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Molitch-Hou E, Zhang H, Gala P, Tate A. Impact of the COVID-19 Public Health Crisis and a Structured COVID Unit on Physician Behaviors in Code Status Ordering. Am J Hosp Palliat Care 2023:10499091231204943. [PMID: 37786255 PMCID: PMC10985045 DOI: 10.1177/10499091231204943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Purpose: Code status orders are standard practice impacting end-of-life care for individuals. This study reviews the impact of a COVID unit on physician behaviors towards goal-concordant end-of-life care at an urban academic tertiary-care hospital. Methods: We conducted a retrospective cohort study of code status ordering on adult inpatients comparing the pre-pandemic period to patients who tested positive, negative and were not tested during the pandemic from January 1, 2019, to December 31, 2020. Results: We analyzed 59,471 unique patient encounters (n = 35,317 pre-pandemic and n = 24,154 during). 1,631 cases of COVID-19 were seen. The rate of code status orders among all inpatients increased from 22% pre-pandemic to 29% during the pandemic (P < .001). Code status orders increased for both patients who were COVID-negative (32% P < .001) and COVID-positive (65% P < .001). Being in a cohorted COVID unit increased code status ordering by an odds of 4.79 (P < .001). Compared to the pre-pandemic cohort, the COVID-positive cohort is less female (50% to 56% P < .001), more Black (66% to 61% P < .001), more Hispanic (6.5% to 5%) and less white (26% to 30% P < .001). Compared to Black patients, white patients had lower odds (.86) of code status ordering (P < .001). Other race/ethnicity categories were not significant. Conclusions: Code status ordering remains low. Compared to pre-pandemic rates, the frequency of orders placed significantly increased for all patients during the pandemic. The largest increase occurred in patients with COVID-19. This increase likely occurred due to protocols in the COVID unit and disease uncertainty.
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Affiliation(s)
- Ethan Molitch-Hou
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
| | - Hui Zhang
- Center for Health and The Social Sciences, The University of Chicago, Chicago, IL, USA
| | - Pooja Gala
- NYU Grossman School of Medicine, New York University, New York, NY, USA
| | - Alexandra Tate
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, IL, USA
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2
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Addressing Futility: A Practical Approach. Crit Care Explor 2022; 4:e0706. [PMID: 35815180 PMCID: PMC9257305 DOI: 10.1097/cce.0000000000000706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Limiting or withdrawing nonbeneficial medical care is considered ethically responsible throughout most of critical care and medical ethics literature. Practically, however, setting limits to treatment is often challenging. We review the literature to identify best practices for using the definition of futility as an anchoring concept to aid the ethical practice of ICU clinicians.
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3
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Avant LC, Kezar CE, Swetz KM. Advances in Cardiopulmonary Life-Support Change the Meaning of What It Means to be Resuscitated. Palliat Med Rep 2021; 1:67-71. [PMID: 34223459 PMCID: PMC8241316 DOI: 10.1089/pmr.2020.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2020] [Indexed: 01/10/2023] Open
Abstract
As options for advanced cardiopulmonary support proliferate, the use of mechanical circulatory support, such as left ventricular assist device as destination therapy (LVAD-DT), is becoming increasingly commonplace. In the current case, a patient was hospitalized for complications related to his LVAD-DT requests “full code” status, despite a clinician's warning that performing chest compressions may damage the LVAD device or vascular structures leading to poor outcome. This discussion explores the ethical and legal considerations regarding a patient request for cardiopulmonary resuscitation when limited options for survival or further treatment are available.
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Affiliation(s)
- Leslie C Avant
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carolyn E Kezar
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Keith M Swetz
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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Rosenwohl-Mack S, Dohan D, Matthews T, Batten JN, Dzeng E. Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study. J Gen Intern Med 2021; 36:1890-1897. [PMID: 33111237 PMCID: PMC7592132 DOI: 10.1007/s11606-020-06314-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Moral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems. OBJECTIVE We investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees. DESIGN Semi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress. PARTICIPANTS Sixteen internal medicine residents in the US and fourteen junior doctors in the UK. APPROACH The work was analyzed using thematic analysis. KEY RESULTS Some drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it. CONCLUSION This research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries' healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.
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Affiliation(s)
- Sarah Rosenwohl-Mack
- Department of Family Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Dohan
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Thea Matthews
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | | | - Elizabeth Dzeng
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA.
