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Muishout G, El Amraoui A, Wiegers GA, van Laarhoven HWM. Muslim Jurisprudence on Withdrawing Treatment from Incurable Patients: A Directed Content Analysis of the Papers of the Islamic Fiqh Council of the Muslim World League. JOURNAL OF RELIGION AND HEALTH 2024; 63:1230-1267. [PMID: 36446918 DOI: 10.1007/s10943-022-01700-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 06/16/2023]
Abstract
This study investigates the views of contemporary Muslim jurists about withdrawing treatment of the terminally ill. Its aim is threefold. Firstly, it analyses jurists' views concerning core themes within the process of withdrawing treatment. Secondly, it provides insight into fatwas about withdrawing treatment. Thirdly, it compares these views with current medical standards in Europe and the Atlantic world on withdrawing treatment. The data consisted of six papers by Muslim jurists presented at the conference of the Islamic Fiqh Council in 2015. We conducted a directed content analysis (DCA) through a predetermined framework and compiled an overview of all previous fatwas referred to in the papers, which are also analysed. The results show that the general consensus is that if health cannot be restored, treatment may be withdrawn at the request of the patient and/or his family or on the initiative of the doctor. The accompanying fatwa emphasizes the importance of life-prolonging treatment if this does not harm the patient. It becomes apparent in the fatwa that the doctor has the monopoly in decision-making, which is inconsistent with current medical standards in Europe. Managing disclosure in view of the importance of maintaining the hope of Muslim patients may challenge the doctor's obligation to share a diagnosis with them.
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Affiliation(s)
- George Muishout
- Department of History, European Studies and Religious Studies, Amsterdam School for Historical Studies, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - Gerard Albert Wiegers
- Department of History, European Studies and Religious Studies, Amsterdam School for Historical Studies, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Wilma Marlies van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Damps M, Gajda M, Kowalska M, Kucewicz-Czech E. Limitation of Futile Therapy in the Opinion of Nursing Staff Employed in Polish Hospitals-Results of a Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16975. [PMID: 36554855 PMCID: PMC9778965 DOI: 10.3390/ijerph192416975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
The debate on limiting futile therapy in the aspect of End of Life (EoL) care has been going on in Poland over the last decade. The growing demand for EoL care resulting from the aging of societies corresponds to the expectation of a satisfactory quality of life and self-determination. The authors designed a cross-sectional study using a newly designed questionnaire to assess the opinions of 190 nurses employed in intensive care units (ICUs) on futile therapy, practices, and the respondents' approach to the issue. The problem of futile therapy and its clinical implications are known to the nursing community. Among the most common reasons for undertaking futile therapy in adult patients, the respondents declared fear of legal liability for not taking such actions (71.58%), as well as fear of being accused of unethical conduct (56.32%), and fear of talking to the patient/patient's family and their reaction (43.16%). In the case of adult patients, the respondents believed that discontinuation of futile therapy should be decided by the patient (84.21%), followed by a doctor (64.21%). As for paediatric patients, two-thirds of the respondents mentioned a doctor and a court (64.74% and 64.21%, respectively). Overall, 65.26% of the respondents believe and agree that the comfort of the patient's last days is more important than the persistent continuation of therapy and prolonging life at all costs. The presented results clearly show the attitude of the respondents who defend the patient's dignity and autonomy.
