Ethical decision-making in critical care in Hong Kong

Shared Decision-Making on Life-Sustaining Treatment: A Survey of Current Barriers in Practice Among Clinicians Across China

Background: The perceptions of practicing physicians regarding the current situation and appropriateness of shared decision-making (SDM) in life-sustaining treatment (LST) are of essential importance. The objective of this study is to investigate the clinical practice patterns and barriers to this process in China. Methods: A cross-sectional survey of physicians in China was conducted to assess perceived practices of SDM in LST. The survey instrument was developed through the Delphi method. Descriptive analyses and an exploratory factor analysis were performed to explore the correlations of factors. Results: We polled 977 physicians, of whom 971 completed the survey and 834 (85.9%) have experience of decision-making conversations for LST and entered the final analysis. Physicians expressed that in the process of doctor-patient communication, over-expectations of disease prognosis (778 [93.3%]), lack of general medical knowledge (716 [85.9%]), and negative emotional status (574 [68.8%]) served as the main barriers to decision-making communication from the patient/family side, while under-expressed patient value (429 [51.4%]), limited communication due to work-load (359 [43%]), lack of communication skills (310 [37.2%]), and insufficient ability to cope with difficult cases (203 [24.3%]) as obstacles from the physician side. Only 185 (22.2%) physicians chose to disclose medical information according to literature evidence. The direct effects of physician service year and disclosure pattern on patient/family decision-making ability revealed statistically significant correlations (βDMA Collapse

Key Words

• barriers
• decision-making conversation
• life-sustaining treatment

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MESH Headings Collapse

Grants

• 20-378 China Medical Board-Open Competition Program
• BYSYLXHG2020004 Peking University Third Hospital Fund for Returned Scholars
• 301-2305 the special fund of the National Clinical Key Specialty Construction Program, P. R. China (2022)

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Affiliation(s)

Yang Liang Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
Hua Zhang Clinical Epidemiology Research Center, Peking University Third Hospital, Beijing 100191, China
Shu Li Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China
Qingbian Ma Department of Emergency Medicine, Peking University Third Hospital, Beijing 100191, China Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Beijing 100191, China

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Prevalence and factors of discordance attitudes toward advance care planning between older patients and their family members in the primary medical and healthcare institution

Background

This study aimed at investigating the prevalence and factors of the discordant attitudes toward advance care planning (ACP) among older patients and their family members toward patients' engagement in ACP in the primary medical and healthcare institution.

Methods

In a cross-sectional study, a total of 117 older patients and 117 family members from Jinhua Fifth Hospital in China were enrolled. The questionnaire included sociodemographic characteristics, functional capacity assessment, and attitudes toward patients' engagement in ACP. Functional capacity assessment scales included the Modified Barthel Index (MBI), the Short-Form Mini-Nutritional Assessment (MNA-SF), the 15-item Geriatric Depression Scale (GDS-15), the Mini-Mental State Examination (MMSE), the Clinical Frailty Scale (CFS), and the SARC-F questionnaire.

Results

The discordance attitudes toward patients' engagement in ACP between patients and family members accounted for 41(35.0%). In the multivariate logistic analysis, factors associated with higher odds of discordance attitudes toward patients' engagement in ACP included greater age differences between patients and family members (OR = 1.043, 95% CI: 1.007-1.081), lower educational level for family members (OR = 3.373, 95% CI: 1.239-9.181), the patient's higher GDS-15 score (OR = 1.437, 95% CI: 1.185-1.742), and patient's higher MNA-SF score (OR = 1.754, 95% CI: 1.316-2.338).

Conclusion

Older patients and their family members had little ACP knowledge, and factors that influence discordance attitudes toward patients' engagement in ACP included the age gaps between patients and family members, family members' educational level, patients' depressive symptoms, and patients' nutritional status.

Obstacles and Facilitating Factors in Decision-Making of Elderly Patients' Living Will in the Chinese Context-A Literature Review

Background

The living will provide patients at the end of life with the autonomy to choose medical care, so that the patients at the end of life can get dignified and die. In many countries such as Europe and the United States, this choice of people is guaranteed by the law. However, China is in its infancy in the field of living wills, lacking legal support, and the Chinese people have relatively low awareness of living wills and their acceptance is not optimism. China's aging population is developing rapidly, and death education is getting more and more attention, and the popularity of living wills will increase further in the future.

Objective

The aim of this review is to find out the obstacles and facilitating factors in the decision-making of elderly patients in the Chinese context, and to propose countermeasures.

