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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 The results show that the general consensus is that if health cannot be restored, treatment may be withdrawn at the request of the patient and/or his family or on the initiative of the doctor.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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Ishii J, Nishikimi M, Ohshimo S, Shime N. The Current Discussion Regarding End-of-Life Care for Patients with Out-of-Hospital Cardiac Arrest with Initial Non-Shockable Rhythm: A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:533. [PMID: 38674179 PMCID: PMC11052369 DOI: 10.3390/medicina60040533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/04/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Despite recent advances in resuscitation science, outcomes in patients with out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythm remains poor. Those with initial non-shockable rhythm have some epidemiological features, including the proportion of patients with a witnessed arrest, bystander cardiopulmonary resuscitation (CPR), age, and presumed etiology of cardiac arrest have been reported, which differ from those with initial shockable rhythm. The discussion regarding better end-of-life care for patients with OHCA is a major concern among citizens. As one of the efforts to avoid unwanted resuscitation, advance directive is recognized as a key intervention, safeguarding patient autonomy. However, several difficulties remain in enhancing the effective use of advance directives for patients with OHCA, including local regulation of their use, insufficient utilization of advance directives by emergency medical services at the scene, and a lack of established tools for discussing futility of resuscitation in advance care planning. In addition, prehospital termination of resuscitation is a common practice in many emergency medical service systems to assist clinicians in deciding whether to discontinue resuscitation. However, there are also several unresolved problems, including the feasibility of implementing the rules for several regions and potential missed survivors among candidates for prehospital termination of resuscitation. Further investigation to address these difficulties is warranted for better end-of-life care of patients with OHCA.
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Affiliation(s)
| | - Mitsuaki Nishikimi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8551, Japan; (J.I.); (S.O.); (N.S.)
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Rubin EB, Robinson EM, Cremens MC, McCoy TH, Courtwright AM. Declining to Provide or Continue Requested Life-Sustaining Treatment: Experience With a Hospital Resolving Conflict Policy. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:457-466. [PMID: 37380828 DOI: 10.1007/s11673-023-10270-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/31/2022] [Indexed: 06/30/2023]
Abstract
In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.
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Affiliation(s)
- Emily B Rubin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, Bullfinch Building, Boston, MA, 02114, USA.
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Patient Care Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry Massachusetts General Hospital, Boston, MA, USA
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Piscitello GM, Tyker A, Schenker Y, Arnold RM, Siegler M, Parker WF. Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic. Crit Care Med 2023; 51:1012-1022. [PMID: 36995088 PMCID: PMC10526631 DOI: 10.1097/ccm.0000000000005863] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic. DESIGN We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021. SETTING Two academic medical centers in the Chicago metropolitan area. PATIENTS Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7). CONCLUSIONS In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Albina Tyker
- Division of Respirology, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mark Siegler
- Department of Medicine, University of Chicago, Chicago, IL
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| | - William F Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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Ostermann M, Bagshaw SM, Lumlertgul N, Wald R. Indications for and Timing of Initiation of KRT. Clin J Am Soc Nephrol 2023; 18:113-120. [PMID: 36100262 PMCID: PMC10101614 DOI: 10.2215/cjn.05450522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
KRT is considered for patients with severe AKI and associated complications. The exact indications for initiating KRT have been debated for decades. There is a general consensus that KRT should be considered in patients with AKI and medically refractory complications ("urgent indications"). "Relative indications" are more common but defined with less precision. In this review, we summarize the latest evidence from recent landmark clinical trials, discuss strategies to anticipate the need for KRT in individual patients, and propose an algorithm for decision making. We emphasize that the decision to consider KRT should be made in conjunction with other forms of organ support therapies and important nonkidney factors, including the patient's preferences and overall goals of care. We also suggest future research to differentiate patients who benefit from timely initiation of KRT from those with imminent recovery of kidney function. Until then, efforts are needed to optimize the initiation and delivery of KRT in routine clinical practice, to minimize nonessential variation, and to ensure that patients with persistent AKI or progressive organ failure affected by AKI receive KRT in a timely manner.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King’s College London, Guy’s & St. Thomas’ Hospital, London, United Kingdom
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Nuttha Lumlertgul
- Department of Critical Care, King’s College London, Guy’s & St. Thomas’ Hospital, London, United Kingdom
- Division of Nephrology and Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Department of Nephrology, Center of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Ron Wald
- Division of Nephrology, St. Michael’s Hospital and the University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada
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Wijdicks EFM. The History of Self-Fulfilling Prophesy: Sociocultural Thinkers Enter Medicine. Neurocrit Care 2022:10.1007/s12028-022-01628-7. [PMID: 36396740 DOI: 10.1007/s12028-022-01628-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Eelco F M Wijdicks
- Neurocritical Care Services, Saint Marys Hospital Mayo Clinic, 200 First Street SW, Rochester, MN, USA.
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Koets V, Montagnini M. Acute Myeloid Leukemia: Challenges in Delivering End-of-Life Care. Am J Hosp Palliat Care 2022:10499091221124110. [DOI: 10.1177/10499091221124110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with Acute Myeloid Leukemia (AML) have a complex disease trajectory characterized by high symptom and psychosocial burden, a high rate of hospitalization and intensive care unit admission at the end-of-life (EOL), and frequent use of chemotherapy near the EOL. In addition, palliative and hospice care are underutilized in patients with AML despite their poor prognosis. Clinicians providing care to patients with end-stage AML frequently encounter multiple challenges, particularly surrounding the frequent administration of blood products near the EOL. We present a case of a patient with end-stage AML whose desire for transfusions causes significant patient and caregiver distress at the EOL. Balancing patient autonomy with the potentially inappropriate use of blood transfusions at the EOL and having good communication and collaboration among healthcare teams are important considerations when delivering optimal EOL care to patients with AML.
