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Bakke BM, Feuz MA, McMahan RD, Barnes DE, Li B, Volow AM, Powell J, Sudore RL. Surrogate Decision Makers Need Better Preparation for Their Role: Advice from Experienced Surrogates. J Palliat Med 2022; 25:857-863. [DOI: 10.1089/jpm.2021.0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brian M. Bakke
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Mariko A. Feuz
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- Des Moines University College of Osteopathic Medicine, Des Moines, Iowa, USA
| | - Ryan D. McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Deborah E. Barnes
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aiesha M. Volow
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jana Powell
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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Hammami MM, Abuhdeeb K, Hammami MB, De Padua SJS, Al-Balkhi A. Prediction of life-story narrative for end-of-life surrogate's decision-making is inadequate: a Q-methodology study. BMC Med Ethics 2019; 20:28. [PMID: 31053127 PMCID: PMC6500001 DOI: 10.1186/s12910-019-0368-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background Substituted judgment assumes adequate knowledge of patient’s mind-set. However, surrogates’ prediction of individual healthcare decisions is often inadequate and may be based on shared background rather than patient-specific knowledge. It is not known whether surrogate’s prediction of patient’s integrative life-story narrative is better. Methods Respondents in 90 family pairs (30 husband-wife, 30 parent-child, 30 sibling-sibling) rank-ordered 47 end-of-life statements as life-story narrative measure (Q-sort) and completed instruments on decision-control preference and healthcare-outcomes acceptability as control measures, from respondent’s view (respondent-personal) and predicted pair’s view (respondent-surrogate). They also scored their confidence in surrogate’s decision-making (0 to 4 = maximum) and familiarity with pair’s healthcare-preferences (1 to 4 = maximum). Life-story narratives’ prediction was examined by calculating correlation of statements’ ranking scores between respondent-personal and respondent-surrogate Q-sorts (projection) and between respondent-surrogate and pair-personal Q-sorts before (simulation) and after controlling for correlation with respondent-personal scores (adjusted-simulation), and by comparing percentages of respondent-surrogate Q-sorts co-loading with pair-personal vs. respondent-personal Q-sorts. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was determined by percent concordance. Results were compared among subgroups defined by intra-pair relationship, surrogate’s decision-making confidence, and healthcare-preferences familiarity. Results Mean (SD) age was 35.4 (10.3) years, 69% were females, and 73 and 80% reported ≥ very good health and life-quality, respectively. Mean surrogate’s decision-making confidence score was 3.35 (0.58) and 75% were ≥ familiar with pair’s healthcare-preferences. Mean (95% confidence interval) projection, simulation, and adjusted-simulation correlations were 0.68 (0.67–0.69), 0.42 (0.40–0.44), and 0.26 (0.24–0.28), respectively. Out of 180 respondent-surrogate Q-sorts, 24, 9, and 32% co-loaded with respondent-personal, pair-personal, or both Q-sorts, respectively. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was 47 and 52%, respectively. Surrogate’s decision-making confidence score correlated with adjusted-simulation’s correlation score (rho = 0.18, p = 0.01). There were significant differences among the husband-wife, parent-child, and sibling-sibling subgroups in percentage of respondent-surrogate Q-sorts co-loading with pair-personal Q-sorts (38, 32, 55%, respectively, p = 0.03) and percent agreement on healthcare-outcomes acceptability (55, 35, and 67%, respectively, p = 0.002). Conclusions Despite high self-reported surrogate’s decision-making confidence and healthcare-preferences familiarity, family surrogates are variably inadequate in simulating life-story narratives. Simulation accuracy may not follow the next-of-kin concept and is 38% based on shared background. Electronic supplementary material The online version of this article (10.1186/s12910-019-0368-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | | | - Sophia J S De Padua
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | - Areej Al-Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
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Abstract
Medicine, law, and social values are not static. Reexamining the ethical tenets of medicine and their application in new circumstances is a necessary exercise. The seventh edition of the American College of Physicians (ACP) Ethics Manual covers emerging issues in medical ethics and revisits older ones that are still very pertinent. It reflects on many of the ethical tensions in medicine and attempts to shed light on how existing principles extend to emerging concerns. In addition, by reiterating ethical principles that have provided guidance in resolving past ethical problems, the Manual may help physicians avert future problems. The Manual is not a substitute for the experience and integrity of individual physicians, but it may serve as a reminder of the shared duties of the medical profession.