Methods

By searching for relevant literature in databases such as Cnki, Wanfang date, Weipu, Pubmed, Springer, Elsevier, etc., we can understand the connotation of the living wills of elderly patients at home and abroad and the obstacles and promotion factors that affect the signing of the living wills of elderly patients in China.

Results

In the Chinese context, obstacles and facilitating factors in the decision-making of elderly patients' living will can be summarized at the individual, social, and national levels. The obstacles are: low quality of hospice care, social ethics, and lack of legal support. Facilitating factors include: meeting people's psychological expectations, respecting personal autonomy, conducive to the mental health of dying patients and their caregivers, and patients' willingness to accept living will.

Conclusion

Need to determine relevant specific influencing factors, formulate intervention measures, and promote the development of death education in China to ensure gradual progress.

Perceptions of Patients and Their Families Regarding Limitation of Therapeutic Effort in the Intensive Care Unit

OBJECTIVE

Our objective was to determine and describe the opinion and attitudes of patients and their families regarding the limitation of therapeutic effort and advanced directives in critical patients and whether end-of-life planning occurs. Religious affiliation, education level, and pre-admission quality of life were also evaluated to determine whether they may influence decisions regarding appropriate therapeutic effort.

METHODS

A prospective, observational and descriptive study, approved by the center's ethical committee, was carried out with 257 participants (94 patients and 163 family members) in the intensive care unit (ICU). A questionnaire regarding the opinions of patients and relatives about situations of therapeutic appropriateness in case of poor prognosis or poor quality of life was used. The questionnaire had three sections. In the first section, sociodemographic features were investigated. In the second section, information was collected on the quality of life and functional situation before ICU admission (taking as a reference the situation one month before admission) assessed by the Karnofsky scale, Barthel index, and the PAEEC scale (Project for the Epidemiological Analysis of Critical Care Patients). The third section aimed to determine whether the family knew the patient's opinion regarding his/her end of life.

RESULTS

Of those interviewed, 62.2% would agree to limit treatment in case of poor prognosis or poor quality of future life. In contrast, 37.7% considered that they should fight for life, even if it is irretrievable. Only 1.6% had advanced directives registered, 43.9% of the participants admitted deterioration in their quality of life before ICU admission, 18.2% with moderate-severe deterioration. Our study shows that the higher the educational level, the lower the desire to fight for life when it is irretrievable and the greater the agreement to limit treatment. Besides, those participants not affiliated with a religion were significantly less likely to fight for life, including when irretrievable, than Catholics and were more likely to agree to limit treatment.

CONCLUSIONS

More than half of the participants would agree to limit treatment in the case of a poor prognosis. Our results indicate that patients do not prepare for the dying process well in advance. Religion and educational level were determining factors for the choice of procedures at the end of life, both for patients and their families.

When Hanging on at All Costs is the Only Option

Having hope that a terminally ill patient may recover is not an unfamiliar sight in intensive care units across the globe. However, cultural heritage may make it even tougher. This fictional case study, which is a collection of years of experience, addresses decision-making within the Chinese Immigrant culture and focusses on how this may influence the care team. A new initiative, the Goals of Care (GOC) team, is also described.

Attitudes Toward Advance Directives Among Patients and Their Family Members in China

OBJECTIVES

Chinese people are generally unfamiliar with the concept of advance care planning or advance directives (ACP/ADs), which raises dilemmas in life-support choice and can even affect clinical decision making. To understand and address the issues involved better, we investigated the awareness of ACP/ADs in China, as well as people's attitudes toward medical autonomy and end-of-life care.

DESIGN

A multicenter cross-sectional survey, conducted from August 1 to December 31, 2016.

SETTING

Twenty-five hospitals located in 15 different provinces throughout mainland China.

PARTICIPANTS

Pairs of adult patients without dementia or malignancies, and a family member.

MEASUREMENTS

Participants self-filled anonymous questionnaires, and the data collected were analyzed to relate patients' sociodemographic characteristics to their awareness of ACP/ADs and attitudes to health care autonomy and end-of-life care.