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5
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Bible KC, Kebebew E, Brierley J, Brito JP, Cabanillas ME, Clark TJ, Di Cristofano A, Foote R, Giordano T, Kasperbauer J, Newbold K, Nikiforov YE, Randolph G, Rosenthal MS, Sawka AM, Shah M, Shaha A, Smallridge R, Wong-Clark CK. 2021 American Thyroid Association Guidelines for Management of Patients with Anaplastic Thyroid Cancer. Thyroid 2021; 31:337-386. [PMID: 33728999 PMCID: PMC8349723 DOI: 10.1089/thy.2020.0944] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Since the guidelines for the management of ATC by the American Thyroid Association were first published in 2012, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, and researchers on published evidence relating to the diagnosis and management of ATC. Methods: The specific clinical questions and topics addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of the Task Force members (authors of the guideline). Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. Results: The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, targeted/systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues, including end of life. The guidelines include 31 recommendations and 16 good practice statements. Conclusions: We have developed evidence-based recommendations to inform clinical decision-making in the management of ATC. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with ATC.
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Affiliation(s)
- Keith C. Bible
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Electron Kebebew
- Stanford University, School of Medicine, Stanford, California, USA
| | - James Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Juan P. Brito
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria E. Cabanillas
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Antonio Di Cristofano
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert Foote
- Department of Radiation Oncology, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Thomas Giordano
- Department of Pathology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jan Kasperbauer
- Department of Otolaryngology, Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kate Newbold
- The Royal Marsden NHS Foundation Trust, Fulham Road, London, United Kingdom
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - M. Sara Rosenthal
- Program for Bioethics and Markey Cancer Center Oncology Ethics Program, Departments Internal Medicine, Pediatrics and Behavioral Science, University of Kentucky, Lexington, Kentucky, USA
| | - Anna M. Sawka
- Division of Endocrinology, Department of Medicine, University Health Network and University of Toronto, Toronto, Canada
| | - Manisha Shah
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Ashok Shaha
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Rosenwohl-Mack S, Dohan D, Matthews T, Batten JN, Dzeng E. How individual ethical frameworks shape physician trainees' experiences providing end-of-life care: a qualitative study. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106690. [PMID: 33593875 DOI: 10.1136/medethics-2020-106690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/20/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The end of life is an ethically challenging time requiring complex decision-making. This study describes ethical frameworks among physician trainees, explores how these frameworks manifest and relates these frameworks to experiences delivering end-of-life care. DESIGN We conducted semistructured in-depth exploratory qualitative interviews with physician trainees about experiences of end-of-life care and moral distress. We analysed the interviews using thematic analysis. SETTING Academic teaching hospitals in the United States and United Kingdom. PARTICIPANTS We interviewed 30 physician trainees. We purposefully sampled across three domains we expected to be associated with individual ethics (stage of training, gender and national healthcare context) in order to elicit a diversity of ethical and experiential perspectives. RESULTS Some trainees subscribed to a best interest ethical framework, characterised by offering recommendations consistent with the patient's goals and values, presenting only medically appropriate choices and supporting shared decision-making between the patient/family and medical team. Others endorsed an autonomy framework, characterised by presenting all technologically feasible choices, refraining from offering recommendations and prioritising the voice of patient/family as the decision-maker. CONCLUSIONS This study describes how physician trainees conceptualise their roles as being rooted in an autonomy or best interest framework. Physician trainees have limited clinical experience and decision-making autonomy and may have ethical frameworks that are dynamic and potentially highly influenced by experiences providing end-of-life care. A better understanding of how individual physicians' ethical frameworks influences the care they give provides opportunities to improve patient communication and advance the role of shared decision-making to ensure goal-aligned end-of-life care.
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Affiliation(s)
- Sarah Rosenwohl-Mack
- Family and Community Medicine, University of California San Francisco, San Francisco, California, USA
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Thea Matthews
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
| | - Jason Neil Batten
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Cicely Saunders institute, King's College London, London, UK
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Johnson KA, Quest T, Curseen K. Will You Hear Me? Have You Heard Me? Do You See Me? Adding Cultural Humility to Resource Allocation and Priority Setting Discussions in the Care of African American Patients With COVID-19. J Pain Symptom Manage 2020; 60:e11-e14. [PMID: 32889037 PMCID: PMC7462785 DOI: 10.1016/j.jpainsymman.2020.08.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/15/2020] [Accepted: 08/28/2020] [Indexed: 11/02/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has refocused our attention on health care disparities affecting patients of color, with a growing body of literature focused on the etiology of these disparities and strategies to eliminate their effects. In considering the unique impact COVID-19 is having on African American communities, added measure must be given to ensure for sensitivity, empathy, and supportive guidance in medical decision making among African American patients faced with critical illness secondary to COVID-19. In this article, we explore the applications of cultural humility over cultural competency in optimizing the care we provide to African American patients faced with critical health care decisions during this pandemic. In turn, we charge one another as health care providers to consider how ethical principles and guidance can be applied to honor African American patients' unique stories and experiences.