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Affiliation(s)
- Maria Damps
- Department of Anaesthesiology and Intensive Care, Upper Silesian Child Health Centre, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 16, 40-752 Katowice, Poland
| | - Maksymilian Gajda
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Malgorzata Kowalska
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Ewa Kucewicz-Czech
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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Elmahjub E. Normative account of Islamic bioethics in end-of-life care. Glob Bioeth 2022; 33:133-154. [PMID: 36506006 PMCID: PMC9733680 DOI: 10.1080/11287462.2022.2118977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This article addresses the bioethical challenges raised by end-of-life care (EoLC) from the perspective of Islamic normativity. Rejecting positivist positions, it argues for the use of a flexible approach midway between a deontological conception of human life as having a sacred value that cannot be bargained over, as represented by the teachings of Abū Ḥāmid al-Ghazālī's, and one that introduces considerations of pain (alam) and pleasure (ladhdah) into ethical evaluations, as expounded by the jurist Fakhr al-Dīn al-Rāzī. Under this approach, described as "Islamic evaluator relativity," moral agents formulate a normative position tailored to their beliefs and the circumstances of the case, in which the right course of action is expressed as a value judgement (amr ijtihādi) and the evaluator (mujtahid) is rewarded regardless of the choices they make. Keywords: Islamic bioethics, End-of-life-care, bioethics, normative ethics.
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Affiliation(s)
- Ezieddin Elmahjub
- Associate Professor of Law, Qatar University, Doha, Qatar, Ezieddin Elmahjub
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Voultsos P, Tsompanian A, Tsaroucha AK. The medical futility experience of nursing professionals in Greece. BMC Nurs 2021; 20:254. [PMID: 34930253 PMCID: PMC8690940 DOI: 10.1186/s12912-021-00785-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background Providing futile medical care is an ever-timely ethical problem in clinical practice. While nursing personnel are very closely involved in providing direct care to patients nearing the end of life, their role in end-of-life decision-making remains unclear. Methods This was a prospective qualitative study conducted with experienced nursing professionals from December 2020 through May 2021. Individual in-depth qualitative interviews were conducted with sixteen participants. We performed a thematic analysis of the data. Results Importantly, many participants were half-hearted in their attitude towards accepting or defining futile medical care. Furthermore, interestingly, a list of well-described circumstances emerged, under which the dying process is most likely to be a “bad and undignified” process. These circumstances reflected situations revolving around a) pain and suffering, b) treating patients with respect, c) the appearance and image of the patient body, and d) the interaction between patients and their relatives. Fear of legal action, the lack of a regulatory framework, physicians being pressured by (mostly uninformed) family members and physicians’ personal motives were reported as important reasons behind providing futile medical care. The nursing professional’s role as a participant in decisions on futile care and as a mediator between physicians and patients (and family members) was highlighted. Furthermore, the patient’s role in decisions on futile care was prioritized. The patient’s effort to keep themselves alive was also highlighted. This effort impacts nursing professionals’ willingness to provide care. Providing futile care is a major factor that negatively affects nursing professionals’ inner attitude towards performing their duties. Finally, the psychological benefits of providing futile medical care were highlighted, and the importance of the lack of adequately developed end-of-life care facilities in Greece was emphasized. Conclusions These findings enforce our opinion that futile medical care should be conceptualized in the strict sense of the term, namely, as caring for a brain-dead individual or a patient in a medical condition whose continuation would most likely go against the patient’s presumed preference (strictly understood). Our findings were consistent with prior literature. However, we identified some issues that are of clinical importance.
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Affiliation(s)
- Polychronis Voultsos
- Laboratory of Forensic Medicine & Toxicology (Medical Law and Ethics), School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, GR, Greece.
| | - Anna Tsompanian
- Postgraduate Program on Bioethics, Democritus University of Thrace, School of Medicine, Dragana, 68100, Alexandroupolis, GR, Greece
| | - Alexandra K Tsaroucha
- Postgraduate Program on Bioethics, Laboratory of Bioethics, Laboratory of Experimental Surgery and Surgical Research, Democritus University of Thrace, School of Medicine, Dragana, 68100, Alexandroupolis, GR, Greece
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Considering Futility of Care Decisions in Neurosurgical Practice. World Neurosurg 2021; 156:120-124. [PMID: 34563717 DOI: 10.1016/j.wneu.2021.09.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 12/25/2022]
Abstract
Neurosurgeons commonly encounter futility of care decisions in their practice. Are these decisions being made with adequate consideration? What is the preparation of neurosurgical trainees for making these decisions? The advent of the COVID-19 pandemic with its extreme pressure on resources and, in particular, intensive care unit beds, has prompted many health care providers including neurosurgeons to consider more fully the potentially futile nature of some treatments and how we might better manage limited resources for the future. We review the concept of futility in neurosurgery and suggest potential solutions to the multiple challenges that arise.
