < 0.001) and the communication during the process (p = 0.016). INTERPRETATION The perspectives towards limiting LST for pediatric patients with UWS are markedly different between physicians from countries with very high and lower HDIs.
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Affiliation(s)
- Leah Schembs
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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10
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Alexander D, Quirke M, Doyle C, Hill K, Masterson K, Brenner M. Technology solutionism in paediatric intensive care: clinicians' perspectives of bioethical considerations. BMC Med Ethics 2023; 24:55. [PMID: 37507700 PMCID: PMC10386660 DOI: 10.1186/s12910-023-00937-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 07/24/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND The use of long-term life-sustaining technology for children improves survival rates in paediatric intensive care units (PICUs), but it may also increase long-term morbidity. One example of this is children who are dependent on invasive long-term ventilation. Clinicians caring for these children navigate an increasing array of ethical complexities. This study looks at the meaning clinicians give to the bioethical considerations associated with the availability of increasingly sophisticated technology. METHODS A hermeneutic phenomenological exploration of the experiences of clinicians in deciding whether to initiate invasive long-term ventilation in children took place, via unstructured interviews. Data were analysed to gain insight into the lived experiences of clinicians. Participants were from PICUs, or closely allied to the care of children in PICUs, in four countries. RESULTS Three themes developed from the data that portray the experiences of the clinicians: forming and managing relationships with parents and other clinicians considering, or using, life sustaining technology; the responsibility for moral and professional integrity in the use of technology; and keeping up with technological developments, and the resulting ethical and moral considerations. DISCUSSION There are many benefits of the availability of long-term life-sustaining technology for a child, however, clinicians must also consider increasingly complex ethical dilemmas. Bioethical norms are adapting to aid clinicians, but challenges remain. CONCLUSION During a time of technological solutionism, more needs to be understood about the influences on the initiation of invasive long-term ventilation for a child. Further research to better understand how clinicians, and bioethics services, support care delivery may positively impact this arena of health care.
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Affiliation(s)
- Denise Alexander
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Mary Quirke
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Carmel Doyle
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Katie Hill
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Kate Masterson
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland.
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11
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Beil M, de Lange D, Leaver S, Szczeklik W, Fjolner J, Nachshon A, van Heerden PV, Joskowicz L, Jung C, Hyams G, Sviri S. The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU. Ann Intensive Care 2023; 13:40. [PMID: 37162595 PMCID: PMC10170430 DOI: 10.1186/s13613-023-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. METHODS This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. RESULTS The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. CONCLUSIONS Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, service MIR, Paris, France
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Akiva Nachshon
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Christian Jung
- Division of Cardiology, Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
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12
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George LS, Epstein RM, Akincigil A, Saraiya B, Trevino KM, Kuziemski A, Pushparaj L, Policano E, Prigerson HG, Godwin K, Duberstein P. Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis. J Gen Intern Med 2023; 38:1516-1525. [PMID: 36732436 PMCID: PMC10160244 DOI: 10.1007/s11606-022-08011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. OBJECTIVE Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. METHODS Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. RESULTS The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. CONCLUSIONS Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kendra Godwin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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13
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Beil M, van Heerden PV, de Lange DW, Szczeklik W, Leaver S, Guidet B, Flaatten H, Jung C, Sviri S, Joskowicz L. Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care. BMC Med Inform Decis Mak 2023; 23:1. [PMID: 36609257 PMCID: PMC9818057 DOI: 10.1186/s12911-022-02094-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making. METHODS Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions. RESULTS Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree. CONCLUSIONS Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required. TRIAL REGISTRATION VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).
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Affiliation(s)
- Michael Beil
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P. Vernon van Heerden
- grid.9619.70000 0004 1937 0538Department of Anaesthesia, Intensive Care and Pain Medicine, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan W. de Lange
- grid.7692.a0000000090126352Department of Intensive Care Medicine, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Wojciech Szczeklik
- grid.5522.00000 0001 2162 9631Department of Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Susannah Leaver
- grid.451349.eIntensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Bertrand Guidet
- grid.50550.350000 0001 2175 4109Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hans Flaatten
- grid.412008.f0000 0000 9753 1393Intensive Care, Department of Clinical Medicine, Haukeland Universitetssjukehus, Bergen, Norway
| | - Christian Jung
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Sigal Sviri
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- grid.9619.70000 0004 1937 0538School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
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14
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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15
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Andersen SK, Steinberg A. What happens after they leave the hospital? Resuscitation 2022; 181:1-2. [PMID: 36243224 DOI: 10.1016/j.resuscitation.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Alexis Steinberg
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Neurology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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16
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Moynihan KM, Jansen M, Siegel BD, Taylor LS, Kirsch RE. Extracorporeal Membrane Oxygenation Candidacy Decisions: An Argument for a Process-Based Longitudinal Approach. Pediatr Crit Care Med 2022; 23:e434-e439. [PMID: 35609309 DOI: 10.1097/pcc.0000000000002991] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Are all children extracorporeal membrane oxygenation (ECMO) candidates? Navigating ECMO decisions represents an enormous challenge in pediatric critical care. ECMO cannulation should not be a default option as it will not confer benefit for "all" critically ill children; however, "all" children deserve well-considered decisions surrounding their ECMO candidacy. The complexity of the decision demands a systematic, "well-reasoned" and "dynamic" approach. Due to clinical urgency, this standard cannot always be met prior to initiation of ECMO. We challenge the paradigm of "candidacy" as a singular decision that must be defined prior to ECMO initiation. Rather, the determination as to whether ECMO is in the patient's best interest is applicable regardless of cannulation status. The priority should be on collaborative, interdisciplinary decision-making processes aligned with principles of transparency, relevant reasoning, accountability, review, and appeal. To ensure a robust process, it should not be temporally constrained by cannulation status. We advocate that this approach will decrease both the risk of not initiating ECMO in a patient who will benefit and the risk of prolonged, nonbeneficial support. We conclude that to ensure fair decisions are made in a patient's best interest, organizations should develop procedurally fair processes for ECMO decision-making that are not tied to a particular time point and are revisited along the management trajectory.