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Affiliation(s)
- Vani Koets
- Hospice and Palliative Medicine, Spectrum Health Medical Group, Grand Rapids, MI, USA
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The Association Between Factors Promoting Nonbeneficial Surgery and Moral Distress: A National Survey of Surgeons. Ann Surg 2022; 276:94-100. [PMID: 33214444 PMCID: PMC9635854 DOI: 10.1097/sla.0000000000004554] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the prevalence of moral distress among surgeons and test the association between factors promoting non-beneficial surgery and surgeons' moral distress. SUMMARY BACKGROUND DATA Moral distress experienced by clinicians can lead to low-quality care and burnout. Older adults increasingly receive invasive treatments at the end of life that may contribute to surgeons' moral distress, particularly when external factors, such as pressure from colleagues, institutional norms, or social demands, push them to offer surgery they consider non-beneficial. METHODS We mailed surveys to 5200 surgeons randomly selected from the American College of Surgeons membership, which included questions adapted from the revised Moral Distress Scale. We then analyzed the association between factors influencing the decision to offer surgery to seriously ill older adults and surgeons' moral distress. RESULTS The weighted adjusted response rate was 53% (n = 2161). Respondents whose decision to offer surgery was influenced by their belief that pursuing surgery gives the patient or family time to cope with the patient's condition were more likely to have high moral distress (34% vs 22%, P < 0.001), and this persisted on multivariate analysis (odds ratio 1.44, 95% confidence interval 1.02-2.03). Time required to discuss nonoperative treatments or the consulting intensivists' endorsement of operative intervention, were not associated with high surgeon moral distress. CONCLUSIONS Surgeons experience moral distress when they feel pressured to perform surgery they believe provides no clear patient benefit. Strategies that empower surgeons to recommend nonsurgical treatments when they believe this is in the patient's best interest may reduce nonbeneficial surgery and surgeon moral distress.
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10
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Javanmard-Emamghissi H, Lockwood S, Hare S, Lund JN, Tierney GM, Moug SJ. The false dichotomy of surgical futility in the emergency laparotomy setting: scoping review. BJS Open 2022; 6:zrac023. [PMID: 35389427 PMCID: PMC8988868 DOI: 10.1093/bjsopen/zrac023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Futile is defined as 'the fact of having no effect or of achieving nothing'. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This scoping review aimed to identify key concepts around surgical futility as it relates to emergency laparotomy. METHODS Using the Arksey and O'Malley framework, a scoping review was conducted. A search of the Cochrane Library, Google Scholar, MEDLINE, and Embase was performed up until 1 November 2021 to identify literature relevant to the topic of futility in emergency laparotomy. RESULTS Three cohort studies were included in the analysis. A total of 105 157 patients were included, with 1114 patients reported as futile. All studies were recent (2019 to 2020) and focused on the principle of quantitative futility (assessment of the probability of death after surgery) within a timeline after surgery: two defining futility as death within 48 hours of surgery and one as death within 72 hours. In all cases this was derived from a survival histogram. Predictors of defined futile procedures included age, level of independence prior to admission, surgical pathology, serum creatinine, arterial lactate, and pH. CONCLUSION There remains a paucity of research defining, exploring, and analysing futile surgery in patients undergoing emergency laparotomy. With limited published work focusing on quantitative futility and the binary outcome of death, research is urgently needed to explore all principles of futility, including the wishes of patients and their families.
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Affiliation(s)
- Hannah Javanmard-Emamghissi
- Faculty of Medicine, Division of Health Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - Sonia Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - Sarah Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - Jon N. Lund
- Faculty of Medicine, Division of Health Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | | | - Susan J. Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
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Catholic Perspective on Decision-Making for Critically Ill Newborns and Infants. CHILDREN 2022; 9:children9020207. [PMID: 35204927 PMCID: PMC8870660 DOI: 10.3390/children9020207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
In this paper, we discuss the foundational values informing the Catholic perspective on decision-making for critically ill newborns and infants, particularly focusing on the prudent use of medical technologies. Although the Church has consistently affirmed the general good of advances in scientific research and medicine, the technocratic paradigm of medicine may, particularly in cases with severely ill infants, lead to decision-making conflicts and breakdowns in communication between parents and providers. By exploring two paradigm cases, we offer specific practices in which providers can engage to connect with parents and avoid common technologically mediated decision-making conflicts. By focusing on the inherent relationality of all human persons, regardless of debility, and the Christian hope in the life to come, we can make decisions in the midst of the technocratic paradigm without succumbing to it.
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12
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Olson S, Rosenfeld JV, Honeybul S. Neurotrauma, COVID and the rationing intensive care: an ethical approach. Br J Neurosurg 2022; 36:594-599. [DOI: 10.1080/02688697.2021.2024507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Sarah Olson
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
- Department of Surgery, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Australia
- Royal Perth Hospital, Perth, Australia
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Piscitello GM, Kapania EM, Kanelidis A, Siegler M, Parker WF. The Use of Slow Codes and Medically Futile Codes in Practice. J Pain Symptom Manage 2021; 62:326-335.e5. [PMID: 33346066 PMCID: PMC8729118 DOI: 10.1016/j.jpainsymman.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac life support but do not provide full resuscitation efforts, are ethically controversial. OBJECTIVES To describe the use of slow codes in practice and their association with clinicians' attitudes and moral distress. METHODS We conducted a cross-sectional survey at Rush University and University of Chicago in January 2020. Participants included physician trainees, attending physicians, nurses, and advanced practice providers who care for critically ill patients. RESULTS Of the 237 respondents to the survey (31% response rate, n = 237/753), almost half (48%) were internal medicine residents (46% response rate, n = 114/246). Over two-thirds of all respondents (69%) reported caring for a patient where a slow code was performed, with a mean of 1.3 slow codes (SD 1.7) occurring in the past year per participant. A narrow majority of respondents (52%) reported slow codes are ethical if the code is medically futile. Other respondents (46%) reported slow codes are not ethical, with 19% believing no code should be performed and 28% believing a full guideline consistent code should be performed. Most respondents reported moral distress when being required to run (75%), do chest compressions for (80%), or witness (78%) a cardiac resuscitation attempt they believe to be medically futile. CONCLUSION Slow codes occur in practice, even though many clinicians ethically disagree with their use. The use of cardiac resuscitation attempts in medically futile situations can cause significant moral distress to medical professionals who agree or are forced to participate in them.