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Flugelman MY. History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS JOURNAL FOR MEDICAL EDUCATION 2021; 38:Doc109. [PMID: 34651067 PMCID: PMC8493840 DOI: 10.3205/zma001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 01/18/2021] [Accepted: 05/20/2021] [Indexed: 06/13/2023]
Abstract
The relevance and importance of the medical interview has been challenged with improved imaging technologies, web-based medicine, and use of artificial intelligence. The medical interview has three goals: Acquiring accurate medical data about the patient and the etiology of symptoms and signs, learning about the patient's personality, culture, and beliefs, and creating and building trust with the patient. Reduced human resources in the medical system and increased crowding in the interview setting, such as the emergency room and outpatient clinics, have strengthened the need for high quality and efficient interviews that fulfils the three goals of the interview. This manuscript proposes a structured six methods that contribute to the quality and efficiency of the medical interview with special focus on learning about the patients' life and creating trust with him.
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Affiliation(s)
- Moshe Y. Flugelman
- Lady Davis Carmel Medical Center, Department of Cardiovascular Medicine, Haifa, Israel
- Technion, Israel Institute of Technology, Rappaport Faculty of Medicine, Haifa, Israel
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Keller EJ, Rabei R, Heller M, Kothary N. Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis. Cardiovasc Intervent Radiol 2020; 44:127-133. [PMID: 33078233 DOI: 10.1007/s00270-020-02675-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement. METHODS Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1-39 years of experience) and 7 referring physicians (3 males, 4 females, 6-14 years of experience) were analyzed. RESULTS Many IRs (75%) perceived futility as an important issue. Years of experience (r = 0.60, p = 0.03) and being in academics (r = 0.62, p = 0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility. CONCLUSION This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.
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Affiliation(s)
- Eric J Keller
- Department of Radiology, Stanford University, Stanford, 300 Pasteur Drive, H3630, Stanford, CA, 94305, USA.
| | - Rana Rabei
- Department of Radiology and Biomedical Imaging, UCSF, 505 Parnassus Avenue, M-391, San Francisco, CA, 94143, USA
| | - Michael Heller
- Department of Radiology and Biomedical Imaging, UCSF, 505 Parnassus Avenue, M-391, San Francisco, CA, 94143, USA
| | - Nishita Kothary
- Department of Radiology, Stanford University, Stanford, 300 Pasteur Drive, H3630, Stanford, CA, 94305, USA
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Hsu NC, Huang CC, Chen WC, Yu CJ. Impact of patient-centred and family-centred care meetings on intensive care and resource utilisation in patients with terminal illness: a single-centre retrospective observational study in Taiwan. BMJ Open 2019; 9:e021561. [PMID: 30782862 PMCID: PMC6368162 DOI: 10.1136/bmjopen-2018-021561] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE Shared decision making is essential for patients and their families when facing serious and life-threatening diseases. This study aimed to evaluate the impact of patient-centred and family-centred care meetings (PFCCM) on intensive measures and resource utilisation during end-of-life (EOL) hospitalisation among terminally ill patients. DESIGN AND SETTING A retrospective cross-sectional study using electronic medical records was conducted in a tertiary referral medical centre in Taiwan. PARTICIPANTS We identified 6843 deceased patients with terminal illness who either received or did not receive PFCCM during EOL hospitalisation between January 2013 and December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Patients who were transferred to the intensive care unit (ICU). Those who underwent invasive or non-invasive mechanical ventilation, tracheostomy, haemodialysis and surgical intervention during the final hospitalisation were determined by the use of intensive care measures; secondary measures were individual total and daily medical expenditures. A generalised estimating equation (GEE) model was used to compare the differences between the two groups. OR and beta coefficients (β) with 95% CI were estimated. RESULTS This study identified 459 patients (6.7%) who received PFCCM during EOL hospitalisation. Multivariate analyses showed that patients who received PFCCM were less likely to have ICU admissions (OR 0.44, 95% CI 0.34 to 0.57), undergo surgical interventions (OR 0.74, 95% CI 0.58 to 0.95) and invasive mechanical ventilation (OR 0.50, 95% CI 0.38 to 0.66) during the final hospitalisation, after adjusting for patient demographics, clinical conditions and year of admission. Additionally, a significant decrease in daily medical expenditures was observed in PFCCM patients (β -0.18, 95% CI -0.25 to -0.12) than in non-PFCCM patients. CONCLUSIONS Patient-physician discussion through PFCCM is associated with less intensive care utilisation and daily medical expenditure during EOL hospitalisation in terminally ill patients.
