1
|
Li M, Dai S, Wang L, Di H. Perspectives of healthcare providers on withdrawal of life-sustaining treatment and advanced directives for unresponsive wakefulness syndrome in China. Front Neurol 2024; 15:1358747. [PMID: 39206297 PMCID: PMC11350639 DOI: 10.3389/fneur.2024.1358747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 06/28/2024] [Indexed: 09/04/2024] Open
Abstract
Objectives We performed the current research to describe healthcare providers' perspectives toward withdrawal of life-sustaining treatment (WLST) and advanced directive (AD) of patients with unresponsive wakefulness syndrome (UWS) and to identify influencing factors of their perspectives. Methods Healthcare providers were recruited during a professional conference on disorders of consciousness (DoC). Participants completed self-administered questionnaires which included demographics, personal perspectives regarding WLST and the perception of ADs. Results A total of 230 Chinese healthcare providers (female: 69.7%) were included. Only a small proportion reported positive attitudes toward withdrawing artificial nutrition and hydration (35.2%), antibiotics (30.9%), and do-not-resuscitation orders (23.5%) in UWS patients. As for predictors' identification, religion was significantly associated with the positive attitude toward DNR order (p = 0.004). Moreover, although 47.4% of the participants had never heard of ADs before of conference, almost all of them would consider ADs (95.7%) thereafter, especially for non-neurologists (p = 0.033). Conclusion The propensity to WLST for UWS in China is low and perspective on WLST is significantly associated with individual characteristics. The attitudes of healthcare providers toward integrating ADs in the decisional process are positive. Future research regarding ADs and their predictors should be carried out to improve the quality of end-of-life care of UWS in China.
Collapse
Affiliation(s)
- Meiqi Li
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
- Intensive Care Unite, Hangzhou First People’s Hospital, Hangzhou, China
| | - Siyu Dai
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Le Wang
- School of Clinical Medicine, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Unresponsive Wakefulness Syndrome and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
- School of Basic Medicine, Hangzhou Normal University, Hangzhou, China
| |
Collapse
|
2
|
Smrke U, Abalde-Cela S, Loly C, Calbimonte JP, Pires LR, Lin S, Sánchez A, Tement S, Mlakar I. Quality of Life of Colorectal Cancer Survivors: Mapping the Key Indicators by Expert Consensus and Measures for Their Assessment. Healthcare (Basel) 2024; 12:1235. [PMID: 38921349 PMCID: PMC11203183 DOI: 10.3390/healthcare12121235] [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] [Received: 03/26/2024] [Revised: 05/15/2024] [Accepted: 06/18/2024] [Indexed: 06/27/2024] Open
Abstract
Quality of life (QoL) assessments are integral to cancer care, yet their effectiveness in providing essential information for supporting survivors varies. This study aimed to elucidate key indicators of QoL among colorectal cancer survivors from the perspective of healthcare professionals, and to evaluate existing QoL questionnaires in relation to these indicators. Two studies were conducted: a Delphi study to identify key QoL indicators and a scoping review of questionnaires suitable for colorectal cancer survivors. Fifty-four healthcare professionals participated in the Delphi study's first round, with 25 in the second. The study identified two primary QoL domains (physical and psychological) and 17 subdomains deemed most critical. Additionally, a review of 12 questionnaires revealed two instruments assessing the most important general domains. The findings underscored a misalignment between existing assessment tools and healthcare professionals' clinical priorities in working with colorectal cancer survivors. To enhance support for survivors' QoL, efforts are needed to develop instruments that better align with the demands of routine QoL assessment in clinical practice.