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Affiliation(s)
- Gina M Piscitello
- Section of Palliative Medicine, Rush Medical College, Chicago, Illinois, USA.
| | - Esha M Kapania
- Department of Medicine, Rush Medical College, Chicago, Illinois, USA
| | - Anthony Kanelidis
- Section of Cardiology, University of Chicago, Chicago, Illinois, USA
| | - Mark Siegler
- Department of Medicine, University of Chicago, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - William F Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA; Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
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Netters S, Dekker N, van de Wetering K, Hasker A, Paasman D, de Groot JW, Vissers KCP. Pandemic ICU triage challenge and medical ethics. BMJ Support Palliat Care 2021; 11:133-137. [PMID: 33541855 PMCID: PMC7868132 DOI: 10.1136/bmjspcare-2020-002793] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/24/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
The COVID-19 pandemic has made unprecedented global demands on healthcare in general and especially the intensive care unit (ICU). the virus is spreading out of control. To this day, there is no clear, published directive for doctors regarding the allocation of ICU beds in times of scarcity. This means that many doctors do not feel supported by their government and are afraid of the medicolegal consequences of the choices they have to make. Consequently, there has been no transparent discussion among professionals and the public. The thought of being at the mercy of absolute arbitrariness leads to fear among the population, especially the vulnerable groups.
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Affiliation(s)
- Sabine Netters
- Oncology Centre and Internal Medicine Department, Isala, Zwolle, The Netherlands
| | - Nick Dekker
- Oncology Centre and Internal Medicine Department, Isala, Zwolle, The Netherlands
| | | | - Annie Hasker
- Pastoral Care Department, Isala, Zwolle, The Netherlands
| | - Dian Paasman
- Internal Medicine Department, Isala, Zwolle, The Netherlands
| | - Jan Willem de Groot
- Oncology Centre and Internal Medicine Department, Isala, Zwolle, The Netherlands
| | - Kris C P Vissers
- Anaesthesiology Department, Radboud University Medical Center, Nijmegen, The Netherlands
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Critical decision-making in neonatology and pediatrics: the I-P-O framework. J Perinatol 2021; 41:173-178. [PMID: 32999448 DOI: 10.1038/s41372-020-00841-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/25/2020] [Accepted: 09/18/2020] [Indexed: 11/09/2022]
Abstract
Critical decision-making in neonatology and other areas of pediatrics often carries with it a complex and difficult ethical component. For any treatment under consideration, the impermissible-permissible-obligatory (I-P-O) spectrum provides a useful framework for determining how to proceed. Any proposed treatment can be located along this spectrum, and identified as either ethically impermissible, permissible, or obligatory. Treatments determined to be ethically impermissible should not be made available by physicians. Those deemed ethically permissible should be explained to parents, commonly with a specific recommendation. Informed parents should then be free to choose from among permissible options. Potential treatments deemed ethically obligatory should be provided to the patient, even in the face of parental objection. The fundamental ethical work in neonatology and pediatrics is determining where on the I-P-O spectrum a treatment under consideration should be located. This should be determined by the prognosis for the patient with and without the treatment, the feasibility of providing the treatment, and consideration of all relevant rights and obligations. Location on the line is dynamic, and clinicians should be open to movement of a given treatment along the spectrum as new information, particularly regarding effectiveness, toxicity, and/or alternatives, becomes available. This framework provides a structure for ethical conversation and decision-making related to a specific patient, as well as in the formation of institutional and national guidelines.
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Affiliation(s)
- David L S Ryon
- Department of Medicine, Deaconess Health System, Evansville, IN
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17
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Wolf-Meyer M. Neurological disorders, affective bioethics, and the nervous system: reconsidering the Schiavo case from a materialist perspective. MEDICAL HUMANITIES 2020; 46:166-175. [PMID: 30954935 DOI: 10.1136/medhum-2018-011568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 12/28/2018] [Accepted: 01/15/2019] [Indexed: 06/09/2023]
Abstract
This article proposes a novel approach to bioethics, referred to as "affective bioethics", which draws on traditions in anthropology, science and technology studies, disability studies, and Spinozist materialism. By focusing on the case of Michael and Terri Schiavo, in which Terri's personhood and subjectivity are challenged by dominant forms of neurological reductivism in the USA, this article suggests that approaching her condition as a set of relations with the people in her life and her socio-technical environment may have helped to develop new ways to conceptualise personhood and subjectivity moving beyond the view of her as a non-person. Drawing on Michael Schiavo's memoir of his legal battles, and Terri's diagnosis and care, this article shows how Terri's connections to the world disrupt American ideas about the isolatable individual as the basis for personhood and subjectivity. Attending to these interpersonal and socio-technical connections focuses bioethical attention on the worlds that individuals inhabit, and how those worlds might be designed to make more kinds of life livable and new forms of personhood and subjectivity possible.
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Sawhill C, Fipps DC, Palomo JV, Miller M. End-Stage Anorexia Nervosa: When to Say "When"-A Literature Review of an Ethically Complicated Case. PSYCHOSOMATICS 2020; 61:779-786. [PMID: 32674855 DOI: 10.1016/j.psym.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Christine Sawhill
- University of South Carolina, Greenville, Prisma Health, Upstate, Greenville, SC.
| | - David C Fipps
- University of South Carolina, Greenville, Prisma Health, Upstate, Greenville, SC
| | - Jennifer V Palomo
- University of South Carolina, Greenville, Prisma Health, Upstate, Greenville, SC
| | - Melanie Miller
- Consult Liaison Division, Department of Psychiatry, Prisma Health, Upstate, Greenville, SC
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Lotz C, Muellenbach RM, Meybohm P, Rolfes C, Wulf H, Reyher C. [Preclinical management of cardiac arrest-extracorporeal cardiopulmonary resuscitation]. Anaesthesist 2020; 69:404-413. [PMID: 32435820 DOI: 10.1007/s00101-020-00787-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The chances of surviving out-of-hospital cardiac arrest (OHCA) are still very low. Despite intensive efforts the outcome has remained relatively poor over many years. In specific situations, new technologies, such as extracorporeal cardiopulmonary resuscitation (eCPR) could significantly improve survival with a good neurological outcome. OBJECTIVE Does the immediate restoration of circulation and reoxygenation via eCPR influence the survival rate after OHCA? Is eCPR the new link in the chain of survival? MATERIAL AND METHODS Discussion of current study results and guideline recommendations. RESULTS The overall survival rates after OHCA have remained at 10-30% over many years. Despite low case numbers more recent retrospective studies showed that an improved outcome can be achieved with eCPR. In selected patient collectives survival with a favorable neurological outcome is possible in 38% of the cases. CONCLUSION Survival after cardiac arrest and the subsequent quality of life dependent on many different factors. The time factor, i.e. the avoidance of a no-flow phase and reduction of the low-flow phase is of fundamental importance. The immediate restoration of the circulation and oxygen supply by eCPR can significantly improve survival; however, large randomized, controlled trials are currently not available.