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Affiliation(s)
- Nin-Chieh Hsu
- Division of Hospital Medicine, Department of Internal Medicine, National Taiwan Uinversity Hospital, Taipei, Taiwan
| | - Chun-Che Huang
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Chun Chen
- Medical Affairs Office, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Kelley AT, Turner J, Doolittle B. Barriers to Advance Care Planning in End-Stage Renal Disease: Who is to Blame, and What Can be Done? New Bioeth 2018. [PMID: 29513084 DOI: 10.1080/20502877.2018.1438772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patients with end-stage renal disease experience significant mortality and morbidity, including cognitive decline. Advance care planning has been emphasized as a responsibility and priority of physicians caring for patients with chronic kidney disease in order to align with patient values before decision-making capacity is lost and to avoid suffering. This emphasis has proven ineffective, as illustrated in the case of a patient treated in our hospital. Is this ineffectiveness a consequence of failure in the courtroom or the clinic? Through our own experience we affirm what has been written before: that legal precedent favors intensive treatment in virtually all cases without 'clear and convincing evidence' of a patient's previously declared wishes to the contrary. Equally clear is that more than 20 years of support in the clinical literature suggesting advance care planning early in the course of disease can address challenges in the legal system for those lacking capacity. However, many physicians fail to recognize the need for advance care planning in a timely manner and lack the necessary training to provide it. The need for more training and new tools to recognize opportunities for advance care planning in daily practice remains unmet.
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Affiliation(s)
- Alan Taylor Kelley
- a Combined Internal Medicine-Pediatrics Residency Program, Yale University School of Medicine , New Haven , CT , USA
| | - Jeffrey Turner
- b Department of Internal Medicine , Yale University School of Medicine , New Haven , CT , USA
| | - Benjamin Doolittle
- c Departments of Internal Medicine and Pediatrics , Yale University School of Medicine , New Haven , CT , USA
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Williams SB, Dahnke MD. Clarification and Mitigation of Ethical Problems Surrounding Withdrawal of Extracorporeal Membrane Oxygenation. Crit Care Nurse 2018; 36:56-65. [PMID: 27694358 DOI: 10.4037/ccn2016504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is temporary life-support technology that provides time to rest the cardiac and respiratory system of critically ill people with acute, reversible medical conditions. Health care providers face emotional and challenging situations, where death may result, when withdrawing ECMO. A deepening of understanding of the ethical issues involved can aid clinicians in handling such difficult situations, leading to a possible mitigation of the moral problems. Toward this end, the ethical issues raised in the consideration of ECMO withdrawal are analyzed with respect to the ethical principles and concepts of autonomy, nonmaleficence/beneficence, medical futility, moral distress, and justice. In particular, these issues are considered in relation to how they affect and can be addressed by staff nurses and advanced practice nurses in the intensive care unit. Advanced practice nurses in particular can represent the voice of nurses to promote a healthier workplace in situations of moral distress related to stopping ECMO life-support technology and in developing clear and consistent guidelines for ceasing ECMO treatment, all leading toward clarification and mitigation of the ethical problems surrounding the withdrawal of this critical technology.