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Affiliation(s)
- Khaliah A Johnson
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA; Pediatric Palliative Care, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
| | - Tammie Quest
- Department of Family and Preventative Medicine, Emory University, Atlanta, Georgia, USA
| | - Kimberly Curseen
- Palliative Care, Emory University Hospital, Atlanta, Georgia, USA
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Chiang CC, Chang SC, Fan SY. The Concerns and Experience of Decision-Making Regarding Do-Not-Resuscitate Orders Among Caregivers in Hospice Palliative Care. Am J Hosp Palliat Care 2020; 38:123-129. [DOI: 10.1177/1049909120933535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A do-not-resuscitate (DNR) order is an important end-of-life decision. In Taiwan, family caregivers are also involved in this decision-making process. This study aimed to explore the concerns and experiences regarding DNR decisions among caregivers in Taiwan. Qualitative study was conducted. Convenience sampling was used, and 26 caregivers were recruited whose patients had a DNR order and had received hospice care or hospice home care. Semi-structured interviews were used for data collection, including the previous experiences of DNR discussions with the patients and medical staff and their concerns and difficulties in decision-making. The data analysis was based on the principle of thematic analysis. Four themes were identified: (1) Patients: The caregivers respected the patients’ willingness and did not want to make them feel like “giving up.” (2) Caregivers’ self: They did not want to intensify the patients’ suffering but sometimes found it emotionally difficult to accept death. (3) Other family members: They were concerned about the other family members’ opinions on DNR orders, their blame, and their views on filial impiety. (4) Medical staff: The information and suggestions from the medical staff were foundational to their decision-making. The caregivers needed the health care professionals’ supports to deal with the concerns from patients and other family members as well as their emotional reactions.
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Affiliation(s)
- Ching-Chun Chiang
- Heart Lotus palliative ward, Tzu Chi Medical Foundation, Hualien Tzu Chi Hospital, Hualien
| | - Shu-Chuan Chang
- The Nursing Committee, Buddhist Tzu Chi Medical Foundation, Hualien
- School of Nursing, Tzu Chi University, Hualien
| | - Sheng-Yu Fan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan
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9
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Ouyang DJ, Lief L, Russell D, Xu J, Berlin DA, Gentzler E, Su A, Cooper ZR, Senglaub SS, Maciejewski PK, Prigerson HG. Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes. PLoS One 2020; 15:e0227971. [PMID: 32069306 PMCID: PMC7028295 DOI: 10.1371/journal.pone.0227971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 01/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death. Methods 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model. Results 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures. Conclusions Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.
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Affiliation(s)
- Daniel J. Ouyang
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Lindsay Lief
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - David Russell
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Sociology, Appalachian State University, Boone, North Carolina, United State of America
| | - Jiehui Xu
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - David A. Berlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - Eliza Gentzler
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Amanda Su
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Zara R. Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Steven S. Senglaub
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Paul K. Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- Department of Radiology, Weill Cornell Medicine, New York, New York, United State of America
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- * E-mail:
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Hardin J, Forshier B. Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review. J Perianesth Nurs 2019; 34:1054-1068.e18. [PMID: 31230930 DOI: 10.1016/j.jopan.2019.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/12/2019] [Accepted: 03/23/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this systematic review is to assess if Do Not Resuscitate (DNR) orders should be routinely rescinded during anesthesia, determine if consensus on retaining DNR orders exists in the literature, and explore the current state of clinical practice. DESIGN This systematic review followed preferred reporting items for systematic reviews and meta-analyses guidelines. METHODS In June 2018, the Cumulative Index to Nursing and Allied Health Literature and PubMed databases were systematically searched using defined inclusion/exclusion criteria. FINDINGS Ninety-one articles from the databases were pooled with 16 works identified as formative to the research questions. Forty-nine articles were analyzed and included in this study. CONCLUSIONS It is unethical to automatically rescind DNR orders during anesthesia. Patients have the right to retain their DNR orders unaltered or modify them for the perianesthesia period. Sufficient evidence exists to create meaningful policy at every level. A consensus exists among professional organizations that the standard of care is a required reconsideration of DNR orders before anesthesia.
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11
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Stuart RB, Thielke S. Conditional Permission to Not Resuscitate: A Middle Ground for Resuscitation. J Am Med Dir Assoc 2019; 20:679-682. [PMID: 30826272 DOI: 10.1016/j.jamda.2019.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 11/25/2022]
Abstract
Every decision to perform or withhold cardiopulmonary resuscitation (CPR) has ethical implications that are not always well understood. Value-based decisions with far-reaching consequences are made rapidly, based on incomplete or possibly inaccurate information. For some patients, skilled, timely CPR can restore spontaneous circulation, but for others, success may either be unobtainable or bring serious iatrogenic consequences. Because CPR is an aggressive process yielding mixed results, patients must be informed about the likelihood of its positive and adverse outcomes. In considering whether to accept or refuse it, patients should also be given a realistic set of alternatives. Current protocols limit patients' options by restricting them to a choice between accepting or refusing CPR. Adding a "middle" code, DNAR-X (Do Not Attempt Resuscitation-Except), significantly expands patients' right to control what happens to their bodies by allowing them to stipulate CPR in some circumstances but not in others.