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Affiliation(s)
- C Lotz
- Klinik und Poliklinik für Anästhesiologie, Direktor: Univ.-Prof. Dr. P. Meybohm, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - R M Muellenbach
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Kassel, Kassel, Deutschland
| | - P Meybohm
- Klinik und Poliklinik für Anästhesiologie, Direktor: Univ.-Prof. Dr. P. Meybohm, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - C Rolfes
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Kassel, Kassel, Deutschland.,Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Marburg, Marburg, Deutschland
| | - H Wulf
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Marburg, Marburg, Deutschland
| | - C Reyher
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Kassel, Kassel, Deutschland
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20
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Muscatello MRA, Zoccali RA, Bruno A. Is there a time when prescribing pharmacotherapy in psychiatry is futile? Expert Opin Pharmacother 2020; 21:733-735. [DOI: 10.1080/14656566.2020.1729739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Rocco Antonio Zoccali
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Antonio Bruno
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
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21
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Cummings BM, Mercurio MR, Paris JJ. A review of approaches for resolving disputes between physicians and families on end-of-life care for newborns. J Perinatol 2020; 40:1441-1445. [PMID: 32393828 PMCID: PMC7223960 DOI: 10.1038/s41372-020-0675-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 03/27/2020] [Accepted: 04/24/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Brian M. Cummings
- grid.32224.350000 0004 0386 9924Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114 USA
| | - Mark R. Mercurio
- grid.47100.320000000419368710Yale School of Medicine, New Haven, CT 06504 USA
| | - John J. Paris
- grid.208226.c0000 0004 0444 7053Boston College, Chestnut Hill, MA 02167 USA ,grid.262952.80000 0001 0699 5924Present Address: St. Joseph’s University, Philadelphia, PA USA
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Abstract
Patient and family demands for the initiation or continuation of life-sustaining medically non-beneficial treatments continues to be a major issue. This is especially relevant in intensive care units, but is also a challenge in other settings, most notably with cardiopulmonary resuscitation. Differences of opinion between physicians and patients/families about what are appropriate interventions in specific clinical situations are often fraught with highly strained emotions, and perhaps none more so when the family bases their desires on religious belief. In this essay, I discuss non-beneficial treatments in light of these sorts of disputes, when there is a clash between the nominally secular world of fact- and evidence-based medicine and the faith-based world of hope for a miraculous cure. I ask the question whether religious belief can justify providing treatment that has either no or a vanishly small chance of restoring meaningful function. I conclude that non-beneficial therapy by its very definition cannot be helpful, and indeed is often harmful, to patients and hence cannot be justified no matter what the source or kind of reasons used to support its use. Therefore, doctors may legitimately refuse to provide such treatments, so long as they do so for acceptable clinical reasons. They must also offer alternatives, including second (and third) opinions, as well the option of transferring the care of the patient to a more accommodating physician or institution.
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Affiliation(s)
- Philip M Rosoff
- Trent Center for Bioethics, Humanities and History of Medicine, Duke University Medical Center, 108 Seeley G. Mudd Building, Box 3040, 10 Bryan-Searle Drive, Durham, NC, 27710, USA. .,Departments of Pediatrics and Medicine, Duke University Medical Center, Durham, NC, USA.
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23
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Kuczewski MG. Everything I Really Needed to Know to Be a Clinical Ethicist, I Learned From Elisabeth Kübler-Ross. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:13-18. [PMID: 31746704 DOI: 10.1080/15265161.2019.1674410] [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: 06/10/2023]
Abstract
I analyze the insights present in Elisabeth Kübler-Ross's seminal work, On Death and Dying that have laid the foundation for contemporary clinical bioethics as it is practiced by clinical ethics consultants. I highlight the landmark insight of Elisabeth Kübler-Ross that listening to dying patients reveals their needs and enables them to enjoy a better death. But more important for contemporary clinical ethics is that the text highlights three tensions that the clinical ethicist must navigate but can never truly resolve. Clinical ethicists must balance: (1) the need to hear the patient's voice with the temptation to overly medicalize the case, (2) helping the patient achieve a better death with enabling the patient to die in the way he or she chooses, and (3) keeping professional distance with engaging the patient in a way that respects the intimacy of the patient's disclosures.
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25
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Salter EK. The new futility? The rhetoric and role of "suffering" in pediatric decision-making. Nurs Ethics 2019; 27:16-27. [PMID: 31032704 DOI: 10.1177/0969733019840745] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article argues that while the presence and influence of "futility" as a concept in medical decision-making has declined over the past decade, medicine is seeing the rise of a new concept with similar features: suffering. Like futility, suffering may appear to have a consistent meaning, but in actuality, the concept is colloquially invoked to refer to very different experiences. Like "futility," claims of patient "suffering" have been used (perhaps sometimes consciously, but most often unconsciously) to smuggle value judgments about quality of life into decision-making. And like "futility," it would behoove us to recognize the need for new, clearer terminology. This article will focus specifically on secondhand claims of patient suffering in pediatrics, but the conclusions could be similarly applied to medical decisions for adults being made by surrogate decision-makers. While I will argue that suffering, like futility, is not sufficient wholesale justification for making unilateral treatment decisions, I will also argue that claims of patient suffering cannot be ignored, and that they almost always deserve some kind of response. In the final section, I offer practical suggestions for how to respond to claims of patient suffering.