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Bailoor K, Kamil LH, Goldman E, Napiewocki LM, Winiarski D, Vercler CJ, Shuman AG. The Voice Is As Mighty As the Pen: Integrating Conversations into Advance Care Planning. JOURNAL OF BIOETHICAL INQUIRY 2018; 15:185-191. [PMID: 29550975 DOI: 10.1007/s11673-018-9848-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/05/2017] [Indexed: 06/08/2023]
Abstract
Advance care planning allows patients to articulate preferences for their medical treatment, lifestyle, and surrogate decision-makers in order to anticipate and mitigate their potential loss of decision-making capacity. Written advance directives are often emphasized in this regard. While these directives contain important information, there are several barriers to consider: veracity and accuracy of surrogate decision-makers in making choices consistent with the substituted judgement standard, state-to-state variability in regulations, literacy issues, lack of access to legal resources, lack of understanding of medical options, and cultural disparities. Given these issues, it is vital to increase the use of patient and healthcare provider conversations as an advance care planning tool and to increase integration of such discourse into advance care planning policy as adjuncts and complements to written advance directives. This paper reviews current legislation about written advance directives and dissects how documentation of spoken interactions might be integrated and considered. We discuss specific institutional policy changes required to facilitate implementation. Finally, we explore the ethical issues surrounding the increased usage and recognition of clinician-patient conversations in advance care planning.
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Affiliation(s)
- Kunal Bailoor
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Leslie H Kamil
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Ed Goldman
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Laura M Napiewocki
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Denise Winiarski
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Christian J Vercler
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Andrew G Shuman
- University of Michigan Medical School, 1904 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Denniss DL. Legal and ethical issues associated with Advance Care Directives in an Australian context. Intern Med J 2017; 46:1375-1380. [PMID: 27981764 DOI: 10.1111/imj.13288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 07/13/2016] [Accepted: 07/30/2016] [Indexed: 11/30/2022]
Abstract
The need for appropriate mechanisms guiding end-of-life care is increasingly vital. This commentary compares the use of Advance Care Directives (ACD) in New South Wales and South Australia in order to highlight the inconsistency in Australian legislation, before exploring common problems, legal concerns and ethical issues associated with their application in an adult population. The benefits and detriments of statutory legislation for ACD are also evaluated.
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Affiliation(s)
- D L Denniss
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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Meltzer EC. Improving Communication With Surrogate Decision-Makers: A Pilot Initiative. J Grad Med Educ 2017; 9:461-466. [PMID: 28824759 PMCID: PMC5559241 DOI: 10.4300/jgme-d-17-00035.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Difficult conversations in medical care often occur between physicians and patients' surrogates, individuals entrusted with medical decisions for patients who lack the capacity to make them. Poor communication between patients' surrogates and physicians may exacerbate anxiety and guilt for surrogates, and may contribute to physician stress and burnout. OBJECTIVE This pilot study assesses the effectiveness of an experiential learning workshop that was conducted in a clinical setting, and aimed at improving resident physician communication skills with a focus on surrogate decision-making. METHODS From April through June 2016, we assessed internal medicine residents' baseline communication skills through an objective structured clinical examination (OSCE) with actors representing standardized surrogates. After an intensive, 6-hour communication skills workshop, residents were reassessed via an OSCE on the same day. A faculty facilitator and the surrogate evaluated participants' communication skills via the expanded Gap Kalamazoo Consensus Statement Assessment Form. Wilcoxon signed rank tests (α of .05) compared mean pre- and postworkshop scores. RESULTS Of 44 residents, 33 (75%) participated. Participants' average preworkshop OSCE scores (M = 3.3, SD = 0.9) were significantly lower than postworkshop scores (M = 4.3; SD = 0.8; Z = 4.193; P < .001; effect size r = 0.52). After the workshop, the majority of participants self-reported feeling "more confident." CONCLUSIONS Residents' communication skills specific to surrogate decision-making benefit from focused interventions. Our pilot assessment of a workshop showed promise, and additionally demonstrated the feasibility of bringing OSCEs and simulated encounters into a busy clinical practice.
