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Viana JN, Pilbeam C, Howard M, Scholz B, Ge Z, Fisser C, Mitchell I, Raman S, Leach J. Maintaining High-Touch in High-Tech Digital Health Monitoring and Multi-Omics Prognostication: Ethical, Equity, and Societal Considerations in Precision Health for Palliative Care. OMICS : A JOURNAL OF INTEGRATIVE BIOLOGY 2023; 27:461-473. [PMID: 37861713 DOI: 10.1089/omi.2023.0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Advances in digital health, systems biology, environmental monitoring, and artificial intelligence (AI) continue to revolutionize health care, ushering a precision health future. More than disease treatment and prevention, precision health aims at maintaining good health throughout the lifespan. However, how can precision health impact care for people with a terminal or life-limiting condition? We examine here the ethical, equity, and societal/relational implications of two precision health modalities, (1) integrated systems biology/multi-omics analysis for disease prognostication and (2) digital health technologies for health status monitoring and communication. We focus on three main ethical and societal considerations: benefits and risks associated with integration of these modalities into the palliative care system; inclusion of underrepresented and marginalized groups in technology development and deployment; and the impact of high-tech modalities on palliative care's highly personalized and "high-touch" practice. We conclude with 10 recommendations for ensuring that precision health technologies, such as multi-omics prognostication and digital health monitoring, for palliative care are developed, tested, and implemented ethically, inclusively, and equitably.
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Affiliation(s)
- John Noel Viana
- Australian National Centre for the Public Awareness of Science, College of Science, The Australian National University, Canberra, Australia
- Responsible Innovation Future Science Platform, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - Caitlin Pilbeam
- School of Medicine and Psychology, College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Mark Howard
- Monash Data Futures Institute, Monash University, Clayton, Australia
- Department of Philosophy, School of Philosophical, Historical and International Studies, Monash University, Clayton, Australia
| | - Brett Scholz
- School of Medicine and Psychology, College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Zongyuan Ge
- Monash Data Futures Institute, Monash University, Clayton, Australia
- Department of Data Science & AI, Monash University, Clayton, Australia
| | - Carys Fisser
- Australian National Centre for the Public Awareness of Science, College of Science, The Australian National University, Canberra, Australia
- School of Medicine and Psychology, College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Imogen Mitchell
- School of Medicine and Psychology, College of Health and Medicine, The Australian National University, Canberra, Australia
- Intensive Care Unit, Canberra Hospital, Canberra, Australia
| | - Sujatha Raman
- Australian National Centre for the Public Awareness of Science, College of Science, The Australian National University, Canberra, Australia
| | - Joan Leach
- Australian National Centre for the Public Awareness of Science, College of Science, The Australian National University, Canberra, Australia
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Basta LL. Routine Implantation of Cardioverter/Defibrillator Devices in Patients Aged 75 Years and Older With Prior Myocardial Infarction and Left Ventricular Ejection Fraction <30: Antagonist Viewpoint. ACTA ACUST UNITED AC 2007; 12:363-5. [PMID: 14610386 DOI: 10.1111/j.1076-7460.2003.02917.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The Multicenter Automatic Defibrillator Implantation Trial (MADIT II) investigators assert that their results justify the placement of artificial implantable defibrillator cardioverter devices in patients aged 75 years and older with prior myocardial infarction and left ventricular dysfunction (ejection fraction of 30 or less). The authors claim that the results of the trial do not justify this conclusion. The majority of patients were male (84%) and aged 64+/-10 years. Also, 2.8% of patients assigned to the defibrillator group and 1.5% had their device removed. Of the latter subgroup, nine patients (1.3%) received a heart transplant. Twelve had their artificial implantable defibrillator cardioverter device deactivated mostly because of terminal illness. Although the study results show a significant reduction in mortality over the control group (absolute reduction=5.6%), almost the same percentage required hospitalization because of manifestation of congestive heart failure (absolute value 5%; p=0.09). Also, 1.8% had lead problems, 0.7% had infections, and the benefits were only seen after the first year. Caution is needed before the results of this study are applied to a much older cohort comprised mainly of women in whom heart transplant is contraindicated and who have multiple health problems, including cognitive impairment. Artificial implantable cardioverter/defibrillator devices are expensive and this study's results need to be duplicated in other comparable cohorts.