RESULTS

Among 1084 patients who completed the questionnaire, 415 (38.3%) had heard about ACP/ADs. Having been informed about ACP/ADs, 995 (91.8%) were willing to find out their true health status and decide for themselves; 549 (50.6%) wanted to institute ACP/ADs. Regarding end-of-life care, 473 (43.6%) chose Do Not Resuscitate, and 435 (40.1%) wished to forgo life-support treatment if irreversibly moribund. Patients predominantly (481, 44.4%) chose general hospital as their preferred place to spend their last days of life; only 114 (10.5%) favored a special hospice facility. Patients' main concerns during end-of-life care were symptom control (35.1%), followed by functional maintenance and quality of life (29.8%), and prolonging life (18.9%). More highly educated patients had significantly greater awareness of ACP/ADs than less well educated ones (χ² = 59.22, P < .001) and were more willing to find out the truth for themselves (χ² = 58.30, P ≤ .001) and make medical decisions in advance (χ² = 55.92, P < .001). Younger patients were also more willing than older ones to know the truth (χ² = 38.23, P = .001) and make medical decisions in advance (χ² = 18.42, P = .018), and were also more likely to wish to die at home (χ² = 96.25, P < .001). Only 212 patients' family members (19.6%) wanted life-support treatment for themselves if irreversibly moribund, whereas 592 (54.6%) would want their relative to receive such procedures in the same circumstances; a similar discrepancy was evident for end-of-life invasive treatment (18.3% vs 42.7%).

CONCLUSIONS

Awareness about ACP/ADs in China is still low. Providing culturally sensitive knowledge, education, and communication regarding ACP/ADs is a feasible first step to promoting this sociomedical practice.

Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study

BACKGROUND

In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient's autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown.

AIM

To determine the barriers and perceptions in discussion of code status by physicians.

DESIGN

Questionnaire-based cross-sectional study.

SETTING AND PARTICIPANTS

This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included.

RESULTS

A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians.

CONCLUSION

Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries.

Team Approach in Cross-Cultural Ethical Decision Making: A Case Study

The increasing cultural diversity in modern society creates difficulties in cross-cultural ethical decision making for healthcare workers. Nurses need to be sensitive and knowledgeable about the cultural background of individual patients. Acknowledging an individual's cultural background and considering the characteristics of different cultures when planning the patient's care may facilitate the process of ethical decision making.

Using a Checklist to Improve Family Communication in Trauma Care

Modern concepts of patient-centered care emphasize effective communication with patients and families, an essential requirement in acute trauma settings. We hypothesized that using a checklist to guide the initial family conversation would improve the family's perception of the interaction. Institutional Review Board–approved, prospective pre/post study involving families of trauma patients admitted to our Level I trauma center for >24 hours. In the control group, families received information according to existing practices. In the study group, residents gave patient information to a first-degree family member using a checklist that guided the interaction. The checklist included a physician introduction, patient condition, list of known injuries, admission unit or intensive care unit, any consultants involved, plans for additional studies or operations, and opportunity for family to ask questions. An 11-item survey was administered 24 to 48 hours after admission to each group that evaluated the trauma team's communication in the areas of physician introduction, patient condition, ongoing treatment, and family perception of the interaction. Responses were on a Likert scale and analyzed using the Wilcoxon-Mann-Whitney test. There were 130 patients in each group. The study group had significantly ( P < 0.05) better responses in 8 of 11 items surveyed: physician spoke to family, physician introduction, understanding of their relative's injuries, admitting unit, consultants involved, urgent surgical procedures required, ongoing diagnostic studies, and understanding of the treatment plan. In conclusion, using a checklist improves the perception of the initial communication between the trauma team and family members of trauma patients, especially their understanding of the treatment plan.

Attitudes towards Advance Care Planning and Healthcare Autonomy among Community-Dwelling Older Adults in Beijing, China

OBJECTIVES

To investigate the preferences of ACP and healthcare autonomy in community-dwelling older Chinese adults.

METHODS

A community-based cross-sectional study was conducted with older adults living in the residential estate of Chaoyang District, Beijing.

RESULTS

900 residents were enrolled. 80.9% of them wanted to hear the truth regarding their own condition from the physician; 52.4% preferred to make their own healthcare decisions. Only 8.9% of them preferred to endure life-prolonging interventions when faced with irreversible conditions. 78.3% of the respondents had not heard of an ACP; only 39.4% preferred to document in an ACP. Respondents with higher education had significantly higher proportion of having heard of an ACP, as well as preferring to document in an ACP, compared to those with lower education. Those aged <70 years had higher proportion of having heard of an ACP, as well as refusing life-prolonging interventions when faced with irreversible conditions, compared to those aged ≥ 70 years.