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Berger JT. The Limits of Surrogates’ Moral Authority and Physician Professionalism:Can the Paradigm of Palliative Sedation Be Instructive? Hastings Cent Rep 2017; 47:20-23. [DOI: 10.1002/hast.665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Withdrawal of life-sustaining treatment: patient and proxy agreement: a secondary analysis of "contracts, covenants, and advance care planning". Dimens Crit Care Nurs 2016; 34:91-9. [PMID: 25650494 DOI: 10.1097/dcc.0000000000000097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Families of critically ill patients often make difficult decisions related to end-of-life (EOL) care including the withdrawal of life-sustaining therapies. OBJECTIVES This study explored patient and proxy decisions related to mechanical ventilator withdrawal in scenarios characterizing 3 distinct disease trajectories (cancer, stroke, and heart failure [HF]) with different prognoses. The relationship between patient directives, modification of directives, prognosis, trust, and EOL decisions were examined. METHODS This secondary analysis of data obtained in the "Contracts, Covenants, and Advance Care Planning" study included a sample of 110 subjects with 50 patient-proxy pairs. Patient and proxy agreement was assessed in response to questions regarding mechanical ventilator withdrawal while considering directives or modification of directives in 3 different scenarios. RESULTS Patient and proxy agreement ranged from 48% (n = 24 pairs) to 94% (n = 47 pairs). Agreement was lowest in HF (uncertain prognosis) when the directive indicated "do nothing" or "did not indicate any preference." Modified directives yielded 48% (n = 24 pairs) to 84% (n = 42 pairs) agreement. Changing directives from "do nothing" to "more hopeful" in HF (uncertain prognosis) had the highest agreement among modified scenarios. Despite wide variability in agreement, patients reported a high level of trust in their proxies' decisions. DISCUSSION This study highlighted differences in patient and proxy agreement about withdrawal of mechanical ventilation. Critical care nurses provide a key role in supporting EOL decisions. Encouraging ongoing communication about preferences and understanding the role of disease process and prognosis in decision making are paramount. Future research needs to explore factors that may improve patient and proxy agreement in EOL decisions and ways critical care nurses can support patients and proxies in these decisions, ultimately improving EOL care.
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Sussman B. A narrative approach to the ethical dilemmas of surrogate decision making. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Michael N, O'Callaghan C, Baird A, Hiscock N, Clayton J. Cancer caregivers advocate a patient- and family-centered approach to advance care planning. J Pain Symptom Manage 2014; 47:1064-77. [PMID: 24144996 DOI: 10.1016/j.jpainsymman.2013.07.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/19/2013] [Accepted: 07/23/2013] [Indexed: 11/29/2022]
Abstract
CONTEXT Cancer caregivers have important roles in delivering practical, emotional, and end-of-life support to patients; however, they express multiple unmet needs, particularly information on future care planning. Early regular communication and decision making may improve access to timely information, alleviate anxiety, reduce uncertainty, and improve coping strategies. OBJECTIVES This study examines how cancer caregivers view advance care planning (ACP) to inform an ACP program in an Australian cancer center. METHODS This study used a qualitative descriptive design with grounded theory overtones. Eighteen caregivers of patients from lung and gastrointestinal tumor streams participated in focus groups or semistructured interviews, which incorporated the vignette technique. RESULTS Caregivers believe that, although confronting, ACP discussions can be helpful. Conversations are sometimes patient initiated, although caregivers may intend to sensitively broach conversations over time. Findings highlight the impact of caregiver hierarchies, adaptive family decision-making styles, and complex cultural influences on decision making. Some caregivers may develop subsidiary care intentions, based on "knowing" or overriding patients' desires. Hindrances on caregivers supporting patients' ACPs include limited information access, patient or caregiver resistance to engage in conversations, and ACPs association in oncology with losing hope. Many caregivers wanted professional support and further opportunities to obtain information, develop subsidiary plans, and help patients engage in ACP discussions. CONCLUSION Findings highlight the influence of cancer caregivers and family dynamics over ACP decisions and actualization of future care plans. A patient- and family-centered care approach to ACP, promoting shared decision making and caregiver support, is recommended. Given that caregivers may override and, plausibly, misinterpret patients' desires, caregivers' subsidiary planning warrants further investigation.
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Affiliation(s)
- Natasha Michael
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
| | - Clare O'Callaghan
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Departments of Oncology and Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela Baird
- Department of Pain and Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Nathaniel Hiscock
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Josephine Clayton
- Hammond Care Palliative and Supportive Care Service, Greenwich Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Rhee JJ, Zwar NA, Kemp LA. Why Are Advance Care Planning Decisions Not Implemented? Insights from Interviews with Australian General Practitioners. J Palliat Med 2013; 16:1197-204. [DOI: 10.1089/jpm.2013.0156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joel J. Rhee
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Nicholas A. Zwar
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Lynn A. Kemp
- Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia
- Centre for Health Equity Training Research and Evaluation (CHETRE), University of New South Wales, Sydney, Australia
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Abstract
OBJECTIVE To understand what influences surrogate decision-makers' expectation that a patient with a disorder of consciousness (DOC; those in a coma, the vegetative state or the minimally conscious state) will recover. SUBJECTS Forty-one surrogates representing 37 DOC patients completed a survey about their experiences in having a family member with a DOC. METHODS A quantitative questionnaire assessed surrogate and patient's demographic, medical and psychosocial features that may explain surrogate's expectation of patient recovery. RESULTS Surrogates who were more relationally enmeshed with the patient thought the patient could communicate better and thought technology would improve treatment of patients with brain injury had greater expectations of recovery. Source of injury and patient's current diagnosis did not explain expectations. CONCLUSION Relational factors between the patient and the surrogate may explain the surrogate's expectation that the patient will recover more than factors that matter to clinicians such as the source of injury or the patient's diagnosis.