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Affiliation(s)
- Richard B Stuart
- Swedish Edmonds Hospital, Samish Island Volunteer Fire Department, Bow, WA; Department of Psychiatry, University of Washington, Seattle, WA.
| | - Stephen Thielke
- Department of Psychiatry, University of Washington, Seattle, WA; Geriatric Research, Education, and Clinical Center, Puget Sound VA Medical Center, Seattle, WA
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Avcu R, Gökhan Ş, Pamukçu Günaydın G, Özhasenekler A, Tanrıverdi F, Kurtoğlu Çelik G, Şener A. How Would Doctors Want to Die if They Had a Terminal Stage Illness? A Survey Study. ANKARA MEDICAL JOURNAL 2018. [DOI: 10.17098/amj.497277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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13
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Fan SY, Wang YW, Lin IM. Allow natural death versus do-not-resuscitate: titles, information contents, outcomes, and the considerations related to do-not-resuscitate decision. BMC Palliat Care 2018; 17:114. [PMID: 30305068 PMCID: PMC6180419 DOI: 10.1186/s12904-018-0367-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND As the "do not resuscitate" (DNR) discussion involves communication, this study explored (1) the effects of a title that included "allow natural death", and of information contents and outcomes of the decision; and (2) the information needs and consideration of the DNR decision, and benefits and barriers of the DNR discussion. METHODS Healthy adults (n = 524) were presented with a scenario with different titles, information contents, and outcomes, and they rated the probability of a DNR decision. A questionnaire including information needs, consideration of the decision, and benefits and barriers of DNR discussion was also used. RESULTS There was a significantly higher probability of signing the DNR order when the title included "allow natural death" (t = - 4.51, p < 0.001), when comprehensive information was provided (F = 60.64, p < 0.001), and when there were worse outcomes (F = 292.16, p < 0.001). Common information needs included remaining life period and the prognosis. Common barriers were the families' worries and uncertainty about future physical changes. CONCLUSION The title, information contents, and outcomes may influence the DNR decisions. Health-care providers should address the concept of natural death, provide comprehensive information, and help patients and families to overcome the barriers.
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Affiliation(s)
- Sheng-Yu Fan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Wei Wang
- Department of Family Medicine, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | - I-Mei Lin
- Department of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
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Wee S, Chang ZY, Lau YH, Wong Y, Ong C. Cardiopulmonary resuscitation-from the patient's perspective. Anaesth Intensive Care 2017; 45:344-350. [PMID: 28486892 DOI: 10.1177/0310057x1704500309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
With increasing emphasis on patient autonomy, patients are encouraged to be more involved in end-of-life issues, including the use of extraordinary efforts to prolong their lives. Being able to make anticipatory decisions is seen to promote autonomy, empower patients and optimise patient care. To facilitate shared decision-making, patients need to have a clear and accurate understanding of cardiopulmonary resuscitation (CPR). This study aims to understand the knowledge and perspectives of the local community regarding resuscitation options and end-of-life decision-making and to explore ways to improve the quality of end-of-life discussions. An interviewer-administered survey was conducted with a prospectively recruited group of surgical patients admitted postoperatively to the day surgery ward of a single tertiary institution in Singapore from April to May 2015. The survey, modelled after two validated questionnaires, measured patients' knowledge, attitudes and preferences regarding CPR in a series of 18 questions. Fifty-one out of 67 (76.1%) patients completed the survey. Results indicated that 80.4% (n=41) of participants correctly understood the purpose of CPR, but 64.7% (n=33) did not know of any possible complications of CPR. Less than half (n=21, 41.2%) of participants had thought about life support measures they wanted for themselves. Most of the participants agreed that they should personally be involved in making end-of-life decisions (n=44, 86.3%). Many patients had a poor knowledge of CPR and other resuscitation measures and the majority overestimated the success rate of CPR. However, a majority were receptive to improving their knowledge and keen to discuss end-of-life issues with physicians.
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Affiliation(s)
- S Wee
- Resident, Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Z Y Chang
- Medical student, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Y H Lau
- Consultant, Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
| | - Yky Wong
- Senior Epidemiologist, Clinical Research and Innovation Office, Tan Tock Seng Hospital, Singapore
| | - Cym Ong
- Consultant, Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore
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Bjorklund P, Lund DM. Informed consent and the aftermath of cardiopulmonary resuscitation: Ethical considerations. Nurs Ethics 2017; 26:84-95. [PMID: 28443357 DOI: 10.1177/0969733017700234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Patients often are confronted with the choice to allow cardiopulmonary resuscitation (CPR) should cardiac arrest occur. Typically, informed consent for CPR does not also include detailed discussion about survival rates, possible consequences of survival, and/or potential impacts on functionality post-CPR. OBJECTIVE: A lack of communication about these issues between providers and patients/families complicates CPR decision-making and highlights the ethical imperative of practice changes that educate patients and families in those deeper and more detailed ways. DESIGN: This review integrates disparate literature on the aftermath of CPR and the ethics implications of CPR decision-making as it relates to and is affected by informed consent and subsequent choices for code status by seriously ill patients and their surrogates/proxies within the hospital setting. Margaret Urban Walker's moral philosophy provides a framework to view informed consent as a practice of responsibility. ETHICAL CONSIDERATIONS: Given nurses' communicative skills, ethos of care and advocacy, and expertise in therapeutic relationships, communication around DNAR decision-making might look quite different if institutional norms in education, healthcare, law, and public policy held nurses overtly responsible for informed consent in some greater measure. FINDINGS: Analysis from this perspective shows where changes in informed consent practices are needed and where leverage might be exerted to create change in the direction of deeper and more detailed discussions about CPR survival rates and possible consequences of survival.