CONCLUSIONS

Although the majority of community-dwelling older Chinese adults appeared to have healthcare autonomy and refuse life-prolonging interventions in terms of end-of-life care, a low level of "Planning ahead" awareness and preference was apparent. Age and education level may be the influential factors.

Older people and decision-making following acute stroke in China: ‘hiding’ as a barrier to active involvement

Decision-making among older patients with stroke, their families and professionals has been extensively studied in a Western context, but there has been little prior work in China. The study reported here explored how decision-making took place between older people with stroke, their family carers and professionals in an acute care context in mainland China using a constructivist grounded theory approach. Data were collected through semi-structured interviews, participant observation and documentary analysis. Constant comparative analysis of the data was carried out. This paper focuses on the key social process of ‘hiding’ and its dynamic relationship with the core category ‘keeping the peace’. In order to meet the traditional Chinese cultural value of ‘maintaining harmony’, both family carers and professionals hid essential information from older stroke survivors who, as a consequence, were effectively precluded from playing an active role in major decisions. In understanding ‘hiding’, the paper draws upon both Chinese cultural values and ‘awareness context theory’ and in so doing questions the relevance to the Chinese context of key Western notions such as involvement in health-care decision-making. A better understanding of the experiences of decision-making processes between older people with stroke, their family carers and professionals in China will help professionals to provide the best possible support and care whilst promoting informed decision-making amongst all concerned.

The Durban World Congress Ethics Round Table IV: health care professional end-of-life decision making

INTRODUCTION

When terminal illness exists, it is common clinical practice worldwide to withhold (WH) or withdraw (WD) life-sustaining treatments. Systematic documentation of professional opinion and perceived practice similarities and differences may allow recommendations to be developed.

MATERIALS AND METHODS

Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress that took place in Durban (2013), with an interest in ethics, were approached to participate in an ethics round table. Key domains of health care professional end-of-life decision making were defined, explored by discussion, and then questions related to current practice and opinion developed and subsequently answered by round-table participants to establish the presence or absence of agreement.

RESULTS

Agreement was established for the desirability for early goal-of-care discussions and discussions between health care professionals to establish health care provider consensus and confirmation of the grounds for WH/WD, before holding formal WH/WD discussions with patients/surrogates. Nurse and other health care professional involvement were common in most but not all countries/regions. Principles and practical triggers for initiating discussions on WH/WD, such as multiorgan failure, predicted short-term survival, and predicted poor neurologic outcome, were identified.

CONCLUSIONS

There was majority agreement for many but not all statements describing health care professional end-of-life decision making.

Determinants and outcomes associated with decisions to deny or to delay intensive care unit admission in Morocco

PURPOSE

To report determinants and outcomes associated with decisions to deny or to delay intensive care unit (ICU) admission in critically ill patients.

METHODS

An observational prospective study over a 6-month period. All adult patients triaged for admission to a medical ICU were included prospectively. Age, gender, reasons for requesting ICU admission, severity of underlying disease, severity of acute illness, mortality and ICU characteristics were recorded. Multinomial logistic regression analysis was used for evaluating predicting factors of refused ICU admission.

RESULTS

ICU admission was requested for 398 patients: 110 were immediately admitted (27.8%), 142 were never admitted (35.6%), and 146 were admitted at a later time (36.6%). The reasons for refusal were: too sick to benefit (31, 10.8%), too well to benefit (55, 19.1%), unit full (117, 40.6%), and more data about the patient were needed to make a decision (85, 29.5%). Multivariate analysis revealed that late ICU admission was associated with the lack of available ICU beds (OR 1.91; 95% CI 1.46-2.50; p = 0.003), cardiac disease (OR 7.77; 95% CI 2.41-25.04; p < 0.001), neurological disease (OR 3.78; 95% CI 1.40-10.26; p = 0.009), shock and sepsis (OR 2.55; 95% CI 1.06-6.13; p = 0.03), and metabolic disease (OR 2.84; 95% CI 1.11-7.30; p = 0.02). Factors for ICU refusal for never admitted patients were: severity of acute illness (OR 4.83; 95% CI 1.11-21.01; p = 0.03), cardiac disease (OR 14.26; 95% CI 3.95-51.44; p < 0.001), neurological disease (OR 4.05; 95% CI 1.33-12.28; p = 0.01) and lack of available ICU beds (OR 6.26; 95% CI 4.14-9.46; p < 0.001). Hospital mortality was 33.3% (37/110) for immediately admitted patients, 43.8% (64/146) for patients admitted later and 49.3% (70/142) for never admitted patients.