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Affiliation(s)
- Alexandra Suppes
- Division of Medical Ethics, Weill Medical College of Cornell University, New York, NY, USA.
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Understanding how cancer patients actualise, relinquish, and reject advance care planning: implications for practice. Support Care Cancer 2013; 21:2195-205. [PMID: 23494583 DOI: 10.1007/s00520-013-1779-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 02/25/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Although advance care planning (ACP) is recognised as integral to quality cancer care, it remains poorly integrated in many settings. Given cancer patients' unpredictable disease trajectories and equivocal treatment options, a disease-specific ACP model may be necessary. This study examines how Australian cancer patients consider ACP. Responses will inform the development of an Australian Cancer Centre's ACP programme. METHODS A constructivist research approach with grounded theory design was applied. Eighteen adults from lung and gastro-intestinal tumour streams participated. Participants first described their initial understanding of ACP, received ACP information, and finally completed a semi-structured interview assisted by the vignette technique. Qualitative inter-rater reliability was integrated. RESULTS Participants initially had scant knowledge of ACP. On obtaining further information, their responses indicated that: For cancer patients, ACP is an individualised, dynamic, and shared process characterised by myriad variations in choices to actualise, relinquish, and/or reject its individual components (medical enduring power of attorney, statement of choices, refusal of treatment certificate, and advanced directive). Actualisation of each component involves considering, possibly conversing about, planning, and communicating a decision, usually iteratively. Reactions can change over time and are informed by values, memories, personalities, health perceptions, appreciation of prognoses, and trust or doubts in their substitute decision makers. CONCLUSION Findings endorse the value of routinely, though sensitively, discussing ACP with cancer patients at various time points across their disease trajectory. Nonetheless, ACP may also be relinquished or rejected and ongoing offers for ACP in some patients may be offensive to their value system.
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Tunzi M. A New Standard for Incapacitated Patient Decision Making: The Clinical Standard of Surrogate Empowerment. THE JOURNAL OF CLINICAL ETHICS 2012. [DOI: 10.1086/jce201223404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Rhee JJ, Zwar NA, Kemp LA. Uptake and implementation of Advance Care Planning in Australia: findings of key informant interviews. AUST HEALTH REV 2012; 36:98-104. [PMID: 22513028 DOI: 10.1071/ah11019] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 04/27/2011] [Indexed: 11/23/2022]
Abstract
Objective. Advance Care Planning (ACP) has an important role in enhancing patient autonomy and guiding end-of-life care. However, there is low uptake of ACP and evidence that advance care plans are often not implemented. We explored these issues in interviews with expert clinicians and representatives of key stakeholder organisations with interest in end-of-life care. Method. Qualitative descriptive study of semi-structured telephone interviews with 23 participants. Results. Participants thought that the low uptake of ACP in Australia is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals’ involvement in ACP. Problems in implementation of advance care plans were thought to be a result of problems in accessing ACP documents; interpreting written documents; making binding decisions for future unpredictable situations; and paternalistic attitudes of health professionals and families. Participants had different perspectives on how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. Implications. Low uptake and poor implementation of advance care plans may be addressed by (1) increasing community awareness; (2) encouraging health professional involvement; and (3) system-wide implementation of multi-faceted interventions. A patient-centred approach to ACP is required to resolve the differences in views on how advance care plans should be implemented. What is known about the topic? Advance Care Planning (ACP) has been gaining prominence in Australia for its role in enhancing a patient’s autonomy and as an important component of good end-of-life care. Evidence from overseas and a limited number of Australian studies have identified several problems with ACP. First, the uptake of ACP seems to be low. Second, even when ACP process takes place, the resultant plans are often not implemented and make little effect on delivery of end-of-life care. What does this paper add? This paper confirms that the uptake of ACP is limited in Australia and is a result of inadequate awareness, societal reluctance to discuss end-of-life issues, and lack of health professionals’ involvement in ACP. Problems in implementation of advance care plans may be because of problems in: accessing ACP documents, interpreting written documents, making binding decisions for future unpredictable situations, and paternalistic attitudes of health professionals and families. This paper also shows that there are different perspectives in how advance care plans should be implemented, with some believing in strict implementation, whereas others believed in a more flexible approach. What are the implications for practitioners? This paper outlines several ways in which problems in the uptake and implementation of advance care plans may be addressed. This involves (1) increasing community awareness; (2) encouraging health professional involvement in ACP; and (3) system-wide implementation of multi-faceted interventions in ACP. Our findings also suggest that there needs to be a shift from a one-size-fits-all approach to implementing advance care plans to a more flexible patient-centred approach. This approach could ensure that a patient’s autonomy and right to self-determination are adequately protected, while also catering to the needs of those requiring more flexible approaches to end-of-life decision-making.