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Launer J. Reducing futile attempts at resuscitation. Postgrad Med J 2017; 93:239-240. [DOI: 10.1136/postgradmedj-2017-134944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Rosoff PM, Schneiderman LJ. Irrational Exuberance: Cardiopulmonary Resuscitation as Fetish. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:26-34. [PMID: 28112611 DOI: 10.1080/15265161.2016.1265163] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The Institute of Medicine and the American Heart Association have issued a "call to action" to expand the performance of cardiopulmonary resuscitation (CPR) in response to out-of-hospital cardiac arrest. Widespread advertising campaigns have been created to encourage more members of the lay public to undergo training in the technique of closed-chest compression-only CPR, based upon extolling the virtues of rapid initiation of resuscitation, untempered by information about the often distressing outcomes, and hailing the "improved" results when nonprofessional bystanders are involved. We describe this misrepresentation of CPR as a highly effective treatment as the fetishization of this valuable, but often inappropriately used, therapy. We propose that the medical profession has an ethical duty to inform the public through education campaigns about the procedure's limitations in the out-of-hospital setting and the narrow clinical indications for which it has been demonstrated to have a reasonable probability of producing favorable outcomes.
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Abstract
Studies have shown that advanced care planning improves communication and reduces suffering for patients and their bereaved caregivers. Despite this knowledge, the rates of advance care plans are low and physicians, as the primary gatekeepers, have made little progress in improving their rates. Through the lens of critical social theory, we examine these forces and identify the ideologies, assumptions, and social structures that curtail completion of advanced care plans such as Preserving Life, Ageism, Paternalism, and Market-Driven Healthcare System. A critical discourse provides suggestions to eliminate oppressive ideologies that act as barriers to advanced care planning.
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Gibbs AJO, Malyon AC, Fritz ZBM. Themes and variations: An exploratory international investigation into resuscitation decision-making. Resuscitation 2016; 103:75-81. [PMID: 26976676 PMCID: PMC4879149 DOI: 10.1016/j.resuscitation.2016.01.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/17/2015] [Accepted: 01/25/2016] [Indexed: 10/31/2022]
Abstract
BACKGROUND Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made in hospitals throughout the globe. International variation in clinicians' perception of DNACPR decision-making and implementation and the factors influencing such variation has not previously been explored. METHODS A questionnaire asking how DNACPR decisions are made, communicated and perceived in their country was composed: it consisted of seven closed-answer and four open-answer questions. It was distributed to 143 medical professionals with prior published material relating to DNACPR decisions. Under-represented geographical areas were identified and an additional 34 physicians were contacted through medical colleagues and students at the university hospital from which this study was based. The respondents had 4 weeks to answer the questionnaire. RESULTS 78 responses (44%) were received from 43 countries. All continents were represented. 88% of respondents reported a method for implementing DNACPR decisions, 90% of which discussed resuscitation wishes with the patient at least half of the time. 94% of respondents thought that national guidance for DNACPR order implementation should exist; 53% of countries surveyed reported existence of such guidance. Cultural attitudes towards death, medical education and culture, health economics and the societal role of family were commonly identified as factors influencing perception of DNACPR decisions. CONCLUSIONS The majority of countries surveyed make some form of DNACPR decision but differing cultures and economic status contribute towards a heterogeneity of approaches to resuscitation decision-making. Adequacy of relevant medical education and national policy are two areas that were regularly identified as impacting upon the processes of DNACPR decision-making and implementation.
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Affiliation(s)
| | - Alexandra C Malyon
- Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK
| | - Zoë B McC Fritz
- Department of Acute Medicine, Cambridge University Hospitals, Box 148, Hills Road, Cambridge, UK; Warwick Medical School, University of Warwick Coventry, CV4 7AL, UK.