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Affiliation(s)
| | - Melanie Jansen
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Bryan D Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Lisa S Taylor
- Department of Pediatric Intensive Care, Children's Hospital at Westmead, Westmead, NSW, Australia
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17
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Alexander D, Quirke MB, Doyle C, Hill K, Masterson K, Brenner M. The Meaning Given to Bioethics as a Source of Support by Physicians Who Care for Children Who Require Long-Term Ventilation. QUALITATIVE HEALTH RESEARCH 2022; 32:916-928. [PMID: 35348409 PMCID: PMC9189592 DOI: 10.1177/10497323221083744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The role and potential of bioethics input when a child requires the initiation of technology dependence to sustain life is relatively unknown. In particular, little is understood about the meaning physicians give to bioethics as a source of support during the care of children in pediatric intensive care who require long-term ventilation (LTV). We used a hermeneutic phenomenological approach to underpin the collection and analysis of data. Unstructured interviews of 40 physicians in four countries took place during 2020. We found that elements of trust, communication and acceptance informed the physicians' perceptions of the relationship with bioethics. These ranged from satisfaction to disappointment with their input into critical decisions. Bioethics services have potential to help physicians gain clarity over distressing and complex care decisions, yet physicians perceive the service inconsistently as a means of support. This research provides a sound basis to guide more beneficial interactions between clinicians and bioethics services.
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Affiliation(s)
- Denise Alexander
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Mary B. Quirke
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Carmel Doyle
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Katie Hill
- School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Kate Masterson
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing and Midwifery, The University of Dublin, Trinity College Dublin, Dublin, Ireland
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18
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Shorey S, Chua C. Nurses and nursing students' experiences on pediatric end-of-life care and death: A qualitative systematic review. NURSE EDUCATION TODAY 2022; 112:105332. [PMID: 35334222 DOI: 10.1016/j.nedt.2022.105332] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 03/02/2022] [Accepted: 03/15/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND End-of-Life care and experiencing death of infants, children, and teenagers remain one of the most difficult and traumatic events for nurses and nursing students, potentially leading to personal and professional distress. Although efforts have been made to alleviate stressors in these settings, improvements remain slow. Understanding nurses and nursing students' experiences of pediatric End-of-Life care and death in multiple care settings may direct interventions to better support quality of care and healthcare professionals in these areas. OBJECTIVE This review aimed to qualitatively synthesize existing literature to examine the nurses and nursing students' experiences of providing End-of-Life care to children and the death of pediatric patients. DESIGN The qualitative systematic review was conducted using Sandelowski and Barroso's guidelines. The included studies were appraised using the Critical Appraisal Skill Program. DATA SOURCES This qualitative systematic review was registered with the International Prospective Register of Systematic Reviews. Six electronic databases (Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, PsychINFO, Scopus, and Mednar) were searched from the database inception date through May 2021. RESULTS Thirty articles were included to form three key themes: (1) Emotional impact of pediatric End-of-Life care and death, (2) Perspective of delivering optimal care: What works and what does not, and (3) The complex role of nurses in pediatric End-of-Life care. Overall, the findings suggested that in an emotionally taxing environment, clinical and emotional support were paramount. Furthermore, there is a need to examine nurses' role in End-of-Life decision making and provide more discussion on professional boundaries. CONCLUSION This review offered nurses' and nursing students' perceptions of pediatric End-of Life care and death in the nursing profession. Findings can provide useful insights towards the planning of educational programs and institutional changes that supports nurses and nursing students in these settings.
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Affiliation(s)
- Shefaly Shorey
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Crystal Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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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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20
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Popejoy E, Almack K, Manning JC, Johnston B, Pollock K. Communication strategies and persuasion as core components of shared decision-making for children with life-limiting conditions: A multiple case study. Palliat Med 2022; 36:519-528. [PMID: 34965779 DOI: 10.1177/02692163211068997] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Families and professionals caring for children with life-limiting conditions face difficult healthcare decisions. Shared decision-making is promoted in many countries, however little is known about factors influencing these processes. AIM To explore the communication strategies used in shared decision-making for children with life-limiting conditions. DESIGN A longitudinal, qualitative, multiple-case study. Cases were centred around the child and parent/carer(s). Most cases also included professionals or extended family members. Data from interviews, observations and medical notes were re-storied for each case into a narrative case summary. These were subject to comparative thematic analysis using NVivo11. SETTING/PARTICIPANTS Eleven cases recruited from three tertiary hospitals in England. 23 participants were interviewed (46 interviews). Cases were followed for up to 12 months between December 2015 and January 2017. 72 observations were conducted and the medical notes of nine children reviewed. FINDINGS Strategies present during shared decision-making were underpinned by moral work. Professionals presented options they believed were in the child's best interests, emphasising their preference. Options were often presented in advance of being necessary to prevent harm, therefore professionals permitted delay to treatment. Persuasion was utilised over time when professionals felt the treatment was becoming more urgent and when families felt it would not promote the child's psychosocial wellbeing. CONCLUSIONS Communication strategies in shared decision-making are underpinned by moral work. Professionals should be aware of the models of shared decision-making which include such communication strategies. Open discussions regarding individuals' moral reasoning may assist the process of shared decision-making.