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Affiliation(s)
- Joel J Rhee
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
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Rhee JJ, Zwar NA. How is advance care planning conceptualised in Australia? Findings from key informant interviews. AUST HEALTH REV 2011; 35:197-203. [PMID: 21612734 DOI: 10.1071/ah10883] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Accepted: 10/19/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Advance Care Planning (ACP) has been gaining prominence as an important component of good end-of-life care. This study explored how ACP is conceptualised by stakeholder organisations and clinicians involved in aged care and end-of-life care in Australia, in particular their views on the aim, appropriate context and settings for ACP, and how ACP should be facilitated. PARTICIPANTS Twenty-three participants including expert clinicians and representatives of government organisations, professional societies, consumer groups and other organisations involved in aged care and end-of-life care. DESIGN Qualitative descriptive analysis of semi-structured telephone interviews. RESULTS Most participants viewed ACP as an ongoing process aimed at enhancing an individual's autonomy and ensuring good end-of-life care. However, there were significant differences in how this process was conceptualised. Some viewed ACP as a process undertaken by patients to define and communicate their treatment preferences. Others viewed ACP as discussions undertaken by health professionals to gain a better understanding of the patient's values and goals in order to provide good care. IMPLICATIONS Our findings highlight significant differences in how ACP is conceptualised in Australia. A shared conceptualisation and agreement on purpose is needed to ensure a successful implementation of ACP in Australia.
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Affiliation(s)
- Joel J Rhee
- Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, AGSM Building, Sydney, NSW 2052, Australia.
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Kirchhoff KT, Hammes BJ, Kehl KA, Briggs LA, Brown RL. Effect of a disease-specific planning intervention on surrogate understanding of patient goals for future medical treatment. J Am Geriatr Soc 2010; 58:1233-40. [PMID: 20649686 DOI: 10.1111/j.1532-5415.2010.02760.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether a disease-specific planning process can improve surrogate understanding of goals of patients with life-limiting illnesses for future medical treatments. DESIGN A multisite randomized controlled trial conducted between January 1, 2004 and July 31, 2007. SETTING Six outpatient clinics of large community or university health systems in three Wisconsin cities. PARTICIPANTS Competent, English-speaking adults aged 18 and older with chronic congestive heart failure or chronic renal disease and their surrogate decision-makers. INTERVENTION Trained health professionals conducted a structured, patient-centered interview intended to promote informed decision-making and to result in the completion of a document clarifying the goals of the patient with regard to four disease-specific health outcome situations and the degree of decision-making latitude granted to the surrogate. MEASUREMENTS Surrogate understanding of patient goals for care with regard to four expected, disease-specific outcomes situations and of the degree of surrogate latitude in decision-making. RESULTS Three hundred thirteen patient-surrogate pairs completed the study. As measured according to kappa scores and in all four situations and in the degree of latitude, intervention group surrogates demonstrated a significantly higher degree of understanding of patient goals than control group surrogates. Intervention group kappa scores ranged from 0.61 to 0.78, whereas control group kappa scores ranged from 0.07 to 0.28. CONCLUSION Surrogates in the intervention group had a significantly better understanding of patient goals and preferences than surrogates in the control group. This finding is the first step toward ensuring that patient goals for care are known and honored.
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Affiliation(s)
- Karin T Kirchhoff
- School of Nursing, University of Wisconsin at Madison, Madison, WI, USA.
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Karasz A, Sacajiu G, Kogan M, Watkins L. The Rational Choice Model in Family Decision Making at the End of Life. THE JOURNAL OF CLINICAL ETHICS 2010. [DOI: 10.1086/jce201021302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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21
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Abstract
Let’s face it, the humanities are in trouble. Last year, in The Chronicle of Higher Education, Thomas H. Benton warned prospective graduate students to avoid doctoral studies in the humanities. His rationale: a job market down 40%, the improbability of tenure, the more certain prospect of life as an adjunct, and eventual outright exile from one’s chosen field. Benton, the pen name of William Pannapacker, an associate professor of English at Hope College in Holland, Michigan, pulled no punches. His piece was entitled, “Graduate School in the Humanities: Just Don’t Go.”