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Brown A, Clark JD. A Parent's Journey: Incorporating Principles of Palliative Care into Practice for Children with Chronic Neurologic Diseases. Semin Pediatr Neurol 2015; 22:159-65. [PMID: 26358425 DOI: 10.1016/j.spen.2015.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Rather than in conflict or in competition with the curative model of care, pediatric palliative care is a complementary and transdisciplinary approach used to optimize medical care for children with complex medical conditions. It provides care to the whole child, including physical, mental, and spiritual dimensions, in addition to support for the family. Through the voice of a parent, the following case-based discussion demonstrates how the fundamentals of palliative care medicine, when instituted early in the course of disease, can assist parents and families with shared medical decision making, ultimately improving the quality of life for children with life-limiting illnesses. Pediatric neurologists, as subspecialists who provide medical care for children with chronic and complex conditions, should consider invoking the principles of palliative care early in the course of a disease process, either through applying general facets or, if available, through consultation with a specialty palliative care service.
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Affiliation(s)
- Allyson Brown
- Department of Pediatrics, Division of Critical Care Medicine, University of Washington School of Medicine, Seattle, WA; Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Jonna D Clark
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA; Treuman Katz Center for Pediatric Bioethics, University of Washington School of Medicine, Seattle, WA.
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A. Mayer P, Daly BJ. CPR and hospice: Incompatible goals, irreconcilable differences. PROGRESS IN PALLIATIVE CARE 2015. [DOI: 10.1179/1743291x14y.0000000098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Khalaileh MA. Jordanian critical care nurses' attitudes toward and experiences of do not resuscitate orders. Int J Palliat Nurs 2014; 20:403-8. [PMID: 25151868 DOI: 10.12968/ijpn.2014.20.8.403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Do not resuscitate (DNR) decisions are an issue of considerable sensitivity for patients and their relatives, as well as health professionals. PURPOSE The aim of this study was to explore Jordanian critical care nurses' attitudes towards and experiences of DNR decisions in clinical practice. METHODS A cross-sectional survey design was used. The sample consisted of 111 nurses working in intensive care units in three government hospitals in Jordan. RESULTS Fifty nine per cent of the participants were female. Most were under the age of 35 (69%) and 75% had a bachelor's degree. Most (67%) thought that the patient's family should be involved in DNR decision making. The majority (81%) reported that they preferred a coding system documenting DNR decisions in either the physician or nursing notes. Fifty eight per cent agreed that a standard DNR form should be kept with the patient's medical notes. Only 21% reported actual participation in DNR decisions. CONCLUSION This study demonstrates that Jordanian critical care nurses are willing to participate in DNR discussions and decision-making processes. Each hospital in the country should have a written DNR policy to guide and discipline health-care providers' practice.
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Affiliation(s)
- Murad Al Khalaileh
- Assistant Professor, School of Nursing, Al al-Bayt University, PO Box 130040, Mafraq 25113, Jordan
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‘Do not attempt cardiopulmonary resuscitation’ or ‘allowing natural death’? The time for resuscitation community to review its boundaries and its terminology. Resuscitation 2014; 85:1644-5. [DOI: 10.1016/j.resuscitation.2014.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/14/2014] [Indexed: 11/21/2022]
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Chiong W, Kim AS, Huang IA, Farahany NA, Josephson SA. Inability to consent does not diminish the desirability of stroke thrombolysis. Ann Neurol 2014; 76:296-304. [PMID: 24980651 DOI: 10.1002/ana.24209] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/27/2014] [Accepted: 06/27/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Some have argued that physicians should not presume to make thrombolysis decisions for incapacitated patients with acute ischemic stroke because the risks and benefits of thrombolysis involve deeply personal values. We evaluated the influence of the inability to consent and of personal health-related values on older adults' emergency treatment preferences for both ischemic stroke and cardiac arrest. METHODS A total of 2,154 US adults age ≥50 years read vignettes in which they had either suffered an acute ischemic stroke and could be treated with thrombolysis, or had suffered a sudden cardiac arrest and could be treated with cardiopulmonary resuscitation. Participants were then asked (1) whether they would want the intervention, or (2) whether they would want to be given the intervention even if their informed consent could not be obtained. We elicited health-related values as predictors of these judgments. RESULTS Older adults were as likely to want stroke thrombolysis when unable to consent (78.1%) as when asked directly (76.2%), whereas older adults were more likely to want cardiopulmonary resuscitation when unable to consent (83.6% compared to 75.9%). Greater confidence in the medical system and reliance on statistical information in decision making were both associated with desiring thrombolysis. INTERPRETATION Older adults regard thrombolysis no less favorably when considering a situation in which they are unable to consent. These findings provide empirical support for recent professional society recommendations to treat ischemic stroke with thrombolysis in appropriate emergency circumstances under a presumption of consent.
