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Rubin MA, Lewis A, Creutzfeldt CJ, Shrestha GS, Boyle Q, Illes J, Jox RJ, Trevick S, Young MJ. Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness. Neurocrit Care 2024; 41:345-356. [PMID: 38872033 DOI: 10.1007/s12028-024-02012-3] [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: 03/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.
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Affiliation(s)
- Michael A Rubin
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | | | - Claire J Creutzfeldt
- Harborview Medical Center, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, Seattle, WA, USA
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Quinn Boyle
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ralf J Jox
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Michael J Young
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Neurocritical Care, Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Boston, USA.
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Malhotra AK, Shakil H, Smith CW, Sader N, Ladha K, Wijeysundera DN, Singhal A, Kulkarni AV, Wilson JR, Witiw CD, Nathens AB. Withdrawal of Life-Sustaining Treatment for Pediatric Patients With Severe Traumatic Brain Injury. JAMA Surg 2024; 159:287-296. [PMID: 38117514 PMCID: PMC10733846 DOI: 10.1001/jamasurg.2023.6531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/13/2023] [Indexed: 12/21/2023]
Abstract
Importance The decision to withdraw life-sustaining treatment for pediatric patients with severe traumatic brain injury (TBI) is challenging for clinicians and families with limited evidence quantifying existing practices. Given the lack of standardized clinical guidelines, variable practice patterns across trauma centers seem likely. Objective To evaluate the factors influencing decisions to withdraw life-sustaining treatment across North American trauma centers for pediatric patients with severe TBI and to quantify any existing between-center variability in withdrawal of life-sustaining treatment practices. Design, Setting, and Participants This retrospective cohort study used data collected from 515 trauma centers through the American College of Surgeons Trauma Quality Improvement Program between 2017 and 2020. Pediatric patients younger than 19 years with severe TBI and a documented decision for withdrawal of life-sustaining treatment were included. Data were analyzed from January to May 2023. Main Outcomes and Measures A random intercept multilevel logistic regression model was used to quantify patient, injury, and hospital characteristics associated with the decision to withdraw life-sustaining treatment; the median odds ratio was used to characterize residual between-center variability. Centers were ranked by their conditional random intercepts and quartile-specific adjusted mortalities were computed. Results A total of 9803 children (mean [SD] age, 12.6 [5.7]; 2920 [29.8%] female) with severe TBI were identified, 1003 of whom (10.2%) had a documented decision to withdraw life-sustaining treatment. Patient-level factors associated with an increase in likelihood of withdrawal of life-sustaining treatment were young age (younger than 3 years), higher severity intracranial and extracranial injuries, and mechanism of injury related to firearms. Following adjustment for patient and hospital attributes, the median odds ratio was 1.54 (95% CI, 1.46-1.62), suggesting residual variation in withdrawal of life-sustaining treatment between centers. When centers were grouped into quartiles by their propensity for withdrawal of life-sustaining treatment, adjusted mortality was higher for fourth-quartile compared to first-quartile centers (odds ratio, 1.66; 95% CI, 1.45-1.88). Conclusions and Relevance Several patient and injury factors were associated with withdrawal of life-sustaining treatment decision-making for pediatric patients with severe TBI in this study. Variation in withdrawal of life-sustaining treatment practices between trauma centers was observed after adjustment for case mix; this variation was associated with differences in risk-adjusted mortality rates. Taken together, these findings highlight the presence of inconsistent approaches to withdrawal of life-sustaining treatment in children, which speaks to the need for guidelines to address this significant practice pattern variation.
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Affiliation(s)
- Armaan K. Malhotra
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Husain Shakil
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Christopher W. Smith
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
| | - Nicholas Sader
- Division of Neurosurgery, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Karim Ladha
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Anesthesiology, Unity Health, Toronto, Ontario, Canada
| | - Duminda N. Wijeysundera
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Anesthesiology, Unity Health, Toronto, Ontario, Canada
| | - Ashutosh Singhal
- Division of Neurosurgery, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Abhaya V. Kulkarni
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jefferson R. Wilson
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Christopher D. Witiw
- Division of Neurosurgery, Unity Health, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
| | - Avery B. Nathens
- Institute for Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Sullivan MD, Owattanapanich N, Schellenberg M, Matsushima K, Lewis MR, Lam L, Martin M, Inaba K. Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients. Injury 2023; 54:111088. [PMID: 37833232 DOI: 10.1016/j.injury.2023.111088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST. METHODS The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients. RESULTS Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h. CONCLUSIONS More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.
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Affiliation(s)
- Michael D Sullivan
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Natthida Owattanapanich
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Lydia Lam
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Matthew Martin
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
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Nakao-Hayashizaka KC. End-of-Life Preparedness Among Japanese Americans: A Community Survey. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2022; 18:216-234. [PMID: 35815782 DOI: 10.1080/15524256.2022.2093312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The purpose of this study was to investigate the level of preparedness among Japanese American older adults for life's end by examining their knowledge, preferences, and arrangements for end-of-life issues. A total of 248 community dwelling Japanese Americans aged 50 and older participated in the study. The cross-sectional survey results indicated that participants believed they were well-informed about end-of-life issues and well-prepared for their lives' end. While most participants were in favor of making end-of-life arrangements, particularly with regard to making a will/living trust, creating an advance health care directive, appointing a health care agent, and funeral planning, relatively few favored life-prolonging treatment or planning for organ donation. They placed a high value on natural death and family-centered decision-making processes. These findings highlight the importance of awareness and cultural humility for social workers when providing culturally informed services at life's end to diverse Americans, including Japanese American older adults and their families.
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