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26
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Affiliation(s)
- Rebecca Dresser
- Washington University in St. Louis, Washington University Law School, St. Louis, Missouri, USA
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27
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Spill GR, Vente T, Frader J, Smith S, Giacino J, Zafonte R, Coppard B, Jensen G, Mukherjee D. Futility in Rehabilitation. PM R 2019; 11:420-428. [DOI: 10.1002/pmrj.12152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/07/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Gayle R. Spill
- Northwestern University Feinberg School of Medicine and Shirley Ryan AbilityLab Chicago IL
| | - Teresa Vente
- Pediatric Palliative Care and HospiceAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | - Joel Frader
- Department of Pediatrics and Bioethics and Humanities and Division of Pediatric Palliative CareAnn & Robert H. Lurie Children's Hospital of Chicago Chicago IL
| | - Sean Smith
- Departments of PM&R and Cancer Rehabilitation MedicineUniversity of Michigan Medical School Ann Arbor MI
| | - Joseph Giacino
- Rehabilitation Neuropsychology and Department of PM&R, Spaulding Rehabilitation Hospital, Harvard Medical SchoolMassachusetts General Hospital Boston MA
| | - Ross Zafonte
- Department of PM&R, Spaulding Rehabilitation Hospital, Harvard Medical School, MassachusettsGeneral Hospital and Brigham and Women's Hospital Boston MA
| | - Brenda Coppard
- Occupational Therapy at the School of Pharmacy and Health ProfessionsCreighton University Omaha NE
| | - Gail Jensen
- Physical therapy at the School of Pharmacy and Health ProfessionsCreighton University Omaha NE
| | - Debjani Mukherjee
- Northwestern University Feinberg School of Medicine and Shirley Ryan AbilityLab Chicago IL
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Henry B, Verbeek PR, Cheskes S. Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: Ethical considerations. Resuscitation 2019; 137:1-6. [PMID: 30731112 DOI: 10.1016/j.resuscitation.2019.01.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 10/18/2018] [Accepted: 01/26/2019] [Indexed: 01/05/2023]
Abstract
Out-of-hospital cardiac arrest (OHCA) continues to be a leading cause of mortality worldwide. In Canada over 40,000 cardiac arrests that occur each year, a majority occur unexpectedly outside of the hospital setting. However, the reality is that without rapid and appropriate treatment within minutes, most victims will die before reaching the hospital. In the late 1980s case reports identifying favorable outcomes with the use of extracorporeal cardiopulmonary resuscitation (eCPR) in out-of-hospital cardiac arrest (OHCA) began to be reported. Since then case reports, observational studies, propensity analysis, and a systematic review of international practices continues to suggest eCPR as a feasible intervention for refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in select adult patients. However, in spite of this mounting base of evidence, clinicians continue to report concerns over a paucity of robust data showing definitive eCPR effectiveness compared with conventional resuscitation. This review will explore the ethical issues related to the impact eCPR might have on the orthodoxy pertaining to current resuscitation strategies, the impact of shifting decision-making on families particularly in dealing with a "bridge to nowhere" scenario, a call to accounting for greater data integrity and improved outcome reporting to assess eCPR effectiveness, and addressing the "Should we just do it" question. A recommendation is proposed for the creation of an ethics consultation service to assist families and staff in dealing with the invariable value conflicts and stresses likely to arise.
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Affiliation(s)
- B Henry
- Sunnybrook Health Sciences Centre, Canada; Dept. of Family and Community Medicine, University of Toronto, Canada.
| | - P R Verbeek
- Sunnybrook Center for Prehospital Medicine, Canada
| | - S Cheskes
- Sunnybrook Center for Prehospital Medicine, Canada; Department of Family Community Medicine, Division of Emergency Medicine, University of Toronto, Canada
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29
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Paris JJ, Cummings BM, Patrick Moore M. Compassion and mercy are not helpful in resolving intractable family-physician conflicts on end-of-life care. J Perinatol 2019; 39:11-17. [PMID: 30470768 DOI: 10.1038/s41372-018-0272-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 11/09/2022]
Abstract
"Compassion and mercy" are important values for humanizing medicine. There are limits, however, in their ability to help resolve disputes between physicians and families regarding appropriate end-of-life care. The recent cases of Charlie Gard and Alfie Evans in England highlight the issue. The English courts resolve such conflicts by an independent assessment of a court. The American judicial system does not share the centralized system of the English courts. In the United States Federal structure some 50 state legislatures and 50 state court systems go their separate ways. The result is differing, frequently conflicting, standards. We explore possible ways to avoid court involvement in the American context for resolving such disputes within the patient-physician relationship.
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Affiliation(s)
- John J Paris
- Boston College, 140 Commonwealth Ave, Chestnut Hill, MA, 02467, USA.
| | - Brian M Cummings
- Department of Pediatrics, Massachusetts General Hospital, MGH Pediatrics Ethics Committee, 55 Fruit St, Boston, MA, 02119, USA.,Harvard Medical School, Boston, MA, 02115, USA
| | - M Patrick Moore
- Boston College Law School, 885 Centre St., Newton, MA, 02459, USA
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30
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Müller R, Kaiser S. Perceptions of medical futility in clinical practice – A qualitative systematic review. J Crit Care 2018; 48:78-84. [DOI: 10.1016/j.jcrc.2018.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/24/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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31
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Paris JJ, Cummings BM, Moreland MP, Batten JN. Approaches to parental demand for non-established medical treatment: reflections on the Charlie Gard case. JOURNAL OF MEDICAL ETHICS 2018; 44:443-447. [PMID: 29776977 PMCID: PMC6585939 DOI: 10.1136/medethics-2018-104902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 04/27/2018] [Indexed: 06/08/2023]
Abstract
The opinion of Mr. Justice Francis of the English High Court which denied the parents of Charlie Gard, who had been born with an extremely rare mutation of a genetic disease, the right to take their child to the United States for a proposed experimental treatment occasioned world wide attention including that of the Pope, President Trump, and the US Congress. The case raise anew a debate as old as the foundation of Western medicine on who should decide and on what standard when there is a conflict between a family and the treating physicians over a possible treatment. This paper will explore the different approaches of the British and American courts on the issue and the various proposals from that of John Rawls in his A Theory of Justice to a processed-based approach for resolving such disputes.