Collapse
Affiliation(s)
- Urška Smrke
- Faculty of Electrical Engineering and Computer Science, University of Maribor, 2000 Maribor, Slovenia
| | - Sara Abalde-Cela
- RUBYnanomed LDA, Praça Conde de Agrolongo, 4700-314 Braga, Portugal
| | - Catherine Loly
- Gastroenterology Department, University Hospital of Liège, 4000 Liège, Belgium
| | - Jean-Paul Calbimonte
- Institute of Informatics, University of Applied Sciences and Arts Western Switzerland HES-SO, 3960 Sierre, Switzerland
- The Sense Innovation & Research Center, 1007 Lausanne, Switzerland
| | - Liliana R. Pires
- RUBYnanomed LDA, Praça Conde de Agrolongo, 4700-314 Braga, Portugal
| | - Simon Lin
- Science Department, Symptoma GmbH, 5020 Vienna, Austria
- Department of Internal Medicine, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Alberto Sánchez
- Department of eHealth, Galician Research & Development Center in Advanced Telecommunications (GRADIANT), 26334 Vigo, Spain
| | - Sara Tement
- Department of Psychology, Faculty of Arts, University of Maribor, 2000 Maribor, Slovenia
| | - Izidor Mlakar
- Faculty of Electrical Engineering and Computer Science, University of Maribor, 2000 Maribor, Slovenia
| |
Collapse
|
3
|
Young MJ. Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas. Phys Med Rehabil Clin N Am 2024; 35:209-221. [PMID: 37993190 DOI: 10.1016/j.pmr.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
Collapse
Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
| |
Collapse
|
4
|
Abstract
Covert consciousness is a state of residual awareness following severe brain injury or neurological disorder that evades routine bedside behavioral detection. Patients with covert consciousness have preserved awareness but are incapable of self-expression through ordinary means of behavior or communication. Growing recognition of the limitations of bedside neurobehavioral examination in reliably detecting consciousness, along with advances in neurotechnologies capable of detecting brain states or subtle signs indicative of consciousness not discernible by routine examination, carry promise to transform approaches to classifying, diagnosing, prognosticating and treating disorders of consciousness. Here we describe and critically evaluate the evolving clinical category of covert consciousness, including approaches to its diagnosis through neuroimaging, electrophysiology, and novel behavioral tools, its prognostic relevance, and open questions pertaining to optimal clinical management of patients with covert consciousness recovering from severe brain injury.
Collapse
Affiliation(s)
- Michael J. Young
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Yelena G. Bodien
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Carlson JM, Lin DJ. Prognostication in Prolonged and Chronic Disorders of Consciousness. Semin Neurol 2023; 43:744-757. [PMID: 37758177 DOI: 10.1055/s-0043-1775792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.
Collapse
Affiliation(s)
- Julia M Carlson
- Division of Neurocritical Care, Department of Neurology, University of North Carolina Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Division of Neurocritical Care and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Neurorestoration and Neurotechnology, Rehabilitation Research and Development Service, Department of Veterans Affairs, Providence, Rhode Island
| |
Collapse
|
6
|
Naci L, Owen AM. Uncovering consciousness and revealing the preservation of mental life in unresponsive brain-injured patients. Semin Neurol 2022; 42:299-308. [PMID: 35790202 DOI: 10.1055/a-1892-1715] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Lorina Naci
- Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland
| | | |
Collapse
|
7
|
Mlakar I, Lin S, Nateqi J, Gruarin S, Diéguez L, Piairo P, Pires LR, Tement S, Aleksandraviča I, Leja M, Arcimoviča K, Bleret V, Kaux JF, Kolh P, Maquet D, Gómez JG, Mata JG, Salgado M, Horvat M, Ravnik M, Flis V, Smrke U. Establishing an Expert Consensus on Key Indicators of the Quality of Life among Breast Cancer Survivors: A Modified Delphi Study. J Clin Med 2022; 11:2041. [PMID: 35407649 PMCID: PMC8999421 DOI: 10.3390/jcm11072041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: The needs of cancer survivors are often not reflected in practice. One of the main barriers of the use of patient-reported outcomes is associated with data collection and the interpretation of patient-reported outcomes (PROs) due to a multitude of instruments and measuring approaches. The aim of the study was to establish an expert consensus on the relevance and key indicators of quality of life in the clinical practice of breast cancer survivors. (2) Methods: Potential indicators of the quality of life of breast cancer survivors were extracted from the established quality of life models, depicting survivors' perspectives. The specific domains and subdomains of quality of life were evaluated in a two-stage online Delphi process, including an international and multidisciplinary panel of experts. (3) Results: The first round of the Delphi process was completed by 57 and the second by 37 participants. A consensus was reached for the Physical and Psychological domains, and on eleven subdomains of quality of life. The results were further supported by the additional ranking of importance of the subdomains in the second round. (4) Conclusions: The current findings can serve to optimize the use of instruments and address the challenges related to data collection and interpretation as the facilitators of the adaption in routine practice.