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Affiliation(s)
- Emma Popejoy
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kathryn Almack
- School of Health and Social Work, University of Hertfordshire, Hertfordshire, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Bridget Johnston
- School of Medicine, Dentistry and Nursing Glasgow, University of Glasgow, Glasgow, UK.,NHS Greater Glasgow and Clyde, Scotland, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
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21
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Walzl N, Sammy IA, Taylor PM, Smith JE, Lowe DJ. Systematic review of factors influencing decisions to limit treatment in the emergency department. Emerg Med J 2022; 39:147-156. [PMID: 33658272 DOI: 10.1136/emermed-2019-209398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/28/2021] [Accepted: 02/04/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Emergency physicians are frequently faced with making decisions regarding how aggressive to be in caring for critically ill patients. We aimed to identify factors that influence decisions to limit treatment in the Emergency Department (ED) through a systematic search of the available literature. DESIGN Prospectively registered systematic review of studies employing any methodology to investigate factors influencing decisions to limit treatment in the ED. Medline and EMBASE were searched from their inception until January 2019. Methodological quality was assessed using the Mixed Methods Appraisal Tool, but no studies were excluded based on quality. Findings were summarised by narrative analysis. RESULTS 10 studies published between 1998 and 2016 were identified for inclusion in this review, including seven cross-sectional studies investigating factors associated with treatment-limiting decisions, two surveys of physicians making treatment-limiting decisions and one qualitative study of physicians making treatment-limiting decisions. There was significant heterogeneity in patient groups, outcome measures, methodology and quality. Only three studies received a methodology-specific rating of 'high quality'. Important limitations of the literature include the use of small single-centre retrospective cohorts often lacking a comparison group, and survey studies with low response rates employing closed-response questionnaires. Factors influencing treatment-limiting decisions were categorised into 'patient and disease factors' (age, chronic disease, functional limitation, patient and family wishes, comorbidity, quality of life, acute presenting disorder type, severity and reversibility), 'hospital factors' (colleague opinion, resource availability) and 'non-patient healthcare factors' (moral, ethical, social and cost factors). CONCLUSIONS Several factors influence decisions to limit treatment in the ED. Many factors are objective and quantifiable, but some are subjective and open to individual interpretation. This review highlights the complexity of the subject and the need for more robust research in this field.
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Affiliation(s)
- Nathan Walzl
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Ian A Sammy
- Emergency Department, Scarborough General Hospital, Lower Scarborough, Trinidad and Tobago
- Tobago Regional Health Authority, Lower Scarborough, Trinidad and Tobago
| | - Paul M Taylor
- The University of Sheffield School of Health and Related Research, Sheffield, UK
- St Luke's Hospice, Sheffield, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Birmingham, UK
| | - David J Lowe
- Emergency Department, Queen Elizabeth University Hospital, Glasgow, UK
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
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22
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Hewitt J. End-of-life decisions, nurses, and the law. Aust Crit Care 2022; 35:1-2. [DOI: 10.1016/j.aucc.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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23
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Wilkinson DJC. Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:48-63. [PMID: 33289443 PMCID: PMC8567739 DOI: 10.1080/15265161.2020.1851809] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.
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24
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Joffe AR, Khaira G, de Caen AR. The intractable problems with brain death and possible solutions. Philos Ethics Humanit Med 2021; 16:11. [PMID: 34625089 PMCID: PMC8500820 DOI: 10.1186/s13010-021-00107-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 09/14/2021] [Indexed: 05/21/2023] Open
Abstract
Brain death has been accepted worldwide medically and legally as the biological state of death of the organism. Nevertheless, the literature has described persistent problems with this acceptance ever since brain death was described. Many of these problems are not widely known or properly understood by much of the medical community. Here we aim to clarify these issues, based on the two intractable problems in the brain death debates. First, the metaphysical problem: there is no reason that withstands critical scrutiny to believe that BD is the state of biological death of the human organism. Second, the epistemic problem: there is no way currently to diagnose the state of BD, the irreversible loss of all brain functions, using clinical tests and ancillary tests, given potential confounders to testing. We discuss these problems and their main objections and conclude that these problems are intractable in that there has been no acceptable solution offered other than bare assertions of an 'operational definition' of death. We present possible ways to move forward that accept both the metaphysical problem - that BD is not biological death of the human organism - and the epistemic problem - that as currently diagnosed, BD is a devastating neurological state where recovery of sentience is very unlikely, but not a confirmed state of irreversible loss of all [critical] brain functions. We argue that the best solution is to abandon the dead donor rule, thus allowing vital organ donation from patients currently diagnosed as BD, assuming appropriate changes are made to the consent process and to laws about killing.
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Affiliation(s)
- Ari R Joffe
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada.
- University of Alberta, John Dossetor Health Ethics Center, 4-546 Edmonton Clinic Health Academy, 11405 112 Street, Edmonton, Alberta, T6G 1C9, Canada.
| | - Gurpreet Khaira
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada
| | - Allan R de Caen
- University of Alberta and Stollery Children's Hospital, Division of Pediatric Critical Care, Edmonton, Alberta, Canada
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25
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Kirby L, Basu S, Close E, Jansen M. Rationing in the Pediatric Intensive Care Unit-ethical or unethical? Transl Pediatr 2021; 10:2836-2844. [PMID: 34765505 PMCID: PMC8578748 DOI: 10.21037/tp-20-334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/29/2021] [Indexed: 01/17/2023] Open
Abstract
Rationing in health care is controversial, and even more so in pediatrics. Children are an inherently vulnerable group because they are reliant on their parents and caregivers to make decisions in their best interests and have no political voice. Historically, there has been general acceptance of the need to ration healthcare at a systems level, however there is controversy over whether healthcare professionals should be involved in rationing at the bedside. The COVID-19 pandemic has highlighted that bedside rationing is unavoidable, at least in times of extreme resource scarcity. Internationally, there has been significant ethical analysis and guideline development to guide intensive care rationing decisions in the event that resources are overwhelmed. This paper explores the principles underlying distributive justice in healthcare rationing and discusses how these were operationalized in ethical guidelines for the COVID-19 pandemic. In fact, rationing is unavoidable and occurs constantly in everyday nursing and medical ICU practice, often in mundane and uncontroversial ways. Some argue that these everyday decisions are not true rationing decisions, but resource allocation, or stewardship decisions. We argue there are no clear lines between resource allocation and rationing decisions, rather that they occur on a spectrum. These everyday rationing decisions are particularly susceptible to personal biases that are often implicit. Due to the subtle and constant nature of most everyday rationing decisions, specific guideline development will rarely be practical or appropriate. However, it is possible to develop other processes to improve decision making. There are a variety of strategies we recommend for this including, encouraging reflective practice; developing explicit frameworks that promote collaborative decision making; being transparent about resource allocation and rationing decisions with colleagues, patients, and families; and promoting a workplace culture of speaking up and accessing support in identifying and managing everyday rationing decisions.