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Affiliation(s)
- John J Paris
- Department of Theology, Boston College, Chestnut Hill, Massachusetts, USA
| | - Brian M Cummings
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael P Moreland
- Department of Law, Law School, Villanova University, Villanova, Pennsylvania, USA
| | - Jason N Batten
- Stanford Center for Bioethics, Stanford University School of Medicine, Stanford, California, USA
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32
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Wilkinson D, Petrou S, Savulescu J. Expensive care? Resource-based thresholds for potentially inappropriate treatment in intensive care. Monash Bioeth Rev 2018; 35:2-23. [PMID: 29349753 PMCID: PMC6096869 DOI: 10.1007/s40592-017-0075-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In intensive care, disputes sometimes arise when patients or surrogates strongly desire treatment, yet health professionals regard it as potentially inappropriate. While professional guidelines confirm that physicians are not always obliged to provide requested treatment, determining when treatment would be inappropriate is extremely challenging. One potential reason for refusing to provide a desired and potentially beneficial treatment is because (within the setting of limited resources) this would harm other patients. Elsewhere in public health systems, cost effectiveness analysis is sometimes used to decide between different priorities for funding. In this paper, we explore whether cost-effectiveness could be used to determine the appropriateness of providing intensive care. We explore a set of treatment thresholds: the probability threshold (a minimum probability of survival for providing treatment), the cost threshold (a maximum cost of treatment), the duration threshold (the maximum duration of intensive care), and the quality threshold (a minimum quality of life). One common objection to cost-effectiveness analysis is that it might lead to rationing of life-saving treatment. The analysis in this paper might be used to inform debate about the implications of applying cost-effectiveness thresholds to clinical decisions around potentially inappropriate treatment.
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Affiliation(s)
- Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK.
- John Radcliffe Hospital, Oxford, UK.
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
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33
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Health related quality of life after extracorporeal cardiopulmonary resuscitation in refractory cardiac arrest. Resuscitation 2018; 127:73-78. [DOI: 10.1016/j.resuscitation.2018.03.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 03/06/2018] [Accepted: 03/29/2018] [Indexed: 11/21/2022]
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Wilkinson D, Petrou S, Savulescu J. Rationing potentially inappropriate treatment in newborn intensive care in developed countries. Semin Fetal Neonatal Med 2018; 23:52-58. [PMID: 29100870 DOI: 10.1016/j.siny.2017.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In newborn intensive care, parents sometimes request treatment that professionals regard as 'futile' or 'potentially inappropriate'. One reason not to provide potentially inappropriate treatment is because it would be excessively costly relative to its benefit. Some public health systems around the world assess the cost-effectiveness of treatments and selectively fund those treatments that fall within a set threshold. This article explores the application of such thresholds to questions in newborn intensive care: (i) when a newborn infant's chance of survival is too small; (ii) how long treatment should continue; (iii) when quality of life is too low; and (iv) when newborn infants are too premature for cost-effective intensive care. This analysis yields some potentially surprising conclusions. Newborn intensive care may be cost-effective even in the setting of very low probability of survival, very poor predicted quality of life, for protracted periods of time, or for the most premature of newborns.
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Affiliation(s)
- Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK; John Radcliffe Hospital, Oxford, UK.
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
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35
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Ethical Challenges When Caring for Orthodox Jewish Patients at the End of Life. J Hosp Palliat Nurs 2018; 20:36-44. [DOI: 10.1097/njh.0000000000000402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Weiss EM, Fiester A. From "Longshot" to "Fantasy": Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:3-11. [PMID: 29313768 DOI: 10.1080/15265161.2017.1401157] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from "longshot" to "fantasy" is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.
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Kummerow Broman K, Ward MJ, Poulose BK, Schwarze ML. Surgical Transfer Decision Making: How Regional Resources are Allocated in a Regional Transfer Network. Jt Comm J Qual Patient Saf 2018; 44:33-42. [PMID: 29290244 PMCID: PMC5751937 DOI: 10.1016/j.jcjq.2017.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tertiary care centers often operate above capacity, limiting access to emergency surgical care for patients at nontertiary facilities. For nontraumatic surgical emergencies there are no guidelines to inform patient selection for transfer to another facility. Such decisions may be particularly difficult for gravely ill patients when the benefits of transfer are uncertain. METHODS To characterize surgeons' decision-making strategies for transfer, a qualitative analysis of semistructured interviews was conducted with 16 general surgeons who refer and accept patients within a regional transfer network. Interviews included case-based vignettes about surgical patients with high comorbidity, multisystem organ failure, and terminal conditions. An inductive coding strategy was used, followed by performance of a higher-level analysis to characterize important themes and trends. RESULTS Surgeons at outlying hospitals seek transfer when the resources to care for patients' surgical needs or comorbid conditions are unavailable locally. In contrast, surgeons at the tertiary center accept all patients regardless of outcome or resource considerations. Bed availability at the tertiary care center restricts transfer capacity, harming patients who cannot be transferred. Surgeons sometimes transfer dying patients in order to exhaust all treatment options or appease families, but they are conflicted about the value of transfer, which displaces patients from their local communities and limits access to tertiary care for others. CONCLUSION Decisions to transfer surgical patients are complex and require comprehensive understanding of local capacity and regional resources. Current decision-making strategies fail to optimize patient selection for transfer and can inappropriately allocate scarce tertiary care beds.
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38
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Marron JM, Jones E, Wolfe J. Is There Ever a Role for the Unilateral Do Not Attempt Resuscitation Order in Pediatric Care? J Pain Symptom Manage 2018; 55:164-171. [PMID: 28916293 PMCID: PMC5735032 DOI: 10.1016/j.jpainsymman.2017.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Abstract
Care for children as they near the end of life is difficult and very complex. More difficult still are the decisions regarding what interventions are and are not indicated during these trying times. Occasionally, families of children who are nearing the end of life disagree with the assessment of the medical team regarding these interventions. In rare cases, the medical team can be moved to enact a do not attempt resuscitation order against the wishes of the patient's parents. This article presents one such illustrative case and discusses the ethical issues relevant to such challenging clinical scenarios. The authors posit that such a unilateral do not attempt resuscitation order is only appropriate in very limited circumstances in pediatric care. Instead, focus should be placed on open discussion between parents and members of the clinical team, shared decision making, and maintenance of the clinician-parent relationship while simultaneously supporting members of the clinical team who express discomfort with parental decisions. The authors propose an alternative framework for approaching such a conflict based on clinician-parent collaboration and open communication.