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Affiliation(s)
- Lofty L Basta
- Project GRACE, Clearwater, FL and the University of Florida, Tampa, FL, USA
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Basta LL. End‐of‐Life and Other Ethical Issues Related to Pacemaker and Defibrillator Use in the Elderly. ACTA ACUST UNITED AC 2007; 15:114-7. [PMID: 16525225 DOI: 10.1111/j.1076-7460.2006.04818.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In the past decade, the rate of implantation of pacemakers and cardioverter-defibrillators in the elderly with cardiac impairment has soared. As patients near the end of life, interventions become more complicated and expensive, and less effective. In this context, "informed consent" requires consideration of issues different from those faced in more routine settings. Informed consent requires full disclosure, patient competence, and free exercise of will-but in practice, few patients or their families are in a position to make fully informed decisions about highly complex treatments at the end of life. Physicians continue to bear the responsibility of advising patients about sophisticated interventions or, alternatively, palliative care. Physician training, with its narrow focus on the treatment of disease with drugs and technology, has not prepared physicians to advise patients on issues arising from the availability of multiple interventions at the end of life. Professional societies can fill a gap by developing programs and materials to help physicians treat their dying patients in a high-technology era.
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Basta LL. Ethical issues in the management of geriatric cardiac patients. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2003; 12:263-4. [PMID: 12888708 DOI: 10.1111/j.1076-7460.2003.02377.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 92-year-old patient dies less than a year after aortic valve replacement, pacemaker-AICD implantation, renal dialysis, and rehabilitation at a cost of over a half million dollars.
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Basta LL. Ethical issue: The patient undergoes surgery that she knows will not benefit her, hoping that she will die in the process while under anesthesia. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2003; 12:207-8. [PMID: 12732818 DOI: 10.1111/j.1076-7460.2003.02372.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Recognizing that little is known about use of quality improvement (QI) processes to enhance care of the dying, 11 large hospices exchanged information about their QI programs. These hospices reported monitoring from 3 to 50 outcomes measured by various indicators and methods. Agencies that related QI to their organization's mission, goals, and strategic plan were more likely to have dedicated QI staff; a more intense, comprehensive, and participatory QI program; and more QI projects resulting in performance enhancement. Both accomplishments and difficulties were identified in several areas, including establishing benchmarks, involving staff, and using computer technology to manage and analyze QI data.
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Affiliation(s)
- C N D'Onofrio
- School of Public Health, University of California at Berkeley, Berkeley, California, USA
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de Vos R, Koster RW, de Haan RJ. Impact of survival probability, life expectancy, quality of life and patient preferences on do-not-attempt-resuscitation orders in a hospital. Resuscitation Committee. Resuscitation 1998; 39:15-21. [PMID: 9918443 DOI: 10.1016/s0300-9572(98)00097-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Consensus exists that a do-not-attempt-resuscitation order (DNAR) is appropriate if a resuscitation attempt is futile. Less agreement exists when this point is reached. We investigated the influence of three major considerations for in-hospital DNAR orders: expected survival probability after resuscitation, prospects of the patients' current condition without a cardiac arrest and the patients' autonomous decision not to want resuscitation. We calculated an expected survival probability according to two multi-morbidity prediction scores for each patient, assuming the event of cardiac arrest. The prospects of the current condition without a cardiac arrest was estimated by the patients' physician, in terms of life expectancy and quality of life (level of dependency after discharge and pain). The patients' preference was documented from the medical records. A total of 470 patients were included in the study. Fifty-eight patients (12%) had a DNAR-order, 11 of these patients (19%) wanted no resuscitation. The patients' prospects (life expectancy, dependency after discharge), and age proved to be independently associated with the presence of a DNAR order. The odds ratio (OR) for the presence of a DNAR order was 37 (CL 14-107) for an estimated life expectancy less than 3 months, 13 (CL 4-41) for a life in a nursing home and four (CL 2-12) for an age of 80 years and older. Expected survival probability after resuscitation and pain were not independently associated with a DNAR order. We conclude that resuscitation is considered futile on the basis of the patients' age and prospects without cardiac arrest and that the impact of expected survival probability on these decisions is small.
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Affiliation(s)
- R de Vos
- Department of Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands.
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