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Affiliation(s)
- Lynette Kirby
- Pediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Shreerupa Basu
- Pediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Melanie Jansen
- Pediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Faculty of Medicine, University of Queensland, Queensland, Australia
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26
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Nordenskjöld Syrous A, Malmgren J, Odenstedt Hergès H, Olausson S, Kock‐Redfors M, Ågård A, Block L. Reasons for physician-related variability in end-of-life decision-making in intensive care. Acta Anaesthesiol Scand 2021; 65:1102-1108. [PMID: 33964009 DOI: 10.1111/aas.13842] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/18/2021] [Accepted: 04/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is increasing evidence that the individual physician is the main factor influencing variability in end-of-life decision-making in intensive care units. End-of-life decisions are complex and should be adapted to each patient. Physician-related variability is problematic as it may result in unequal assessments that affect patient outcomes. The primary aim of this study was to investigate factors contributing to physician-related variability in end-of-life decision-making. METHOD This is a qualitative substudy of a previously conducted study. In-depth thematic analysis of semistructured interviews with 19 critical care specialists from five different Swedish intensive care units was performed. Interviews took place between 1 February 2017 and 31 May 2017. RESULTS Factors influencing physician-related variability consisted of different assessment of patient preferences, as well as intensivists' personality and values. Personality was expressed mainly through pace and determination in the decision-making process. Personal prejudices appeared in decisions, but few respondents had personally witnessed this. Avoidance of criticism and conflicts as well as individual strategies for emotional coping were other factors that influenced physician-related variability. Many respondents feared criticism for making their assessments, and the challenging nature of end-of-life decision-making lead to avoidance as well as emotional stress. CONCLUSION Variability in end-of-life decision-making is an important topic that needs further investigation. It is imperative that such variability be acknowledged and addressed in a more formal and transparent manner. The ethical issues faced by intensivists have recently been compounded by the devastating impact of the COVID-19 pandemic, demonstrating in profound terms the importance of the topic.
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Affiliation(s)
- Alma Nordenskjöld Syrous
- Department of Anesthesiology and Intensive Care Institute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Johan Malmgren
- Department of Anesthesiology and Intensive Care Institute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Helena Odenstedt Hergès
- Department of Anesthesiology and Intensive Care Institute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Sepideh Olausson
- Institute of Health and Care SciencesSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Maria Kock‐Redfors
- Department of Anesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Anders Ågård
- Department of Cardiology Institute of MedicineSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Linda Block
- Department of Anesthesiology and Intensive Care Institute of Clinical SciencesSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
- Department of Anesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
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27
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Morley G, Bradbury-Jones C, Ives J. The moral distress model: An empirically informed guide for moral distress interventions. J Clin Nurs 2021; 31:1309-1326. [PMID: 34423483 DOI: 10.1111/jocn.15988] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/20/2021] [Accepted: 07/15/2021] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To explore moral distress empirically and conceptually, to understand the factors that mitigate and exacerbate moral distress and construct a model that represents how moral distress relates to its constituent parts and related concepts. BACKGROUND There is ongoing debate about how to understand and respond to moral distress in nursing practice. DESIGN The overarching design was feminist empirical bioethics in which feminist interpretive phenomenology provided the tools for data collection and analysis, reported following the COREQ guidelines. Using reflexive balancing, the empirical data were combined with feminist theory to produce normative recommendations about how to respond to moral distress. The Moral Distress Model presented in this paper is a culmination of the empirical data and theory. METHODS Using feminist interpretive phenomenology, critical care nurses in the United Kingdom (n = 21) were interviewed and data analysed. Reflexive Balancing was used to integrate the data with feminist theory to provide normative recommendations about how to understand moral distress. RESULTS There are five compounding factors that exacerbate/ mitigate nurses' experiences of moral distress: epistemic injustice; the roster lottery; conflict between one's professional and personal responsibilities; ability to advocate and team dynamics. In addition to the causal connection and responses to moral distress, these factors make up the moral distress model which can guide approaches to mitigate moral distress. CONCLUSIONS The Moral Distress Model is the culmination of these data and theorising formulated into a construct to explain how each element interacts. We propose that this model can be used to inform the design of interventions to address moral distress.
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Affiliation(s)
- Georgina Morley
- Center for Bioethics and Stanley, S.Zielony Institute for Nursing Excellence, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Caroline Bradbury-Jones
- School of Nursing, University of Birmingham, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Birstol, United Kingdom of Great Britain and Northern Ireland
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28
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Anstey MH, Mitchell IA, Corke C, Murray L, Mitchell M, Udy A, Sarode V, Nguyen N, Flower O, Ho KM, Litton E, Wibrow B, Norman R. Intensive care doctors and nurses personal preferences for Intensive Care, as compared to the general population: a discrete choice experiment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:287. [PMID: 34376239 PMCID: PMC8353726 DOI: 10.1186/s13054-021-03712-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/28/2021] [Indexed: 11/11/2022]
Abstract
Background To test the hypothesis that Intensive Care Unit (ICU) doctors and nurses differ in their personal preferences for treatment from the general population, and whether doctors and nurses make different choices when thinking about themselves, as compared to when they are treating a patient. Methods Cross sectional, observational study conducted in 13 ICUs in Australia in 2017 using a discrete choice experiment survey. Respondents completed a series of choice sets, based on hypothetical situations which varied in the severity or likelihood of: death, cognitive impairment, need for prolonged treatment, need for assistance with care or requiring residential care. Results A total of 980 ICU staff (233 doctors and 747 nurses) participated in the study. ICU staff place the highest value on avoiding ending up in a dependent state. The ICU staff were more likely to choose to discontinue therapy when the prognosis was worse, compared with the general population. There was consensus between ICU staff personal views and the treatment pathway likely to be followed in 69% of the choices considered by nurses and 70% of those faced by doctors. In 27% (1614/5945 responses) of the nurses and 23% of the doctors (435/1870 responses), they felt that aggressive treatment would be continued for the hypothetical patient but they would not want that for themselves. Conclusion The likelihood of returning to independence (or not requiring care assistance) was reported as the most important factor for ICU staff (and the general population) in deciding whether to receive ongoing treatments. Goals of care discussions should focus on this, over likelihood of survival. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03712-4.