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Affiliation(s)
- Susan B Williams
- Susan B. Williams is an expert intensive care nurse and clinical specialist in extracorporeal membrane oxygenation who worked for 25 years in the newborn/infant intensive care unit at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.Michael Dahnke is a bioethicist and adjunct instructor in the School of Nursing at the College of New Rochelle, New Rochelle, New York, and adjunct instructor in the philosophy department at the College of Staten Island, New York, New York
| | - Michael D Dahnke
- Susan B. Williams is an expert intensive care nurse and clinical specialist in extracorporeal membrane oxygenation who worked for 25 years in the newborn/infant intensive care unit at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.Michael Dahnke is a bioethicist and adjunct instructor in the School of Nursing at the College of New Rochelle, New Rochelle, New York, and adjunct instructor in the philosophy department at the College of Staten Island, New York, New York.
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Abstract
PURPOSE OF REVIEW Decisions to forego life-sustaining treatments are complex, and disagreements between physicians and patients occur. This review discusses recent findings regarding what factors influence physicians and patients or their surrogates in these decisions and considers whether futility arguments regarding life-sustaining treatments should be abandoned. RECENT FINDINGS Cardiopulmonary resuscitation is one paradigm in the literature for studying end-of-life decision-making. Outcomes for cardiopulmonary resuscitation are poor, and physicians tend to over-rely on tacit versus evidence-based knowledge for resuscitation decisions. Physician decisions are often inherently biased regarding elderly and intellectually impaired patients. Patient decisions regarding life-sustaining treatments are poorly understood by physicians, and also include inherent bias against the elderly and intellectually impaired. Although patients and their decision-makers frequently incorporate religious or spiritual beliefs in their decisions, physicians rarely discuss these factors with them. Defining 'futility' is problematic, and futility arguments have limited utility in clinical end-of-life treatment discussions. SUMMARY Further research is needed about factors that affect both physicians and patients with regard to forgoing life-sustaining interventions. Physicians need more information regarding religious/spiritual preferences of patients and decision-makers. 'Futility' arguments in end-of-life decision-making are flawed and should probably be abandoned.
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Affiliation(s)
- Gail A Van Norman
- Department of Anesthesiology and Pain Medicine and as Adj Professor of Bioethics, University of Washington, Seattle, Washington, USA
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White B, Willmott L, Close E, Shepherd N, Gallois C, Parker MH, Winch S, Graves N, Callaway LK. What does "futility" mean? An empirical study of doctors' perceptions. Med J Aust 2017; 204:318. [PMID: 27125807 DOI: 10.5694/mja15.01103] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 12/08/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate how doctors define and use the terms "futility" and "futile treatment" in end-of-life care. DESIGN, SETTING, PARTICIPANTS A qualitative study using semi-structured interviews with 96 doctors from a range of specialties which treat adults at the end of life. Doctors were recruited from three large Brisbane teaching hospitals and were interviewed between May and July 2013. RESULTS Doctors' conceptions of futility focused on the quality and prospect of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life. Quality and length of life were linked, but many doctors discussed instances in which benefit was determined by quality of life alone. Most described assessing the prospects of achieving patient benefit as a subjective exercise. Despite a broad conceptual consensus about what futility means, doctors noted variability in how the concept was applied in clinical decision making. More than half the doctors also identified treatment that is futile but nevertheless justified, such as short term treatment that supports the family of a dying person. CONCLUSIONS There is an overwhelming preference for a qualitative approach to assessing futility, which inevitably involves variability in clinical decision making. Patient benefit is at the heart of doctors' definitions of futility. Determining patient benefit requires discussing with patients and their families their values and goals as well as the burdens and benefits of further treatment.