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Affiliation(s)
- Winston Chiong
- Department of Neurology, University of California, San Francisco, San Francisco, CA
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Stein RA, Sharpe L, Bell ML, Boyle FM, Dunn SM, Clarke SJ. Randomized Controlled Trial of a Structured Intervention to Facilitate End-of-Life Decision Making in Patients With Advanced Cancer. J Clin Oncol 2013; 31:3403-10. [DOI: 10.1200/jco.2011.40.8872] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose This study tested the efficacy of an intervention on end-of-life decision making for patients with advanced cancer. Patients and Methods One hundred twenty patients with metastatic cancer who were no longer being treated with curative intent (and 87 caregivers) were randomly assigned to the intervention (n = 55) or treatment as usual (n = 65). Primary outcome measures were the proportion of patients with do-not-resuscitate (DNR) orders, timing of DNR orders, and place of death. Secondary outcome measures were completed at study enrollment, 3 weeks later, and 3 months later, including patients' knowledge, mood, and caregiver burden. Results High, but equivalent, rates of DNR orders were observed in both groups. In per-protocol analyses, DNR orders were placed earlier for patients who received the intervention (median, 27 v 12.5 days; 95% CI, 1.1 to 5.9; P = .03) and they were more likely to avoid a hospital death (19% v 50% (95% CI, 11% to 50%; P = .004). Differences between the groups over time were evident for estimates of cardiopulmonary rehabilitation (CPR) success rates (P = .01) but not knowledge of CPR (P = .2). There was no evidence that the intervention resulted in more anxious or depressive symptoms. Caregivers experienced less burden in terms of disruption to schedule if the patient received the intervention (P = .05). Conclusion An intervention, consisting of an informational pamphlet and discussion, was associated with earlier placement of DNR orders relative to death and less likelihood of death in hospital. There was no negative impact of the intervention on secondary outcomes, although the sample may have been too small to detect differences.
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Affiliation(s)
- Rhea A. Stein
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Louise Sharpe
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Melanie L. Bell
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Fran M. Boyle
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Stewart M. Dunn
- All authors: University of Sydney, Sydney, New South Wales, Australia
| | - Stephen J. Clarke
- All authors: University of Sydney, Sydney, New South Wales, Australia
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Yang GM, Kwee AK, Krishna L. Should Patients and Family be Involved in "Do Not Resuscitate" Decisions? Views of Oncology and Palliative Care Doctors and Nurses. Indian J Palliat Care 2013; 18:52-8. [PMID: 22837612 PMCID: PMC3401735 DOI: 10.4103/0973-1075.97474] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: “Do not resuscitate” (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders. Aim: The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders. Materials and Methods: A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore. Results: Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion. Conclusions: From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.
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Affiliation(s)
- Grace M Yang
- Department of Palliative Medicine, National Cancer Centre Singapore, Singapore
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Abstract
Both dying children and their families are treated with disrespect when the presumption of consent to cardiopulmonary resuscitation (CPR) applies to all hospitalized children, regardless of prognosis and the likely efficacy of CPR. This "opt-out" approach to CPR fails to appreciate the nuances of the special parent-child relationship and the moral and emotional complexity of enlisting parents in decisions to withhold CPR from their children. The therapeutic goal of CPR is not merely to resume spontaneous circulation, but rather it is to provide circulation to vital organs to allow for treatment of the underlying proximal and distal etiologies of cardiopulmonary arrest. When the treating providers agree that attempting CPR is highly unlikely to achieve the therapeutic goal or will merely prolong dying, we should not burden parents with the decision to forgo CPR. Rather, physicians should carry the primary professional and moral responsibility for the decision and use a model of informed assent from parents, allowing for respectful disagreement. As emphasized in the palliative care literature, we recommend a directive and collaborative goal-oriented approach to conversations about limiting resuscitation, in which physicians provide explicit recommendations that are in alignment with the goals and hopes of the family and emphasize the therapeutic indications for CPR. Through this approach, we hope to help parents understand that "doing everything" for their dying child means providing medical therapies that ameliorate suffering and foster the intimacy of the parent-child relationship in the final days of a child's life, making the dying process more humane.
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Affiliation(s)
- Jonna D Clark
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA 98105-037, USA.
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Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Burman KD, Kebebew E, Lee NY, Nikiforov YE, Rosenthal MS, Shah MH, Shaha AR, Tuttle RM. American Thyroid Association guidelines for management of patients with anaplastic thyroid cancer. Thyroid 2012; 22:1104-39. [PMID: 23130564 DOI: 10.1089/thy.2012.0302] [Citation(s) in RCA: 473] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anaplastic thyroid cancer (ATC) is a rare but highly lethal form of thyroid cancer. Rapid evaluation and establishment of treatment goals are imperative for optimum patient management and require a multidisciplinary team approach. Here we present guidelines for the management of ATC. The development of these guidelines was supported by the American Thyroid Association (ATA), which requested the authors, members the ATA Taskforce for ATC, to independently develop guidelines for ATC. METHODS Relevant literature was reviewed, including serial PubMed searches supplemented with additional articles. The quality and strength of recommendations were adapted from the Clinical Guidelines Committee of the American College of Physicians, which in turn was developed by the Grading of Recommendations Assessment, Development and Evaluation workshop. RESULTS The guidelines include the diagnosis, initial evaluation, establishment of treatment goals, approaches to locoregional disease (surgery, radiotherapy, systemic therapy, supportive care during active therapy), approaches to advanced/metastatic disease, palliative care options, surveillance and long-term monitoring, and ethical issues including end of life. The guidelines include 65 recommendations. CONCLUSIONS These are the first comprehensive guidelines for ATC and provide recommendations for management of this extremely aggressive malignancy. Patients with stage IVA/IVB resectable disease have the best prognosis, particularly if a multimodal approach (surgery, radiation, systemic therapy) is used, and some stage IVB unresectable patients may respond to aggressive therapy. Patients with stage IVC disease should be considered for a clinical trial or hospice/palliative care, depending upon their preference.