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Affiliation(s)
- Matthew H Anstey
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia. .,School of Population Health, Curtin University, Bentley, Australia. .,School of Medicine, University of Western Australia, Crawley, Australia.
| | - Imogen A Mitchell
- Australian National University, Canberra, Australia.,Canberra Hospital, Canberra, Australia
| | | | - Lauren Murray
- Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Marion Mitchell
- Griffith University, Griffith, QLD, Australia.,Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | | | - Vineet Sarode
- Monash University, Melbourne, Australia.,Cabrini Hospital, Melbourne, Australia
| | - Nhi Nguyen
- Nepean Hospital, Kingswood, NSW, Australia
| | | | - Kwok M Ho
- School of Medicine, University of Western Australia, Crawley, Australia.,Royal Perth Hospital, Perth, Australia.,School of Veterinary and Life Sciences, Murdoch University, Perth, Australia
| | - Edward Litton
- School of Medicine, University of Western Australia, Crawley, Australia.,Fiona Stanley Hospital, Perth, Australia
| | - Bradley Wibrow
- Intensive Care Department, Sir Charles Gairdner Hospital, Level 4 G Block, Hospital Ave, Nedlands, Perth, WA, 6009, Australia.,School of Medicine, University of Western Australia, Crawley, Australia
| | - Richard Norman
- School of Population Health, Curtin University, Bentley, Australia
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29
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Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study. Intensive Care Med 2021; 47:1115-1129. [PMID: 34351445 PMCID: PMC8486724 DOI: 10.1007/s00134-021-06484-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Background In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression. Results A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3–12.4) or two unreactive pupils (OR 5.8, CI 2.6–13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0–1.1). Timing of WLSM was not significantly associated with region or center. Conclusion WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06484-1.
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Rhodes MG, Fletcher KE, Blumenfeld-Kouchner F, Jacobs EA. Spanish Medical Interpreters' Management of Challenges in End of Life Discussions. PATIENT EDUCATION AND COUNSELING 2021; 104:1978-1984. [PMID: 33563501 PMCID: PMC8217083 DOI: 10.1016/j.pec.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 01/14/2021] [Accepted: 01/16/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Professional medical interpreters facilitate patient understanding of illness, prognosis, and treatment options. Facilitating end of life discussions can be challenging. Our objective was to better understand the challenges professional medical interpreters face and how they affect the accuracy of provider-patient communication during discussions of end of life. METHODS We conducted semi-structured interviews with professional Spanish medical interpreters. We asked about their experiences interpreting end of life discussions, including questions about values, professional and emotional challenges interpreting these conversations, and how those challenges might impact accuracy. We used a grounded theory, constant comparative method to analyze the data. Participants completed a short demographic questionnaire. RESULTS Seventeen Spanish language interpreters participated. Participants described intensive attention to communication accuracy during end of life discussions, even when discussions caused emotional or professional distress. Professional strains such as rapid discussion tempo contributed to unintentional alterations in discussion content. Perceived non-empathic behaviors of providers contributed to rare, intentional alterations in discussion flow and content. CONCLUSION We found that despite challenges, Spanish language interpreters focus intensively on accurate interpretation in discussions of end of life. PRACTICE IMPLICATIONS Provider training on how to best work with interpreters in these important conversations could support accurate and empathetic interpretation.
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Affiliation(s)
- Mary G Rhodes
- Department of Medicine, Medical College of Wisconsin, Milwaukee, USA.
| | - Kathlyn E Fletcher
- Department of Medicine, Medical College of Wisconsin, Milwaukee, USA; Department of Medicine, Clement J. Zablocki VA Medical Center, Milwaukee, USA.
| | - Francois Blumenfeld-Kouchner
- Department of Medicine, Medical College of Wisconsin, Milwaukee, USA; Department of Palliative Care, Aurora Medical Group, Grafton Medical Center, Grafton, USA(1).
| | - Elizabeth A Jacobs
- Departments of Internal Medicine and Population Health, The University of Texas at Austin Dell Medical School, Austin, USA; Maine Medical Center Research Institute, MaineHealth, Portland, ME, USA(1).
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Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study. J Clin Med 2021; 10:jcm10143068. [PMID: 34300235 PMCID: PMC8305175 DOI: 10.3390/jcm10143068] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.
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32
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Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study. Crit Care Med 2021; 48:645-653. [PMID: 32310619 PMCID: PMC7161724 DOI: 10.1097/ccm.0000000000004221] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Supplemental Digital Content is available in the text. To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries.
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33
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Limiting ICU admission from emergency services and wards. Med Clin (Barc) 2021; 157:524-529. [PMID: 33423823 DOI: 10.1016/j.medcli.2020.08.021] [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: 06/08/2020] [Revised: 08/15/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Decisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. METHODS Post hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. RESULTS The ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021). CONCLUSIONS There are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.
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Tajgardoon M, Cooper GF, King AJ, Clermont G, Hochheiser H, Hauskrecht M, Sittig DF, Visweswaran S. Modeling physician variability to prioritize relevant medical record information. JAMIA Open 2020; 3:602-610. [PMID: 33623894 PMCID: PMC7886572 DOI: 10.1093/jamiaopen/ooaa058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/05/2020] [Accepted: 11/02/2020] [Indexed: 02/05/2023] Open
Abstract
Objective Patient information can be retrieved more efficiently in electronic medical record (EMR) systems by using machine learning models that predict which information a physician will seek in a clinical context. However, information-seeking behavior varies across EMR users. To explicitly account for this variability, we derived hierarchical models and compared their performance to nonhierarchical models in identifying relevant patient information in intensive care unit (ICU) cases. Materials and methods Critical care physicians reviewed ICU patient cases and selected data items relevant for presenting at morning rounds. Using patient EMR data as predictors, we derived hierarchical logistic regression (HLR) and standard logistic regression (LR) models to predict their relevance. Results In 73 pairs of HLR and LR models, the HLR models achieved an area under the receiver operating characteristic curve of 0.81, 95% confidence interval (CI) [0.80-0.82], which was statistically significantly higher than that of LR models (0.75, 95% CI [0.74-0.76]). Further, the HLR models achieved statistically significantly lower expected calibration error (0.07, 95% CI [0.06-0.08]) than LR models (0.16, 95% CI [0.14-0.17]). Discussion The physician reviewers demonstrated variability in selecting relevant data. Our results show that HLR models perform significantly better than LR models with respect to both discrimination and calibration. This is likely due to explicitly modeling physician-related variability. Conclusion Hierarchical models can yield better performance when there is physician-related variability as in the case of identifying relevant information in the EMR.