CONCLUSION

Refusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. Further efforts are needed to define which patients are most likely to benefit from ICU admission and to improve the accuracy of data on ICU refusal rates.

Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis

Introduction

Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors.

Methods

This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved.

Results

Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (€82,358) and cost per life-year saved was $7,065 (€5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (€47,656) and $4,088 (€3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses.

Conclusions

Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.

Attitudes towards ethical problems in critical care medicine: the Chinese perspective

INTRODUCTION

Critical care doctors are frequently faced with clinical problems that have important ethical and moral dimensions. While Western attitudes and practice are well documented, little is known of the attitudes or practice of Chinese critical care doctors.

METHODS

An anonymous, written, structured questionnaire survey was translated from previously reported ethical surveys used in Europe and Hong Kong. A snowball method was used to identify 534 potential participants from 21 regions in China.

RESULTS

A total of 315 (59%) valid responses were analysed. Most respondents (66%) reported that admission to an intensive care unit (ICU) was commonly limited by bed availability, but most (63%) would admit patients with a poor prognosis to ICU. Only 19% of respondents gave complete information to patients and family, with most providing individually adjusted information, based on prognosis and the recipient's educational level. Only 28% disclosed all details of an iatrogenic incident, despite 62% stating that they should. The use of do not resuscitate orders or limitation of life-sustaining therapy in terminally ill patients reported as uncommon and according to comparable reports, both are more common practice in Hong Kong or Europe. In contrast to European practices, doctors were more acquiescent to families in decision-making at the end of life.

CONCLUSIONS

A number of differences in ethical attitudes and related behaviour between Chinese, Hong Kong and European ICU doctors were documented. A likely explanation is differing cultural background, and doctors should be aware of likely expectations when treating patients from a different culture.

Encompassing multiple moral paradigms: A challenge for nursing educators

Providing ethically competent care requires nurses to reflect not only on nursing ethics, but also on their own ethical traditions. New challenges for nurse educators over the last decade have been the increasing globalization of the nursing workforce and the internationalization of nursing education. In New Zealand, there has been a large increase in numbers of Chinese students, both international and immigrant, already acculturated with ethical and cultural values derived from Chinese Confucian moral traditions. Recently, several incidents involving Chinese nursing students in morally conflicting situations have led to one nursing faculty reflecting upon how moral philosophy is taught to non-European students and the support given to Chinese students in integrating the taught curriculum into real-life clinical practice settings. This article uses a case study involving a Chinese student to reflect on the challenges for both faculty members and students when encountering situations that present ethical dilemmas.

Decision-making capacity: the core of self-neglect

Self-neglect in the elderly is a pervasive public health issue that affects 1.2 million elderly each year. In working with self-neglect cases, ethical issues are often raised that challenge all professionals. Professional and family's wishes to remove obstacles to the wellbeing of an elderly may be directly in opposition to the individual's wishes. The core of many ethical dilemmas resides in the question of the individual decision-making capacity. Issues surrounding decision-making capacity are complex with many confounding factors. Through case-discussion, fundamental ethical issues of decision-making capacity relating to self-neglect will be explored and strategies will be offered to resolve these dilemmas.

Knowledge and attitudes toward brain stem death among university undergraduates

BACKGROUND

Withdrawal of life support and organ procurement for transplantation are the main implications of a diagnosis of brain stem death (BSD). Various factors may impact this important decision-making process. The present study sought to investigate the knowledge and attitudes about BSD among university undergraduates as a "well-informed" subgroup of our local population.

METHODS

A cross-sectional questionnaire survey was administered to a sample of nonmedical university undergraduate students in Hong Kong.

RESULTS

The subjects' overall knowledge of BSD was unsatisfactory. Only 24% of subjects knew that BSD was the equivalent of legal death in Hong Kong. Among subjects who agreed to withdraw life support treatment from themselves upon the diagnosis of BSD, 30% and 24% refused to do so for their family members or a stranger, respectively. Subjects who agreed to withdraw life support showed significantly better knowledge about BSD than did those who did not agree. Concerns about doctors' inclination to diagnose BSD to save resources and extract organs for transplantation were not observed to negatively affect subjects' decisions about life support withdrawal.

CONCLUSION

The level of knowledge is an important factor affecting an individual's decision concerning withdrawal of life support therapy upon the diagnosis of BSD. Adequate explanation and counseling are important to facilitate family members in coping with this important end-of-life issue.