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Affiliation(s)
- Ben White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD
| | - Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD
| | | | | | | | | | - Nicholas Graves
- Institute of Health and Biomedical Information, Queensland University of Technology, Brisbane, QLD
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Rak A, Raina R, Suh TT, Krishnappa V, Darusz J, Sidoti CW, Gupta M. Palliative care for patients with end-stage renal disease: approach to treatment that aims to improve quality of life and relieve suffering for patients (and families) with chronic illnesses. Clin Kidney J 2016. [PMID: 28638606 PMCID: PMC5469574 DOI: 10.1093/ckj/sfw105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Providing end-of-life care to patients suffering from chronic kidney disease (CKD) and/or end-stage renal disease often presents ethical challenges to families and health care providers. However, as the conditions these patients present with are multifaceted in nature, so should be the approach when determining prognosis and treatment strategies for this patient population. Having an interdisciplinary palliative team in place to address any concerns that may arise during conversations related to end-of-life care encourages effective communication between the patient, the family and the medical team. Through the use of a case study, the authors demonstrate how an interdisciplinary palliative team can be used to make decisions that satisfy the patient's and the medical team's desires for end-of-life care.
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Affiliation(s)
- Amy Rak
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | - Rupesh Raina
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA.,Department of Nephrology, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | - Theodore T Suh
- Division of Geriatric and Palliative Medicine, University of Michigan Health System, Geriatric Research Education and Clinical Center, Ann Arbor VA Hospital, Ann Arbor, MI, USA
| | - Vinod Krishnappa
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA.,Department of Nephrology, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | - Jessica Darusz
- Department of Internal Medicine and Research, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA.,Department of Nephrology, Akron General Medical Center-Cleveland Clinic, Akron, OH, USA
| | | | - Mona Gupta
- Section of Palliative Medicine, Taussig Cancer Institute, Cleveland, OH, USA.,Center for Geriatric Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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14
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Luo N, Rogers JG, Dodson GC, Patel CB, Galanos AN, Milano CA, O'Connor CM, Mentz RJ. Usefulness of Palliative Care to Complement the Management of Patients on Left Ventricular Assist Devices. Am J Cardiol 2016; 118:733-8. [PMID: 27474339 DOI: 10.1016/j.amjcard.2016.06.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/07/2016] [Accepted: 06/07/2016] [Indexed: 12/25/2022]
Abstract
Within the last decade, advancements in left ventricular assist device therapy have allowed patients with end-stage heart failure (HF) to live longer and with better quality of life. Like other life-saving interventions, however, there remains the risk of complications including infections, bleeding episodes, and stroke. The candidate for left ventricular assist device therapy faces complex challenges going forward, both physical and psychological, many of which may benefit from the application of palliative care principles by trained specialists. Despite these advantages, palliative care remains underused in many advanced HF programs. Here, we describe the benefits of palliative care, barriers to use within HF, and specific applications to the integrated care of patients on mechanical circulatory support.
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Affiliation(s)
- Nancy Luo
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina.
| | - Joseph G Rogers
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gwen C Dodson
- Palliative Medicine Section, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Anthony N Galanos
- Palliative Medicine Section, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Christopher M O'Connor
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Robert J Mentz
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina
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Willmott L, White B, Gallois C, Parker M, Graves N, Winch S, Callaway LK, Shepherd N, Close E. Reasons doctors provide futile treatment at the end of life: a qualitative study. JOURNAL OF MEDICAL ETHICS 2016; 42:496-503. [PMID: 27188227 DOI: 10.1136/medethics-2016-103370] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/24/2016] [Indexed: 05/09/2023]
Abstract
OBJECTIVE Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient's life. DESIGN Semistructured in-depth interviews. SETTING Three large tertiary public hospitals in Brisbane, Australia. PARTICIPANTS 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. RESULTS Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care. CONCLUSIONS Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.