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Affiliation(s)
- Mohammadamin Tajgardoon
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory F Cooper
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew J King
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Harry Hochheiser
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Milos Hauskrecht
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Computer Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dean F Sittig
- Department of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shyam Visweswaran
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Close E, White BP, Willmott L. Balancing Patient and Societal Interests in Decisions About Potentially Life-Sustaining Treatment : An Australian Policy Analysis. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:407-421. [PMID: 32964352 DOI: 10.1007/s11673-020-09994-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND This paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources. METHODS All publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation. RESULTS Four resource-related themes were identified: (1) doctors' ethical duties to consider resource allocation; (2) balancing ethical obligations to patient and society; (3) fair process and transparent resource allocation; and (4) legal guidance on distributive justice as a rationale to limit life-sustaining treatment. CONCLUSION Of the policies that addressed resource allocation, this review found broad agreement about the existence of doctors' duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia.
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
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Pope TM, Bennett J, Carson SS, Cederquist L, Cohen AB, DeMartino ES, Godfrey DM, Goodman-Crews P, Kapp MB, Lo B, Magnus DC, Reinke LF, Shirley JL, Siegel MD, Stapleton RD, Sudore RL, Tarzian AJ, Thornton JD, Wicclair MR, Widera EW, White DB. Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement. Am J Respir Crit Care Med 2020; 201:1182-1192. [PMID: 32412853 PMCID: PMC7233335 DOI: 10.1164/rccm.202003-0512st] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice. Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting. Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law. Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight. Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.
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Survey of End-of-Life Care in Intensive Care Units in Ain Shams University Hospitals, Cairo, Egypt. HEC Forum 2020; 34:25-39. [PMID: 32789739 DOI: 10.1007/s10730-020-09423-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Studies on end-of-life care reveal different practices regarding withholding and/or withdrawing life-sustaining treatments between countries and regions. Available data about physicians' practices regarding end-of-life care in ICUs in Egypt is scarce. This study aimed to investigate physicians' attitudes toward end-of-life care and the reported practice in adult ICUs in Ain Shams University Hospitals, Cairo, Egypt. 100 physicians currently working in several ICU settings in Ain Shams University Hospitals were included. A self-administered questionnaire was used for collection of data. Most of the participants agreed to implementation of "do not resuscitate" (DNR) orders and applying pre-written DNR orders (61% and 65% consecutively), while only 13% almost always/often order DNR for terminally-ill patients. 52% of the participants agreed to usefulness of limiting life-sustaining therapy in some cases, but they expressed fear of legal consequences. 47% found withholding life-sustaining treatment is more ethical than its withdrawal. 16% almost always/often withheld further active treatment but continued current ones while only 6% almost always/often withdrew active therapy for terminally-ill patients. The absence of legislation and guidelines for end-of-life care in ICUs at Ain Shams University Hospitals was the main influential factor for the dissociation between participants' attitudes and their practices. Therefore, development of a consensus for end-of-life care in ICUs in Egypt is mandatory. Also, training of physicians in ICUs on effective communication with patients' families and surrogates is important for planning of limitation of life-sustaining treatments.
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Agreement With Consensus Statements on End-of-Life Care: A Description of Variability at the Level of the Provider, Hospital, and Country. Crit Care Med 2020; 47:1396-1401. [PMID: 31305497 DOI: 10.1097/ccm.0000000000003922] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care. DESIGN AND SETTING Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study. SUBJECTS Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments. CONCLUSIONS Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
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Nordenskjöld Syrous A, Ågård A, Kock Redfors M, Naredi S, Block L. Swedish intensivists' experiences and attitudes regarding end-of-life decisions. Acta Anaesthesiol Scand 2020; 64:656-662. [PMID: 31954072 DOI: 10.1111/aas.13549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND To make end-of-life (EOL) decisions is a complex and challenging task for intensive care physicians and a substantial variability in this process has been previously reported. However, a deeper understanding of intensivists' experiences and attitudes regarding the decision-making process is still, to a large extent, lacking. The primary aim of this study was to address Swedish intensivists' experiences, beliefs and attitudes regarding decision-making pertaining to EOL decisions. Second, we aimed to identify underlying factors that may contribute to variability in the decision-making process. METHOD This is a descriptive, qualitative study. Semi-structured interviews with nineteen intensivists from five different Swedish hospitals, with different ICU levels, were performed from 1 February 2017 to 31 May 2017. RESULTS Intensivists strive to make end-of-life decisions that are well-grounded, based on sufficient information. Consensus with the patient, family and other physicians is important. Concurrently, decisions that are made with scarce information or uncertain medical prognosis, decisions made during on-call hours and without support from senior consultants cause concern for many intensivists. Underlying factors that contribute to the variability in decision-making are lack of continuity among senior intensivists, lack of needed support during on-call hours and disagreements with physicians from other specialties. There is also an individual variability primarily depending on the intensivist's personality. CONCLUSION Swedish intensivists' wish to make end-of-life decisions based on sufficient information, medically certain prognosis and consensus with the patient, family, staff and other physicians. Swedish intensivists' experience a variability in end-of-life decisions, which is generally accepted and not questioned.