Understandings of death and dying for people of Chinese origin

This article introduces the primary beliefs about ancestor worship, Taoism, Confucianism, Buddhism and traditional Chinese medicine that have influenced Chinese people for thousands of years, particularly in relation to death and dying. These cultures and traditions remain important for Chinese people wherever they live. Over a long period, Chinese people have integrated these philosophies and religions to form the basis of their culture and traditions. Although they agree that death is a natural part of the life span, a unique belief about death and dying has emerged among the Chinese from this integration. From this, the people find a significant definition of death and dying.

Changes in medical students' attitudes towards end-of-life decisions across different years of medical training

BACKGROUND

Decisions to forgo life-sustaining medical treatments in terminally ill patients are challenging, but ones that all doctors must face. Few studies have evaluated the impact of medical training on medical students' attitudes towards end-of-life decisions and none have compared them with an age-matched group of non-medical students.

OBJECTIVE

To assess the effect of medical education on medical students' attitudes towards end-of-life decisions in acutely ill patients.

DESIGN

Cross-sectional study.

PARTICIPANTS

Four hundred and two students at The Chinese University of Hong Kong.

MEASUREMENTS

Completion of a questionnaire focused on end-of-life decisions.

MAIN RESULTS

The number of students who felt that cardiopulmonary resuscitation must always be provided was higher in non-medical students (76/90 (84%)) and medical students with less training (67/84 (80%) in year 1 vs. 18/67 (27%) in year 5) (p < 0.001). Discontinuing life-support therapy was more accepted among senior medical students compared to junior medical and non-medical students (27/66 (41%) in year 5 vs. 18/83 (22%) in year 1 and 20/90 (22%) in non-medical students) (p = 0.003). An unexpectedly large proportion of non-medical students (57/89 (64%)) and year 1 medical students (42/84 (50%)) found it acceptable to administer fatal doses of drugs to patients with limited prognosis. Euthanasia was less accepted with more years of training (p < 0.001). When making decisions regarding limitation of life-support therapy, students chose to involve patients (98%), doctors (92%) and families (73%) but few chose to involve nurses (38%).

CONCLUSIONS

Medical students' attitudes towards end-of-life decisions changed during medical training and differed significantly from those of non-medical students.

Knowledge, acceptance and perception towards brainstem death among medical students in Hong Kong: a questionnaire survey on brainstem death

BACKGROUND

Brainstem death (BSD), defined as the irreversible loss of consciousness, brainstem reflexes and the capacity to breathe, is not an uncommon scenario seen in the day to day practice of medical personnel. Upon the diagnosis of BSD, controversial issues of withdrawing life-supporting treatments and organ procuring for transplantation inevitably arise. This study evaluated the knowledge, acceptance and perception of BSD amongst medical students in Hong Kong.

METHODS

A total of 126 medical students completed a self-administered questionnaire. Ten questions were used to assess their knowledge of BSD and this was correlated with their responses in three hypothetical vignettes.

RESULTS

The mean score of the subjects' knowledge was 6.03 out of 10. Less than half (48.8%) of the subjects' knew that BSD is different from persistent vegetative state while 49.2% and 36.3% knew that BSD is accepted as death medically and legally in Hong Kong, respectively. When 'diagnosed' with BSD, 63.7%, 46.8% and 52.4% of the subjects would agree to the withdrawal of life-support from themselves, their most-loved one/family member and a stranger, respectively. Subjects with better knowledge and those who thought that doctors may tend to diagnose BSD to save resources or procure organs for transplantation were more ready to accept the withdrawal of life-support.

CONCLUSIONS

We concluded that knowledge of BSD amongst medical students was unsatisfactory and that urgent actions should be taken to remedy the situation. A better knowledge of BSD positively influenced the decision-making on withdrawing life-support and that adequate information regarding the outcome of BSD should be provided. On the other hand, the perception of doctors' intentions behind diagnosing BSD has no direct influence on the decision-making. More emphasis is required on medical education, including a specific emphasis in the undergraduate lecture curriculum and bedside exposure to BSD diagnosis and subsequent counselling of patients' family members.

Ethical dilemmas in intensive care: can the problem be solved?

There is a lack of consistency in ethical decision-making with regard to forgoing life-support, which demands increased efforts to improve clinical competence in end-of-life care, e.g. by proactive ethics consultation or early exploration and documentation of the patient's wishes and preferences. Another current ethical issue is the allocation of limited resources; recent guidelines provide a useful framework for bedside practitioners and health policy makers.