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Berger JT. What about process? Limitations in advance directives, care planning, and noncapacitated decision making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:33-34. [PMID: 20379918 DOI: 10.1080/15265161003632948] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Mitnick S, Leffler C, Hood VL. Family caregivers, patients and physicians: ethical guidance to optimize relationships. J Gen Intern Med 2010; 25:255-60. [PMID: 20063128 PMCID: PMC2839338 DOI: 10.1007/s11606-009-1206-3] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 08/21/2009] [Accepted: 11/10/2009] [Indexed: 10/20/2022]
Abstract
Family caregivers play a major role in maximizing the health and quality of life of more than 30 million individuals with acute and chronic illness. Patients depend on family caregivers for assistance with daily activities, managing complex care, navigating the health care system, and communicating with health care professionals. Physical, emotional and financial stress may increase caregiver vulnerability to injury and illness. Geographically distant family caregivers and health professionals in the role of family caregivers may suffer additional burdens. Physician recognition of the value of the caregiver role may contribute to a positive caregiving experience and decrease rates of patient hospitalization and institutionalization. However, physicians may face ethical challenges in partnering with patients and family caregivers while preserving the primacy of the patient-physician relationship. The American College of Physicians in conjunction with ten other professional societies offers ethical guidance to physicians in developing mutually supportive patient-physician-caregiver relationships.
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Affiliation(s)
- Sheryl Mitnick
- Center for Ethics and Professionalism, American College of Physicians, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA.
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Do palliative patients and carers agree about patients' psychological functioning? Palliat Support Care 2010; 8:69-74. [DOI: 10.1017/s1478951509990721] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjective:Palliative care clinicians and researchers often seek information about patients from informants. This research examines the extent of agreement between information from patients and family caregivers who were asked to serve as collateral sources of information about the patient.Method:Sixty-six patients with advanced cancer and their family caregivers participated in the study. Two measurement contexts were examined: Direct observation of patients' cognitive performance (Mini-Mental State Examination) was compared with carers' subjective reports about patients' everyday cognition (Cognitive Decline subscale of the Psychogeriatric Assessment Scale), and subjective reports about patient depression were compared between patients and carers who completed parallel forms of the same scale (Geriatric Depression Scale and Geriatric Depression Scale–Collateral Source, respectively). The relationship between patient-completed and carer-completed measures was examined in four ways: the correlation between total scores in the sample, agreement about the prevalence of impaired functioning and of specific symptoms in the sample, agreement concerning whether particular patients showed impaired functioning, and agreement about the presence or absence of a specific symptom for a particular patient.Results:Although most measures of agreement showed that information provided by patients and carers was related, the magnitude of discrepancies was substantial.Significance of results:There was no empirical justification for substituting information from a collateral source for information provided by the patient for any of the measures of agreement for either cognition or depression. The use of information from collateral sources is most appropriate when information from the patient is likely to be incomplete or inaccurate, when insight into caregivers' needs or understanding is sought, and when using a multi-informant approach to assessment.
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Berger JT. Patients’ Concerns for Family Burden: A Nonconforming Preference in Standards for Surrogate Decision Making. THE JOURNAL OF CLINICAL ETHICS 2009. [DOI: 10.1086/jce200920207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Deep Brain Stimulation. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Fins JJ, Illes J. Lights, camera, inaction? Neuroimaging and disorders of consciousness. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2008; 8:W1-W3. [PMID: 18853370 DOI: 10.1080/15265160802479568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Torke AM, Alexander GC, Lantos J. Substituted judgment: the limitations of autonomy in surrogate decision making. J Gen Intern Med 2008; 23:1514-7. [PMID: 18618201 PMCID: PMC2518005 DOI: 10.1007/s11606-008-0688-8] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 04/30/2008] [Accepted: 05/21/2008] [Indexed: 11/29/2022]
Abstract
Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. In spite of this, many physicians and bioethicists continue to rely on the notion of substituted judgment. Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient's dignity and individuality rather than his or her autonomy.
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Affiliation(s)
- Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis, IN, USA.
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Wide variation in content of inpatient do-not-resuscitate order forms used at National Cancer Institute-designated cancer centers in the United States. Support Care Cancer 2008; 17:109-15. [DOI: 10.1007/s00520-008-0490-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 07/10/2008] [Indexed: 10/21/2022]
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Abstract
Informed consent is a perennial topic in bioethics. It has given the field a place in clinical practice and the law and is often the starting point for introductory instruction in medical ethics. One would think that nearly everything has been said and done on this well-worn topic.