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Manthous CA, Ivy M. Why surgeons can say "no": exploring "unilateral withholding". J Hosp Med 2012; 7:249-53. [PMID: 22223480 DOI: 10.1002/jhm.986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 09/08/2011] [Accepted: 09/12/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To explore why it is permissible for surgeons to "unilaterally withhold" surgery, whereas it is not commonplace (in the United States) to unilaterally withhold cardiopulmonary resuscitation (CPR) for clinical situations with similar degrees of uncertainty and prognosis. DATA SOURCES The medical literature was sampled using PubMed and Google search engines, employing a variety of search strategies to capture articles relating to medical/surgical decision-making, risk aversion, acute care surgery, and withholding life-saving therapies. These topics are used to highlight interprovider variability that affects all practitioners-not just surgeons-and to consider why we deem it permissible for surgeons to withhold surgery, whereas-in the United States, at least-it is not routinely permissible for clinicians to unilaterally withhold mechanical ventilation and CPR for cases with similar prognoses. CONCLUSIONS While there are no published research studies that deal directly with this topic, knowledge, heuristics, experience, variable aversion to risk, and other features inherent in medical-surgical education likely impact decisions to offer or withhold potentially life-saving therapies of all kinds. Both surgeons and clinicians, who request surgical consultation for hospitalized patients, should consider these issues and politely pursue second opinions when there is any doubt whether forgoing surgery is in the patient's best interests. Similarly, while unilateral withholding of CPR is not commonly employed in some medical cultures, including the United States, beneficence can be facilitated through robust informed consent.
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Clark JD, Dudzinski DM. The false dichotomy: do "everything" or give up. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2011; 11:26-27. [PMID: 22047121 DOI: 10.1080/15265161.2011.603807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Jonna D Clark
- Seattle Children’s Hospital, Critical Care Medicine M/S 8866, 4800 Sand PointWay NE,Seattle,WA 98105-0371, USA.
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Affiliation(s)
- Ann Weinacker
- Stanford University, 300 Pasteur Drive #H3142, Stanford, CA 94065-5236, USA.
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Affiliation(s)
- J J Paris
- Department of Theology, Boston College, Chestnut Hill, MA 02467, USA.
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Truog RD. The conversation around CPR/DNR should not be revived--at least for now. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:84-85. [PMID: 20077354 DOI: 10.1080/15265160903460988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Robert D Truog
- Harvard Medical School, Division of Medical Ethics, 641 Huntington Avenue, Boston, MA 02115, USA.
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Scripko PD, Greer DM. Practical considerations for reviving the CPR/DNR conversation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:74-75. [PMID: 20077349 DOI: 10.1080/15265160903460889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Patricia Diane Scripko
- Cleveland Clinic Lerner College of Medicine, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Pope TM. Restricting CPR to patients who provide informed consent will not permit physicians to unilaterally refuse requested CPR. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:82-83. [PMID: 20077353 DOI: 10.1080/15265160903460996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Ells C. Levels of intervention: communicating with more precision about planned use of critical interventions. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:78-79. [PMID: 20077351 DOI: 10.1080/15265160903460947] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Carolyn Ells
- McGill University, Biomedical Ethics Unit, 3647 Peel St., #305, Montreal, Quebec, H3A 1X1, Canada.
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Feen E. Leave current system of universal CPR and patient request of DNR orders in place. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:80-81. [PMID: 20077352 DOI: 10.1080/15265160903460970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Eli Feen
- Saint Louis University School of Medicine, St. Louis, MO 63104, USA.
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Berger JT. Insult to injury: ethical confusion in American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:68-70. [PMID: 20077346 DOI: 10.1080/15265160903460848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Jeffrey T Berger
- Winthrop University Hospital, 222 Station Plaza North, Mineola, NY 11501, USA.
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Iserson KV. Resuscitation strategies in the United States: realities of hospital and prehospital treatment. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2010; 10:72-73. [PMID: 20077348 DOI: 10.1080/15265160903441053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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