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Affiliation(s)
- Jonathan M Marron
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Office of Ethics, Boston Children's Hospital, Boston, Massachusetts, USA; Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA; Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
| | - Emma Jones
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne Wolfe
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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39
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Harvey D, Butler J, Groves J, Manara A, Menon D, Thomas E, Wilson M. Management of perceived devastating brain injury after hospital admission: a consensus statement from stakeholder professional organizations. Br J Anaesth 2018; 120:138-145. [DOI: 10.1016/j.bja.2017.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 09/20/2017] [Accepted: 10/23/2017] [Indexed: 11/28/2022] Open
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40
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Kuo C, Kuo C, Hsu S, Lin C, Weng Y. The Reliability of Modified Termination of Resuscitation Rules after Arrival at the Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791402100502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Pre-hospital termination of resuscitation (TOR) is not a usual practice in many cities. The current study aimed to examine the reliability of the modified basic life support (ED-BLS) and advanced life support (ED-ALS) rules for TOR after patient arrival at the emergency department (ED). Methods In this retrospective cohort study, adult non-traumatic cardiac arrest patients who received pre-hospital basic life support and defibrillator (BLS-D) mode of service in Taoyuan County in northern Taiwan during the study period were assessed. Data were retrieved from web-based registry records. Results Of the 1612 patients included, 40 (2.5%) achieved survival to discharge. The ED-ALS rule showed higher specificity (ED-ALS rule: 82.5% {95% confidence interval [CI]: 68.1-91.3} vs. ED-BLS rule: 50.0% {95%CI: 35.2-64.8}) and positive predictive value (ED-ALS rule: 99.0% {95% CI: 97.9-99.5} vs. ED-BLS rule: 98.6% {95%CI: 97.8-99.1}) than the ED-BLS rule in terms of predicting no survival to discharge after patient arrival at the ED. Among patients who fulfilled all criteria for the ED-BLS and ED-ALS rule, 20 (1.4%) and seven (1.0%) survived to discharge, respectively. Application of the ED-BLS and ED-ALS rules could have reduced further resuscitation efforts after arrival at the ED by 86.4% and 43.1%, respectively. Conclusion For non-traumatic out-of-hospital cardiac arrest patients who receive BLS-D service, the ED-ALS rule has a higher specificity and PPV than the ED-BLS rule to predict no survival to discharge after patient arrival at the ED. Using the ED-ALS rule to terminate resuscitation after arrival at the ED should be prospectively validated. (Hong Kong j.emerg.med. 2014;21:283-290)
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“Futile Care”—An Emergency Medicine Approach: Ethical and Legal Considerations. Ann Emerg Med 2017; 70:707-713. [DOI: 10.1016/j.annemergmed.2017.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/26/2017] [Accepted: 06/01/2017] [Indexed: 11/18/2022]
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Putman MS, D’Alessandro A, Curlin FA, Yoon JD. Unilateral Do Not Resuscitate Orders. Chest 2017; 152:224-225. [DOI: 10.1016/j.chest.2017.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 03/30/2017] [Indexed: 11/26/2022] Open
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Tanner R, Masterson S, Jensen M, Wright P, Hennelly D, O’Reilly M, Murphy AW, Bury G, O’Donnell C, Deasy C. Out-of-hospital cardiac arrests in the older population in Ireland. Emerg Med J 2017; 34:659-664. [DOI: 10.1136/emermed-2016-206041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/04/2017] [Accepted: 05/10/2017] [Indexed: 11/04/2022]
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Fan KL, Leung LP. Outcomes of Cardiac Arrest in Residential Care Homes for the Elderly in Hong Kong. PREHOSP EMERG CARE 2017; 21:709-714. [PMID: 28467148 DOI: 10.1080/10903127.2017.1317890] [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] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Studies done in the 1990's suggested nursing home residents with cardiac arrest had minimal chance of survival and resuscitation was not recommended. More recent studies showed opposing results. In Hong Kong, the proportion of elderly living in the residential care homes for the elderly is increasing. There is no study of out-of-hospital cardiac arrest outcomes in this population. This study aimed at evaluating the prognosis of out-of-hospital cardiac arrest occurring in the residential care homes for the elderly. It is hoped that the findings may inform the local emergency medical service concerning the issue of futility of resuscitating the residents with cardiac arrest in the residential care homes. METHODS This study was a retrospective analysis of a database of all patients aged 65 years or above with atraumatic out-of-hospital cardiac arrest and who were attended by the emergency medical service in a 12-month period. Data in the database were prospectively collected by the emergency medical service. The characteristics of patients and cardiac arrests, timeliness of the emergency medical service, and survival were analyzed. Comparison was made between elderly living in and not living in the residential care homes. Predictors of survival were evaluated with logistic regression. RESULTS 3919 patients aged ≥ 65 years were analyzed. There were 1506 cases of cardiac arrest occurring in the residential care homes for the elderly. Resuscitation was discontinued at the emergency department in over 70% of these cases. The survival to hospital admission rate and the 30-day survival rate were 9.6% and 0.3% respectively. Both were lower than patients not residing in the residential care homes. Younger age, witnessed arrest, bystander defibrillation, and shorter call to ED interval were associated with higher chance of surviving to hospital admission. CONCLUSION Elderly suffering from cardiac arrest in residential care homes had a poor chance of survival. Except age, witnessed arrest, bystander defibrillation, and call to ED interval are modifiable predictors of survival. It is inappropriate to declare that resuscitating elderly in residential care homes is futile unless those factors have been fully addressed.
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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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Putignano A, Gustot T. New concepts in acute-on-chronic liver failure: Implications for liver transplantation. Liver Transpl 2017; 23:234-243. [PMID: 27750389 DOI: 10.1002/lt.24654] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 09/22/2016] [Accepted: 09/30/2016] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a recently defined syndrome that occurs frequently in patients with cirrhosis and is associated with a poor short-term prognosis. Currently, management of patients with ACLF is mainly supportive. Despite medical progress, this syndrome frequently leads to multiorgan failure, sepsis, and, ultimately, death. The results of attempts to use liver transplantation (LT) to manage this critical condition have been poorly reported but are promising. Currently, selection criteria of ACLF patients for LT, instructions for prioritization on the waiting list, and objective indicators for removal of ACLF patients from the waiting list in cases of clinical deterioration are poorly defined. Before potential changes can be implemented into decisional algorithms, their effects, either on the benefits to individual patients or on global transplant outcomes, should be carefully evaluated using objective longterm endpoints that take into account ethical considerations concerning LT. Liver Transplantation 23 234-243 2017 AASLD.