Collapse
Affiliation(s)
- Izidor Mlakar
- Faculty of Electrical Engineering and Computer Science, University of Maribor, 2000 Maribor, Slovenia;
| | - Simon Lin
- Data Science Department, Symptoma, 1030 Vienna, Austria;
| | - Jama Nateqi
- Medical Department, Symptoma, 4864 Attersee, Austria; (J.N.); (S.G.)
| | - Stefanie Gruarin
- Medical Department, Symptoma, 4864 Attersee, Austria; (J.N.); (S.G.)
| | - Lorena Diéguez
- RUBYnanomed, 4700-314 Braga, Portugal; (L.D.); (P.P.); (L.R.P.)
| | - Paulina Piairo
- RUBYnanomed, 4700-314 Braga, Portugal; (L.D.); (P.P.); (L.R.P.)
| | | | - Sara Tement
- Faculty of Arts, Department of Psychology, University of Maribor, 2000 Maribor, Slovenia;
| | - Ilona Aleksandraviča
- Institute of Clinical and Preventive Medicine of the University of Latvia, LV-1586 Riga, Latvia; (I.A.); (M.L.)
| | - Mārcis Leja
- Institute of Clinical and Preventive Medicine of the University of Latvia, LV-1586 Riga, Latvia; (I.A.); (M.L.)
| | - Krista Arcimoviča
- Oncology Centre of Latvia, Riga East Clinical University Hospital, LV-1038 Riga, Latvia;
| | - Valérie Bleret
- Department of Senology, University Hospital of Liège, 4000 Liège, Belgium; (V.B.); (D.M.)
| | - Jean-François Kaux
- Physical and Rehabilitation Medicine, University Hospital of Liège, 4000 Liège, Belgium;
| | - Philippe Kolh
- Department of Information Systems Management, University Hospital of Liège, 4000 Liège, Belgium;
| | - Didier Maquet
- Department of Senology, University Hospital of Liège, 4000 Liège, Belgium; (V.B.); (D.M.)
| | - Jesús Garcia Gómez
- Oncology Department, University Hospital Complex of Ourense (SERGAS), 32005 Ourense, Spain; (J.G.G.); (J.G.M.)
| | - Jesus García Mata
- Oncology Department, University Hospital Complex of Ourense (SERGAS), 32005 Ourense, Spain; (J.G.G.); (J.G.M.)
| | - Mercedes Salgado
- Department of Medical Oncology, Galician Health Services (SERGAS), 15703 Santiago de Compostela, A Coruña, Spain;
| | - Matej Horvat
- Department of Oncology, University Medical Centre Maribor, 2000 Maribor, Slovenia; (M.H.); (M.R.); (V.F.)
| | - Maja Ravnik
- Department of Oncology, University Medical Centre Maribor, 2000 Maribor, Slovenia; (M.H.); (M.R.); (V.F.)
| | - Vojko Flis
- Department of Oncology, University Medical Centre Maribor, 2000 Maribor, Slovenia; (M.H.); (M.R.); (V.F.)
| | - Urška Smrke
- Faculty of Electrical Engineering and Computer Science, University of Maribor, 2000 Maribor, Slovenia;
| |
Collapse
|
8
|
Peterson A, Mintz K, Owen AM. Unlocking the Voices of Patients with Severe Brain Injury. NEUROETHICS-NETH 2022. [DOI: 10.1007/s12152-022-09492-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
9
|
Goss AL, Creutzfeldt CJ. Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness. Neurol Clin 2022; 40:59-75. [PMID: 34798975 PMCID: PMC8672806 DOI: 10.1016/j.ncl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Research advances in recent years have shown that some individuals with vegetative state or minimally conscious state can emerge to higher states of consciousness even years after injury. A minority of behaviorally unresponsive patients with vegetative state have also been shown to follow commands, or even communicate, using neuroimaging or electrophysiological techniques. These advances raise ethical questions that have important implications for clinical care. In this article, the authors argue that adopting a neuropalliative care approach can help clinicians provide ethical, compassionate care to these patients and their caregivers.
Collapse
Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
| |
Collapse
|
10
|
Abstract
Disorders of consciousness (DOC) continue to profoundly challenge both families and medical professionals. Once a brain-injured patient has been stabilized, questions turn to the prospect of recovery. However, what “recovery” means in the context of patients with prolonged DOC is not always clear. Failure to recognize potential differences of interpretation—and the assumptions about the relationship between health and well-being that underlie these differences—can inhibit communication between surrogate decisionmakers and a patient’s clinical team, and make it difficult to establish the goals of care. The authors examine the relationship between health and well-being as it pertains to patients with prolonged DOC. They argue that changes in awareness or other function should not be equated to changes in well-being, in the absence of a clear understanding of the constituents of well-being for that particular patient. The authors further maintain that a comprehensive conception of recovery for patients with prolonged DOC should incorporate aspects of both experienced well-being and evaluative well-being.