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Robins-Browne K. Autonomy and advance care plans: a relationship oversimplified. Intern Med J 2008; 38:612-3. [DOI: 10.1111/j.1445-5994.2008.01702.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pieracci FM, Ullery BW, Eachempati SR, Nilson E, Hydo LJ, Barie PS, Fins JJ. Prospective analysis of life-sustaining therapy discussions in the surgical intensive care unit: a housestaff perspective. J Am Coll Surg 2008; 207:468-76. [PMID: 18926447 DOI: 10.1016/j.jamcollsurg.2008.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2008] [Revised: 05/05/2008] [Accepted: 05/05/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Prospective data addressing end-of-life care in the surgical ICU are lacking. We determined factors surrounding life-sustaining therapy discussions (LSTDs) in our surgical ICU as experienced by housestaff. STUDY DESIGN Housestaff were interviewed daily about the occurrence of an LSTD between themselves and either a patient or surrogate. Patients for whom at least one LSTD occurred were compared with patients for whom an LSTD never occurred. Housestaff also completed a standardized questionnaire that captured events surrounding each LSTD. RESULTS Eighty LSTDs occurred among 50 patients. Lack of decision-making capacity (p = 0.04), age (p = 0.02), and acuity (p = 0.01) predicted independently the occurrence of an LSTD. Housestaff were significantly more likely to both report recent clinical deterioration (p < 0.01) and to assign a worse prognosis (p < 0.01) to patients for whom an LSTD occurred. Housestaff initiated the majority of LSTDs (70.0%) and usually did so because of clinical deterioration (60.7%); patient surrogates were most commonly believed to initiate LSTDs because of lack of improvement (60.1%). In no instance did a patient initiate an LSTD. For 39 of 50 patients (78.0%), changes in end-of-life care plans were eventually enacted as proposed originally. Housestaff reported that the likelihood of enactment depended on both the preexisting end-of-life care plan and the proposed change in end-of-life care plan. CONCLUSIONS Age, acuity, and lack of decision-making capacity were the most important factors involved in the initiation of an LSTD. Housestaff reported that they initiated LSTDs for different reasons and proposed different end-of-life care plans relative to both patients and their surrogates. These disparities can contribute to failed enactment of proposed changes in end-of-life care plans.
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Affiliation(s)
- Fredric M Pieracci
- Department of Surgery, Weill Cornell Medical College, New York, NY 10021, USA.
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Seamark DA, Seamark CJ, Halpin DMG. Palliative care in chronic obstructive pulmonary disease: a review for clinicians. J R Soc Med 2007; 100:225-33. [PMID: 17470930 PMCID: PMC1861418 DOI: 10.1177/014107680710000512] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by airflow obstruction which ultimately kills many patients. It is common in both men and women and there is a 24-30% 5-year survival rate in the UK for those with severe disease. The annual death rate in the UK from COPD approaches that from lung cancer. Patients' symptoms can be improved by drug therapy, but stopping smoking is also an effective way of improving the outcome in patients at all stages of COPD. Predicting prognosis has been difficult in COPD due to the variable illness trajectory. However, assessment of severity of lung function impairment, frequency of exacerbations and requirement for long term oxygen therapy can help identify patients entering the final 12 months of life. Symptom burden and impact on activities of daily living for patients with COPD are comparable with that of cancer patients, and palliative care approaches are equally necessary, yet few publications exist to guide clinicians in this area. An evidence base exists for the management of dyspnoea with oxygen therapy and opioid drugs. There is less evidence for the effective treatment of depression and anxiety, fatigue and pain, and treatment is based on experience and considered best practice. This review discusses the problems that patients experience and offers practical guidance. The management of patients should be shared between primary and secondary care, with multidisciplinary teams being involved at an early stage. Patients and their families require honest and clear communication about the condition and what to expect in the future. The strict application of advance care planning and directives may not be feasible or appropriate, but there is evidence that attitudes towards resuscitation and artificial ventilation can be explored without distress. The requirement by patients and carers for surveillance and timely support is acknowledged, but how to provide such input is as yet unclear, with little evidence to support the widespread implementation of nurse-led management interventions. The hospice movement has become increasingly involved in the management of life-threatening, non-malignant disease and should be involved in the multidisciplinary care of patients dying from COPD.
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Seamark DA, Seamark CJ, Halpin DMG. Palliative care in chronic obstructive pulmonary disease: a review for clinicians. J R Soc Med 2007. [PMID: 17470930 DOI: 10.1258/jrsm.100.5.225] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by airflow obstruction which ultimately kills many patients. It is common in both men and women and there is a 24-30% 5-year survival rate in the UK for those with severe disease. The annual death rate in the UK from COPD approaches that from lung cancer. Patients' symptoms can be improved by drug therapy, but stopping smoking is also an effective way of improving the outcome in patients at all stages of COPD. Predicting prognosis has been difficult in COPD due to the variable illness trajectory. However, assessment of severity of lung function impairment, frequency of exacerbations and requirement for long term oxygen therapy can help identify patients entering the final 12 months of life. Symptom burden and impact on activities of daily living for patients with COPD are comparable with that of cancer patients, and palliative care approaches are equally necessary, yet few publications exist to guide clinicians in this area. An evidence base exists for the management of dyspnoea with oxygen therapy and opioid drugs. There is less evidence for the effective treatment of depression and anxiety, fatigue and pain, and treatment is based on experience and considered best practice. This review discusses the problems that patients experience and offers practical guidance. The management of patients should be shared between primary and secondary care, with multidisciplinary teams being involved at an early stage. Patients and their families require honest and clear communication about the condition and what to expect in the future. The strict application of advance care planning and directives may not be feasible or appropriate, but there is evidence that attitudes towards resuscitation and artificial ventilation can be explored without distress. The requirement by patients and carers for surveillance and timely support is acknowledged, but how to provide such input is as yet unclear, with little evidence to support the widespread implementation of nurse-led management interventions. The hospice movement has become increasingly involved in the management of life-threatening, non-malignant disease and should be involved in the multidisciplinary care of patients dying from COPD.