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Affiliation(s)
- Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Benjamin White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- Faculty of Social and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Malcolm Parker
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sarah Winch
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Leonie Kaye Callaway
- Department of Internal Medicine, The Royal Brisbane and Womens Hospital, Herston, Queensland, Australia
| | - Nicole Shepherd
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
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16
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Clarke MJ, Fenton KN, Sade RM. Does Declaration of Brain Death Serve the Best Interest of Organ Donors Rather Than Merely Facilitating Organ Transplantation? Ann Thorac Surg 2016; 101:2053-8. [PMID: 27112652 DOI: 10.1016/j.athoracsur.2016.01.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/23/2016] [Accepted: 01/28/2016] [Indexed: 01/10/2023]
Affiliation(s)
| | | | - Robert M Sade
- Department of Surgery, Institute of Human Values in Health Care, Medical University of South Carolina, Charleston, South Carolina.
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17
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Merrick A. A Paradox of Hope? Toward a Feminist Approach to Palliation. INTERNATIONAL JOURNAL OF FEMINIST APPROACHES TO BIOETHICS 2016. [DOI: 10.3138/ijfab.9.1.104] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In this article, I address the role of hope in medical decision making. Against the backdrop of the so-called paradox of hope, I consider the relationship between medical futility and the preservation of hope. I build on the work of feminist bioethicists to argue that only a feminist approach to palliation may properly dissolve the paradox of hope.
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18
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Lanier WL. Celebrating Mayo Clinic Proceedings' 90th Anniversary: A Story of Longevity and Progression of Mission. Mayo Clin Proc 2016; 91:3-9. [PMID: 26763509 DOI: 10.1016/j.mayocp.2015.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 11/18/2022]
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19
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Rab T, Kern KB, Tamis-Holland JE, Henry TD, McDaniel M, Dickert NW, Cigarroa JE, Keadey M, Ramee S. Cardiac Arrest: A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient. J Am Coll Cardiol 2015; 66:62-73. [PMID: 26139060 DOI: 10.1016/j.jacc.2015.05.009] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/28/2015] [Accepted: 05/05/2015] [Indexed: 12/14/2022]
Abstract
Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. Although there is an American College of Cardiology Foundation/American Heart Association Class I recommendation for performing immediate angiography and percutaneous coronary intervention (when indicated) in patients with ST-segment elevation myocardial infarction, no guidelines exist for patients without ST-segment elevation. Early introduction of mild therapeutic hypothermia is an established treatment goal. However, there are no established guidelines for risk stratification of patients for cardiac catheterization and possible percutaneous coronary intervention, particularly in patients who have unfavorable clinical features in whom procedures may be futile and affect public reporting of mortality. An algorithm is presented to improve the risk stratification of these severely ill patients with an emphasis on consultation and evaluation of patients prior to activation of the cardiac catheterization laboratory.
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Affiliation(s)
- Tanveer Rab
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
| | - Karl B Kern
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | | | - Timothy D Henry
- Division of Cardiology, Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael McDaniel
- Division of Cardiology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Neal W Dickert
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Joaquin E Cigarroa
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, Oregon
| | - Matthew Keadey
- Division of Emergency Medicine, Emory University Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Stephen Ramee
- Structural and Valvular Heart Disease Program, Ochsner Medical Center, New Orleans, Louisiana
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20
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LAMPERT RACHEL. “Unilateral ICD Deactivation”: No Ethical Leg to Stand On. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:914-6. [DOI: 10.1111/pace.12645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/12/2015] [Indexed: 11/30/2022]
Affiliation(s)
- RACHEL LAMPERT
- Yale University School of Medicine; New Haven Connecticut
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21