Acculturation and end-of-life decision making: comparison of Japanese and Japanese-American focus groups

Variation in decision-making about end-of-life care among ethnic groups creates clinical conflicts. In order to understand changes in preferences for end-of-life care among Japanese who immigrate to the United States, we conducted 18 focus groups with 122 participants: 65 English-speaking Japanese Americans, 29 Japanese-speaking Japanese Americans and 28 Japanese living in Japan. Negative feelings toward living in adverse health states and receiving life-sustaining treatment in such states permeated all three groups. Fear of being meiwaku, a physical, psychological or financial caregiving burden on loved ones, was a prominent concern. They preferred to die pokkuri (popping off) before they become end stage or physically frail. All groups preferred group-oriented decision-making with family. Although advance directives were generally accepted, Japanese participants saw written directives as intrusive whereas Japanese Americans viewed them mainly as tools to reduce conflict created by dying person's wishes and a family's kazoku no jo--responsibility to sustain the dying patient. These findings suggest that in the United States Japanese cultural values concerning end-of-life care and decision-making process are largely preserved.

Use of the University of California Los Angeles Integrated Staging System (UISS) to predict survival in localized renal cell carcinoma in an Asian population

OBJECTIVES

To evaluate the applicability of the University of California Los Angeles Integrated Staging System (UISS) in predicting the prognosis of Chinese patients with localized renal cell carcinoma after radical nephrectomy, with reference to that reported by Patard et al in an international multicenter study (J Clin Oncol 2004, 22:3316-3322).

METHODOLOGY

One hundred and twenty-eight Chinese patients with localized renal cell carcinoma were stratified into low risk (LR), intermediate risk (IR) and high risk (HR) groups according to the UISS, based on the TMN staging and Fuhrman grading of the tumor and the Eastern Cooperative Oncology Group performance status of the patients. The survival curves of each risk group were then calculated.

RESULTS

The number of patients in the LR, IR and HR was 24 (18.8%), 94 (73.4%) and 10 (7.8%) respectively. The estimated 2-year survival rates were 100%, 89.9% and 100% for the LR, IR and HR groups respectively. Whereas the estimated 5-year survival rates were 93.3%, 72.4% and 80% for the LR, IR and HR groups respectively. The LR and IR patients had comparable 2-year and 5-year estimated survival rates with those reported by Patard et al. However, the estimated survival rate for HR patients was better than that reported.

CONCLUSIONS

UISS provided a valuable tool in predicting the survival of Chinese patients with localized renal cell carcinoma of LR and IR groups, as reported in other international centers. Further large scale study may be needed to confirm the applicability in HR population.

Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death. A prospective multicenter study

STUDY OBJECTIVES

More than two thirds of family members visiting intensive care unit (ICU) patients have symptoms of anxiety or depression during the first days of hospitalization. Identifying determinants of these symptoms would help caregivers support families at patient discharge or when death is imminent.

DESIGN AND SETTING

Prospective multicenter study including 78 ICUs (1184 beds) in France.

PARTICIPANTS

Family members completed the Hospital Anxiety and Depression Scale on the day of patient discharge or death to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression.

RESULTS

Three hundred fifty-seven patients were included in the study, and 544 family members completed the Hospital Anxiety and Depression Scale. Symptoms of anxiety and depression were found in 73.4% and 35.3% of family members, respectively; 75.5% of family members and 82.7% of spouses had symptoms of anxiety or depression (P = .007). Symptoms of depression were more prevalent in family members of nonsurvivors (48.2%) than of survivors (32.7%) (P = .008). The multivariate model identified 3 groups of factors associated with symptoms: (1) patient-related: severity as assessed by the Simplified Acute Physiology Score II (odds ratio [OR] 1.017 per point) and patient age (OR 0.984 per year) predicted anxiety, and Simplified Acute Physiology Score II (OR, 1.015 per point), patient death (OR 2.092), and patient age (OR 0.981) predicted depression; (2) family-related: the spouse predicted anxiety (OR 2.085); and (3) ICU-related: a room with more than 1 bed (OR 1.539) predicted depression.

CONCLUSION

The prevalence of symptoms of anxiety and depression remains high at the end of the ICU stay, whether the patient is well enough to be discharged or is near death.

Family-physician interactions in the intensive care unit

Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.