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Affiliation(s)
- Alma Nordenskjöld Syrous
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology Angereds Hospital Region Västra Götaland Gothenburg Sweden
| | - Anders Ågård
- Department of Cardiology Institute of MedicineSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Maria Kock Redfors
- Department of Anaesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Silvana Naredi
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
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van Veen E, van der Jagt M, Citerio G, Stocchetti N, Epker JL, Gommers D, Burdorf L, Menon DK, Maas AIR, Lingsma HF, Kompanje EJO. End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study. J Crit Care 2020; 58:78-88. [PMID: 32387842 DOI: 10.1016/j.jcrc.2020.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients. MATERIALS AND METHODS Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients. RESULTS In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition. CONCLUSION We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations.
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Affiliation(s)
- Ernest van Veen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; San Gerardo Hospital, ASST-Monza, Italy.
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
| | - Jelle L Epker
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Lex Burdorf
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - David K Menon
- Department of Anaesthesia, University of Cambridge, Cambridge, United Kingdom.
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Dombrecht L, Deliens L, Chambaere K, Baes S, Cools F, Goossens L, Naulaers G, Roets E, Piette V, Cohen J, Beernaert K. Neonatologists and neonatal nurses have positive attitudes towards perinatal end-of-life decisions, a nationwide survey. Acta Paediatr 2020; 109:494-504. [PMID: 30920064 DOI: 10.1111/apa.14797] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/06/2019] [Accepted: 03/25/2019] [Indexed: 11/29/2022]
Abstract
AIM Perinatal death is often preceded by an end-of-life decision (ELD). Disparate hospital policies, complex legal frameworks and ethically difficult cases make attitudes important. This study investigated attitudes of neonatologists and nurses towards perinatal ELDs. METHODS A survey was handed out to all neonatologists and neonatal nurses in all eight neonatal intensive care units in Flanders, Belgium in May 2017. Respondents indicated agreement with statements regarding perinatal ELDs on a Likert-scale and sent back questionnaires via mail. RESULTS The response rate was 49.5% (302/610). Most neonatologists and nurses found nontreatment decisions such as withholding or withdrawing treatment acceptable (90-100%). Termination of pregnancy when the foetus is viable in cases of severe or lethal foetal problems was considered highly acceptable in both groups (80-98%). Physicians and nurses do not find different ELDs equally acceptable, e.g. nurses more often than physicians (74% vs 60%, p = 0.017) agree that it is acceptable in certain cases to administer medication with the explicit intention of hastening death. CONCLUSION There was considerable support for both prenatal and neonatal ELDs, even for decisions that currently fall outside the Belgian legal framework. Differences between neonatologists' and nurses' attitudes indicate that both opinions should be heard during ELD-making.
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Affiliation(s)
- Laure Dombrecht
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Luc Deliens
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Kenneth Chambaere
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Saskia Baes
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Filip Cools
- Department of Neonatology Universitair Ziekenhuis Brussel Vrije Universiteit Brussel Brussel Belgium
| | - Linde Goossens
- Department of Neonatology Ghent University Hospital Ghent Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration KU Leuven Leuven Belgium
| | - Ellen Roets
- Department of Obstetrics Women's Clinic University Hospital Ghent Ghent Belgium
| | - Veerle Piette
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Joachim Cohen
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
| | - Kim Beernaert
- End‐of‐Life Care Research Group Ghent University & Vrije Universiteit Brussel (VUB) Brussel Belgium
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Yotani N, Nabetani M, Feudtner C, Honda J, Kizawa Y, Iijima K. Withholding and withdrawal of life-sustaining treatments for neonate in Japan: Are hospital practices associated with physicians' beliefs, practices, or perceived barriers? Early Hum Dev 2020; 141:104931. [PMID: 31810052 DOI: 10.1016/j.earlhumdev.2019.104931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the current status of withholding or withdrawal of life-sustaining interventions (LSI) for neonates in Japan and to identify physician- and institutional-related factors that may affect advance care planning (ACP) practices with parents. STUDY DESIGN A self-reported questionnaire was administered to assess frequency of withholding and withdrawing intensive care at the respondent's facility, the physician's degree of affirming various beliefs about end-of-life care that was compared to 7 European countries, their self-reported ACP practices and perceived barriers to ACP. Three neonatologists at all 298 facilities accredited by the Japan Society for Neonatal Health and Development were surveyed, with 572 neonatologists at 217 facilities responding. RESULTS At 76% of facilities, withdrawing intensive care treatments was "never" done, while withholding intensive care had been done "sometimes" or more frequently at 82% of facilities. Japanese neonatologists differed from European neonatologists regarding their degree of affirmation of 3 out of 7 queried beliefs about end-of-life care. In hospitals that were more likely to "sometimes" (or more often) withdraw treatments, respondents were less likely to affirm beliefs about doing "everything possible" or providing the "maximum of intensive care". Self-reported ACP practices did not vary between neonatologists based on their hospital's overall pattern of withholding or withdrawing treatments. CONCLUSION Among NICU facilities in Japan, 21% had been sometimes withdrawing LSI and 82% had been "sometimes" withholding LSI. Institutional treatment practices may have a strong association with physicians' beliefs that then affect end-of-life discussions, but not with self-reported ACP practices.
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Affiliation(s)
- Nobuyuki Yotani
- Department of Palliative Medicine, National Centre for Child Health and Development, Tokyo, Japan.
| | | | - Chris Feudtner
- Department Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Junko Honda
- College of Nursing Art and Science, University of Hyogo, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Chen EE, Pu CT, Bernacki RE, Ragland J, Schwartz JH, Mutchler JE. Surrogate Preferences on the Physician Orders for Life-Sustaining Treatment Form. THE GERONTOLOGIST 2019; 59:811-821. [PMID: 29788197 DOI: 10.1093/geront/gny042] [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: 10/29/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The purpose of this study is to compare treatment preferences of patients to those of surrogates on the Physician Orders for Life-Sustaining Treatment (POLST) forms. RESEARCH DESIGN AND METHODS Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST) forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression models estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteristics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site). RESULTS Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24-0.65]; p < .001). This model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regression grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00). DISCUSSION AND IMPLICATIONS Our study took into consideration variation at the patient, clinician, and site level, and showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making processes for patients versus surrogates when the POLST paradigm is employed.