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Volandes AE, Abbo ED. Flipping the Default: A Novel Approach to Cardiopulmonary Resuscitation in End-Stage Dementia. THE JOURNAL OF CLINICAL ETHICS 2007. [DOI: 10.1086/jce200718204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Nilson EG, Fins JJ. Reinvigorating Ethics Consultations: An Impetus from the “Quality” Debate. HEC Forum 2006; 18:298-304. [PMID: 17717754 DOI: 10.1007/s10730-006-9020-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Elizabeth G Nilson
- Division of Medical Ethics, New York Presbyterian-Weill Cornell Medical Center, 435 East 70th Street, Suite 4-J, New York, NY 10021, USA.
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Bacchetta MD, Eachempati SR, Fins JJ, Hydo L, Barie PS. Factors influencing DNR decision-making in a surgical ICU. J Am Coll Surg 2006; 202:995-1000. [PMID: 16735215 DOI: 10.1016/j.jamcollsurg.2006.02.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Revised: 02/09/2006] [Accepted: 02/20/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients. STUDY DESIGN All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p </= 0.05 used to reject the null hypothesis. RESULTS Mortality for DNR patients was 84.7%. Multiple organ dysfunction syndrome was ubiquitous in this group of patients. There were no differences between DNR and no-DNR groups on the basis of age or APACHE III score or multiple organ dysfunction score. ICU lengths of stay were substantially higher in the patients made DNR, 1.8 +/- 0.1 versus 1.0 +/- 0.1, p = 0.0001, and 16.9 +/- 0.2 versus 12.1 +/- 1.2, p = 0.011, respectively. Multivariate ANOVA revealed that only past medical history predicted a DNR order. CONCLUSIONS Although acuity of illness and organ dysfunction consistently predicted mortality in critically ill patient populations, only elements of the past medical history were positively associated with a DNR order in critically ill surgical patients. Additional prospective studies need to be performed to determine the relative influences of physiologic, demographic, and sociologic factors on the creation of DNR orders in critically ill surgical patients.
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Affiliation(s)
- Matthew D Bacchetta
- Department of Surgery, Weill Medical College of Cornell University, New York, NY, USA
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Fins JJ. Clinical pragmatism and the care of brain damaged patients: toward a palliative neuroethics for disorders of consciousness. PROGRESS IN BRAIN RESEARCH 2005; 150:565-82. [PMID: 16186050 DOI: 10.1016/s0079-6123(05)50040-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Unraveling the mysteries of consciousness, lost and regained, and perhaps even intervening so as to prompt recovery are advances for which neither the clinical nor the lay community are prepared. These advances will shake existing expectations about severe brain damage and will find an unprepared clinical context, perhaps even one inhospitable to what should clearly be viewed as important advances. This could be the outcome of this line of inquiry, if this exceptionally imaginative research can continue at all. This work faces a restrictive research environment that has the potential to imperil it. Added to the complexity of the scientific challenges that must be overcome is the societal context in which these investigations must occur. Research on human consciousness goes to the heart of our humanity and asks us to grapple with fundamental questions about the self. Added to this is the regulatory complexity of research on subjects who may be unable to provide their own consent because of impaired decision-making capacity, itself a function of altered or impaired consciousness. These factors can lead to a restrictive view of research that can favor risk aversion over discovery. In this paper, I attempt to explain systematically some of these challenges. I suggest that some of the resistance might be tempered if we view the needs of patients with severe brain injury through the prism of palliative care and adopt that field's ethos and methods when caring for and conducting research on individuals with severe brain damage and disorders of consciousness. To make this argument I draw upon the American pragmatic tradition and utilize clinical pragmatism, a method of moral problem-solving that my colleagues and I have developed to address ethical challenges in clinical care and research.
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Affiliation(s)
- Joseph J Fins
- Division of Medical Ethics, Weill Medical College of Cornell University, 435 East 70th Street, Suite 4-J, NY 10021, USA.
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