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Wu MY, Wu TI, Tseng YH, Shen WC, Chang YS, Huang CC, Lin PJ. The feasibility of venovenous extracorporeal life support to treat acute respiratory failure in adult cancer patients. Medicine (Baltimore) 2015; 94:e893. [PMID: 26020399 PMCID: PMC4616423 DOI: 10.1097/md.0000000000000893] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Venovenous extracorporeal life support (VV-ECLS) is a lifesaving but invasive treatment for acute respiratory failure (ARF) that is not improved with conventional therapy. However, using VV-ECLS to treat ARF in adult cancer patients is controversial. This retrospective study included 14 cancer patients (median age: 58 years [interquartile range: 51-66]; solid malignancies in 13 patients and hematological malignancy in 1 patient) who received VV-ECLS for ARF that developed within 3 months after anticancer therapies. VV-ECLS would be considered in selected patients with a P(a)O2/F(i)O2 ratio ≤70 mmHg under advanced mechanical ventilation. Before ECLS, the medians of intubation day, P(a)O2/F(i)O2 ratio, and Sequential Organ Failure Assessment (SOFA) score were 8 (2-12), 62 mmHg (53-76), and 10 (9-14), respectively. The case numbers of bacteremia, thrombocytopenia (platelet count <50000 cells/μL), and neutropenia (actual neutrophil count <1000 cells/μL) detected before ECLS were 3 (21%), 2 (14%), and 1 (7%), respectively. After 24 hours of ECLS, a significant improvement was seen in P(a)O2/F(i)O2 ratio but not in SOFA score. Six patients experienced major hemorrhages during ECLS. The median ECLS day, ECLS weaning rate, and hospital survival were 11 (7-16), 50% (n = 7), and 29% (n = 4). The development of dialysis-dependent nephropathy predicted death on ECLS (odds ratio: 36; 95% confidence interval: 1.8-718.7; P = 0.01). With a median follow-up of 11 (6-43) months, half of the survivors died of cancer recurrence and the others were in partial remission. The most prominent benefit of VV-ECLS is to improve the arterial oxygenation and rest the lungs. This may increase the chance of recovery from ARF in selected cancer patients.
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Affiliation(s)
- Meng-Yu Wu
- From the Department of Cardiovascular Surgery, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan (M-YW, Y-HT, Y-SC, P-JL); Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University, Taipei (T-IW); Department of Hematology-Oncology (W-CS); and Department of Thoracic Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan (C-CH)
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22
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Daeschler M, Verdino RJ, Caplan AL, Kirkpatrick JN. Defibrillator Deactivation against a Patient's Wishes: Perspectives of Electrophysiology Practitioners. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:917-24. [PMID: 25683098 DOI: 10.1111/pace.12614] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 01/30/2015] [Accepted: 02/09/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unilateral do-not-resuscitate (DNR) orders (against patient/family wishes) have been ethically justified in cases of medical futility. We investigated whether electrophysiology practitioners believe medical futility justifies unilateral implantable cardioverter defibrillator (ICD) deactivation. METHODS AND RESULTS Email invitations to take an online survey were sent to 1,894 electrophysiology practitioners. A total of 384 responses were collected (response rate 20.6%). Though the sample included respondents from Europe, Asia, Australia, South America, and Africa, the majority were from North America (78%), were academically affiliated (64%), and practiced in an urban setting (67.8%). Deactivation of ICD shock function in agreement with patient wishes and a preexisting DNR were not considered physician-assisted suicide (93.2%, 358/384). However, a majority of the sample responded that it was not ethical/moral for doctors to deactivate ICDs against patients' wishes (77.1%, 296/384) or against family/surrogates' wishes (72.4%, 278/384), even in the context of medical futility. A majority indicated that deactivating ICD shock function is not ethically/morally different than withholding cardiopulmonary resuscitation or external defibrillation in a code (72.7%, 277/381), but was different than deactivating pacing in a pacemaker-dependent patient (82.8%, 318/384). In the classification of interventions, a plurality (43.0%, 165/383) regarded ICDs to be unlike any other intervention. Concerning pacemakers, 50% (191/382) considered them to be like dialysis (a therapy that keeps patients alive). CONCLUSIONS This international sample of electrophysiology practitioners considered ICD and pacemaker deactivation to be ethically distinct. While ICD deactivation was considered appropriate in the setting of patient/family agreement, unilateral deactivation was not.
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Recent Literature Feature Editor: Paul C. Rousseau. J Palliat Med 2015. [DOI: 10.1089/jpm.2015.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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