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Affiliation(s)
| | | | - Rachelle E Bernacki
- Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Jan E Mutchler
- Gerontology Department and Institute, University of Massachusetts Boston
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Morley G, Ives J, Bradbury-Jones C. Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare. HEALTH CARE ANALYSIS 2019; 27:185-201. [PMID: 31317374 PMCID: PMC6667688 DOI: 10.1007/s10728-019-00376-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect-moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians' moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times.
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Affiliation(s)
- Georgina Morley
- Department of Bioethics, Heart and Vascular Institute, Cleveland Clinic, Main Campus, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
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Robertsen A, Helseth E, Laake JH, Førde R. Neurocritical care physicians' doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study. Scand J Trauma Resusc Emerg Med 2019; 27:81. [PMID: 31462245 PMCID: PMC6714084 DOI: 10.1186/s13049-019-0648-9] [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: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 11/15/2022] Open
Abstract
Background Multilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt. Method Semi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis. Result All physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical. Conclusion Decisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.
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Affiliation(s)
- Annette Robertsen
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. .,Department of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Helseth
- Department of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Jon Henrik Laake
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Reidun Førde
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
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Duberstein PR, Kravitz RL, Fenton JJ, Xing G, Tancredi DJ, Hoerger M, Mohile SG, Norton SA, Prigerson HG, Epstein RM. Physician and Patient Characteristics Associated With More Intensive End-of-Life Care. J Pain Symptom Manage 2019; 58:208-215.e1. [PMID: 31004774 PMCID: PMC6679778 DOI: 10.1016/j.jpainsymman.2019.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties. OBJECTIVE To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL. METHODS We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life. RESULTS Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification. CONCLUSION Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.
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Affiliation(s)
- Paul R Duberstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Health Behavior, Society, and Policy, Rutgers University School of Public Heath, Piscataway, New Jersey, USA.
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Sacramento, California, USA; Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA
| | - Joshua J Fenton
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; UC Davis Comprehensive Cancer Center, University of California, Davis, Sacramento, California, USA; Department of Family and Community Medicine, University of California, Davis, Sacramento, California, USA
| | - Guibo Xing
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA
| | - Daniel J Tancredi
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California, USA; Department of Pediatrics, University of California, Davis, Sacramento, California, USA
| | - Michael Hoerger
- Tulane Cancer Center, Tulane University, New Orleans, Louisiana, USA; Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Sally A Norton
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; School of Nursing, University of Rochester, Rochester, New York, USA
| | - Holly G Prigerson
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA; Cornell Center for Research on End-of-Life Care, New York, New York, USA
| | - Ronald M Epstein
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; James P. Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA; Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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47
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Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review. J Crit Care 2019; 51:39-45. [DOI: 10.1016/j.jcrc.2019.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
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Close E, White BP, Willmott L, Gallois C, Parker M, Graves N, Winch S. Doctors' perceptions of how resource limitations relate to futility in end-of-life decision making: a qualitative analysis. JOURNAL OF MEDICAL ETHICS 2019; 45:373-379. [PMID: 31092631 DOI: 10.1136/medethics-2018-105199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility. SETTING Three tertiary hospitals in metropolitan Brisbane, Australia. DESIGN Qualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis. RESULTS Doctors' perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing. CONCLUSIONS Doctors' ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors' role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- Faculty of Social and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Interpreting "Do Not Resuscitate": A Cautionary Tale of Physician Influence. Ann Am Thorac Soc 2019; 14:491-492. [PMID: 28362528 DOI: 10.1513/annalsats.201701-094ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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50
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Yadav KN, Josephs M, Gabler NB, Detsky ME, Halpern SD, Hart JL. What's behind the white coat: Potential mechanisms of physician-attributable variation in critical care. PLoS One 2019; 14:e0216418. [PMID: 31095596 PMCID: PMC6522043 DOI: 10.1371/journal.pone.0216418] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/20/2019] [Indexed: 11/25/2022] Open
Abstract
Background Critical care intensity is known to vary across regions and centers, yet the mechanisms remain unidentified. Physician behaviors have been implicated in the variability of intensive care near the end of life, but physician characteristics that may underlie this association have not been determined. Purpose We sought to identify behavioral attributes that vary among intensivists to generate hypotheses for mechanisms of intensivist-attributable variation in critical care delivery. Methods We administered a questionnaire to intensivists who participated in a prior cohort study in which intensivists made prognostic estimates. We evaluated the degree to which scores on six attribute measures varied across intensivists. Measures were selected for their relevance to preference-sensitive critical care: a modified End-of-Life Preferences (EOLP) scale, Life Orientation Test–Revised (LOT-R), Jefferson Scale of Empathy (JSE), Physicians' Reactions to Uncertainty (PRU) scale, Collett-Lester Fear of Death (CLFOD) scale, and a test of omission bias. We conducted regression analyses assessing relationships between intensivists’ attribute scores and their prognostic accuracy, as physicians’ prognostic accuracy may influence preference-sensitive decisions. Results 20 of 25 eligible intensivists (80%) completed the questionnaire. Intensivists’ scores on the EOLP, LOT-R, PRU, CLFOD, and omission bias measures varied considerably, while their responses on the JSE scale did not. There were no consistent associations between attribute scores and prognostic accuracy. Conclusions Intensivists vary in feasibly measurable attributes relevant to preference-sensitive critical care delivery. These attributes represent candidates for future research aimed at identifying mechanisms of clinician-attributable variation in critical care and developing effective interventions to reduce undue variation.
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Affiliation(s)
- Kuldeep N. Yadav
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Michael Josephs
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Nicole B. Gabler
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Michael E. Detsky
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Division of Critical Care Medicine, UHN/Mount Sinai Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Scott D. Halpern
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Joanna L. Hart
- Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Fostering Improvement in End-of-Life Decision Science Program, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
- * E-mail:
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