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Affiliation(s)
- Antonella Putignano
- Department of Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium.,INSERM Unité 1149, Centre de Recherche sur l'inflammation, Paris, France.,Unités Mixtes de Recherche en Santé 1149, Université Paris Diderot, Paris, France
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Coonan E. Medical Futility: A Contemporary Review. THE JOURNAL OF CLINICAL ETHICS 2016. [DOI: 10.1086/jce2016274359] [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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Lotz JD, Jox RJ, Meurer C, Borasio GD, Führer M. Medical indication regarding life-sustaining treatment for children: Focus groups with clinicians. Palliat Med 2016; 30:960-970. [PMID: 26847523 PMCID: PMC5117124 DOI: 10.1177/0269216316628422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Decisions about medical indication are a relevant problem in pediatrics. Difficulties arise from the high prognostic uncertainty, the decisional incapacity of many children, the importance of the family, and conflicts with parents. The objectivity of judgments about medical indication has been questioned. Yet, little is known about the factors pediatricians actually include in their decisions. AIM Our aims were to investigate which factors pediatricians apply in deciding about medical indication, and how they manage conflicts with parents. DESIGN We performed a qualitative focus group study with experienced pediatricians. The transcripts were subjected to qualitative content analysis. SETTING/PARTICIPANTS We conducted three focus groups with pediatricians from different specialties caring for severely ill children/adolescents. They discussed life-sustaining treatment in two case scenarios that varied according to diagnosis, age, and gender. RESULTS The decisions about medical indication were based on considerations relating to the individual patient, to the family, and to other patients. Individual patient factors included clinical aspects and benefit-burden considerations. Physicians' individual views and feelings influenced their decision-making. Different factors were applied or weighed differently in the two cases. In case of conflict with parents, physicians preferred solutions aimed at establishing consensus. CONCLUSION The pediatricians defined medical indication on a case-by-case basis and were influenced by emotional reasoning. In contrast to prevailing ethico-legal principles, they included the interests of other persons in their decisions. Decision-making strategies should incorporate explicit discussions of social aspects and physicians' feelings to improve the transparency of the decision-making process and reduce bias.
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Affiliation(s)
- Julia Desiree Lotz
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Christine Meurer
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Gian Domenico Borasio
- Palliative Care Service, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Monika Führer
- Coordination Center for Pediatric Palliative Care, University Children's Hospital, Ludwig-Maximilians University of Munich, Munich, Germany
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Reynolds JC, Grunau BE, Rittenberger JC, Sawyer KN, Kurz MC, Callaway CW. Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation 2016; 134:2084-2094. [PMID: 27760796 DOI: 10.1161/circulationaha.116.023309] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/03/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Little evidence guides the appropriate duration of resuscitation in out-of-hospital cardiac arrest, and case features justifying longer or shorter durations are ill defined. We estimated the impact of resuscitation duration on the probability of favorable functional outcome in out-of-hospital cardiac arrest using a large, multicenter cohort. METHODS This was a secondary analysis of a North American, single-blind, multicenter, cluster-randomized, clinical trial (ROC-PRIMED [Resuscitation Outcomes Consortium Prehospital Resuscitation Using an Impedance Valve and Early Versus Delayed]) of consecutive adults with nontraumatic, emergency medical services-treated out-of-hospital cardiac arrest. Primary exposure was duration of resuscitation in minutes (onset of professional resuscitation to return of spontaneous circulation [ROSC] or termination of resuscitation). Primary outcome was survival to hospital discharge with favorable outcome (modified Rankin scale [mRS] score of 0-3). Subjects were additionally classified as survival with unfavorable outcome (mRS score of 4-5), ROSC without survival (mRS score of 6), or without ROSC. Subject accrual was plotted as a function of resuscitation duration, and the dynamic probability of favorable outcome at discharge was estimated for the whole cohort and subgroups. Adjusted logistic regression models tested the association between resuscitation duration and survival with favorable outcome. RESULTS The primary cohort included 11 368 subjects (median age, 69 years [interquartile range, 56-81 years]; 7121 men [62.6%]). Of these, 4023 (35.4%) achieved ROSC, 1232 (10.8%) survived to hospital discharge, and 905 (8.0%) had an mRS score of 0 to 3 at discharge. Distribution of cardiopulmonary resuscitation duration differed by outcome (P<0.00001). For cardiopulmonary resuscitation duration up to 37.0 minutes (95% confidence interval, 34.9-40.9 minutes), 99% with an eventual mRS score of 0 to 3 at discharge achieved ROSC. The dynamic probability of an mRS score of 0 to 3 at discharge declined over elapsed resuscitation duration, but subjects with initial shockable cardiac rhythm, witnessed cardiac arrest, and bystander cardiopulmonary resuscitation were more likely to survive with favorable outcome after prolonged efforts (30-40 minutes). After adjustment for prehospital (odds ratio, 0.93; 95% confidence interval, 0.92-0.95) and inpatient (odds ratio, 0.97; 95% confidence interval, 0.95-0.99) covariates, resuscitation duration was associated with survival to discharge with an mRS score of 0 to 3. CONCLUSIONS Shorter resuscitation duration was associated with likelihood of favorable outcome at hospital discharge. Subjects with favorable case features were more likely to survive prolonged resuscitation up to 47 minutes. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00394706.
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Affiliation(s)
- Joshua C Reynolds
- From Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.C. Reynolds); Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada (B.E.G.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (J.C. Rittenberger); Department of Emergency Medicine, Beaumont Health System Royal Oak, MI (K.N.S.); and Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.).
| | - Brian E Grunau
- From Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.C. Reynolds); Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada (B.E.G.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (J.C. Rittenberger); Department of Emergency Medicine, Beaumont Health System Royal Oak, MI (K.N.S.); and Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
| | - Jon C Rittenberger
- From Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.C. Reynolds); Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada (B.E.G.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (J.C. Rittenberger); Department of Emergency Medicine, Beaumont Health System Royal Oak, MI (K.N.S.); and Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
| | - Kelly N Sawyer
- From Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.C. Reynolds); Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada (B.E.G.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (J.C. Rittenberger); Department of Emergency Medicine, Beaumont Health System Royal Oak, MI (K.N.S.); and Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
| | - Michael C Kurz
- From Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.C. Reynolds); Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada (B.E.G.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (J.C. Rittenberger); Department of Emergency Medicine, Beaumont Health System Royal Oak, MI (K.N.S.); and Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
| | - Clifton W Callaway
- From Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids (J.C. Reynolds); Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada (B.E.G.); Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA (J.C. Rittenberger); Department of Emergency Medicine, Beaumont Health System Royal Oak, MI (K.N.S.); and Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham (M.C.K.)
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