Collapse
|
11
|
Aas S, Peterson A, Wasserman D. What Justifies the Allocation of Scarce Health Care Resources to Patients with Disorders of Consciousness: Response to Commentaries. AJOB Neurosci 2021; 12:W1-W4. [PMID: 34686110 DOI: 10.1080/21507740.2021.1988759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
|
12
|
Peterson A, Aas S, Wasserman D. What Justifies the Allocation of Health Care Resources to Patients with Disorders of Consciousness? AJOB Neurosci 2021; 12:127-139. [PMID: 33787458 DOI: 10.1080/21507740.2021.1896594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper critically engages ethical issues in the allocation of novel, and potentially costly, health care resources to patients with disorders of consciousness. First, we review potential benefits of novel health care resources for patients and their families and outline preliminary considerations to address concerns about cost. We then address two problems regarding the allocation of health care resources to patients with disorders of consciousness: (1) the problem of uncertain moral status; and (2) the problem of accurately measuring the welfare burdens these resources would relieve. We conclude by suggesting that opportunity-based frameworks might complement standard approaches for justifying resources allocation to patients with disorders of consciousness.
Collapse
Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University
| | - Sean Aas
- Kennedy Institute of Ethics, Georgetown University
| | | |
Collapse
|
13
|
Abstract
Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient's written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient's best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, by using a patient's past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with "covert awareness" may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values.
Collapse
|
14
|
Lazaridis C. Deciding Under Uncertainty: The Case of Refractory Intracranial Hypertension. Front Neurol 2020; 11:908. [PMID: 32973664 PMCID: PMC7468512 DOI: 10.3389/fneur.2020.00908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/14/2020] [Indexed: 02/05/2023] Open
Abstract
A challenging clinical conundrum arises in severe traumatic brain injury patients who develop intractable intracranial hypertension. For these patients, high morbidity interventions such as surgical decompression and barbiturate coma have to be considered against a backdrop of uncertain outcomes including prolonged states of disordered consciousness and severe disability. The clinical evidence available to guide shared decision-making is mainly limited to one randomized controlled trial, the RESCUEicp. However, since the publication of this trial significant controversy has been ongoing over the interpretation of the results. Is the mortality benefit from surgery merely a trade off for unacceptable long-term disability? How should treatment options, possible outcomes, and results from the trial be communicated to surrogates? How do we incorporate patient values into forming plans of care? The aim of this article is to sketch an approach based on insights from Decision Theory, and specifically deciding under uncertainty. The mainstream normative decision theory, Expected Utility (EU) theory, essentially says that, in situations of uncertainty, one should prefer the option with greatest expected desirability or value. The steps required to compute expected utilities include listing the possible outcomes of available interventions, assigning each outcome a utility ranking representing an individual patient's preferences, and a conditional probability given each intervention. This is a conceptual framework meant to supplement, and enhance shared decision making by assuring that patient values are elicited and incorporated, the possible range and nature of outcomes is discussed, and finally by attempting to connect best available means to patient-individualized ends.
Collapse
Affiliation(s)
- Christos Lazaridis
- Neurocritical Care Unit, Department of Neurology, University of Chicago Medical Center, Chicago, IL, United States.,Section of Neurosurgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL, United States
| |
Collapse
|
15
|
Memory During the Presumed Vegetative State: Implications for Patient Quality of Life. Camb Q Healthc Ethics 2020; 29:501-510. [DOI: 10.1017/s0963180120000274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractA growing number of studies show that a significant proportion of patients, who meet the clinical criteria for the diagnosis of the vegetative state (VS), demonstrate evidence of covert awareness through successful performance of neuroimaging tasks. Despite these important advances, the day-to-day life experiences of any such patient remain unknown. This presents a major challenge for optimizing the patient’s standard of care and quality of life (QoL). We describe a patient who, following emergence from a state of complete behavioral unresponsiveness and a clinical diagnosis of VS, reported rich memories of his experience during this time. This case demonstrates the potential for a sophisticated mental life enabled by preserved memory in a proportion of patients who, similarly, are thought to be unconscious. Therefore, it presents an important opportunity to examine the implications for patient QoL and standard of care, both during the period of presumed unconsciousness and after recovery.
Collapse
|