Ethics roundtable debate: withdrawal of tube feeding in a patient with persistent vegetative state where the patients wishes are unclear and there is family dissension

The decision to withdraw or withhold life supporting treatment in moribund patients is difficult under any circumstances. When the patient becomes incompetent to clarify their wishes regarding continued maintenance in long-term facilities, surrogates sometimes cannot agree, further clouding the issue. We examine a case where the State's interests come into play, forcing a controversial resolution.

Junior versus Senior Physicians for Informing Families of Intensive Care Unit Patients

To compare the effectiveness of information delivered to family members of critically ill patients by junior and senior physicians, we performed a prospective randomized multicenter trial in 11 French intensive care units. Patients (n = 220) were allocated at random to having their family members receive information by only junior or only senior physicians throughout the intensive care unit stay; there were 92 and 93 evaluable cases in the junior and senior groups, respectively, with no significant differences in baseline characteristics. Between Days 3 and 5, one family representative per patient was evaluated for comprehension of the diagnosis, prognosis, and treatment in the patient; satisfaction with information and care; and presence of symptoms of anxiety and depression. No significant differences were found between the two groups for any of these three criteria. Family members informed by a junior physician were more likely to feel they had not been given enough information time (additional time wanted: 3 [0-6.5] vs. 0 [0-5] minutes, p = 0.01) and to have sought additional explanations from their usual doctor (48.9 vs. 34.4%, p = 0.004). Specialty residents, if given opportunities for acquiring experience, can become proficient in communicating with families and share this task with senior physicians.

Limitation of life support: Frequency and practice in a Hong Kong intensive care unit*

OBJECTIVE

To examine the frequency and the decision-making processes involved in limiting (withdrawing and withholding) life support therapy in critically ill Chinese patients in the intensive care unit.

DESIGN

Prospective survey of patients who had life support limited between April 1997 and March 1999.

SETTING

Medical and surgical intensive care unit of a teaching hospital.

PATIENTS

All patients admitted to the intensive care unit of the Prince of Wales Hospital who subsequently died and/or had life support limited. Brain-dead patients were excluded from analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 490 patients who died in the intensive care unit, limitation of life support occurred in 288 (58.8%). Relatives or patients requested limitation of life support in 32 cases (11%). The family and/or patient concurred with limitation of life support in 273 occasions (95%). Therapy was withheld in 30.8% and withdrawn in 28.0% of deaths. Therapy limited included inotropes, additional oxygen, and renal replacement therapy.

CONCLUSIONS

Limitation of therapy in dying Chinese patients occurs frequently in intensive care patients, and both patients and relatives concur with medical decisions to limit therapy in these patients. Withholding therapy rather than withdrawing therapy occurs more frequently than in Western populations.

Team approach in cross-cultural ethical decision making: a case study

The increasing cultural diversity in modern society creates difficulties in cross-cultural ethical decision making for healthcare workers. Nurses need to be sensitive and knowledgeable about the cultural background of individual patients. Acknowledging an individual's cultural background and considering the characteristics of different cultures when planning the patient's care may facilitate the process of ethical decision making.

Research priorities in the evolving demographic landscape of Alzheimer disease and associated dementias

The rapid increase of ethnically diverse late onset dementia-affected persons is bringing a special urgency to Alzheimer disease and associated disorders research. By this decade's end, non-European heritage ethnically diverse persons will account for 25% of the dementia-affected cohort and 33% by mid-century. These populations have received some attention in both dementia-focused basic biomedical and social-behavioral research. However, studies differ greatly with regard to the constructs of culture used, the methodologies used, and representativeness of the populations sampled. Moreover, social status factors are often confounded with cultural variables. Therefore, several clarifying research approaches are suggested. In biomedical research, categorically ascribed (US census type) definitions, or assumed (self-reported) ethnic group designators will not suffice where actual biophysiological sampling precision is needed. A strategy for the phenotypic sampling of cohorts is therefore suggested for this research domain. In social-behavioral research, the acceptance of a common operational definition of culture is urged. And, with reference to a specific social status confound, namely literacy, a neuroimaging research strategy is proposed to determine whether non-literates might not be misclassified relative to the determination of their actual cognitive functioning status. Additionally, two conceptual models for addressing and are briefly presented.

Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity

OBJECTIVE

Anxiety and depression may have a major impact on a person's ability to make decisions. Characterization of symptoms that reflect anxiety and depression in family members visiting intensive care patients should be of major relevance to the ethics of involving family members in decision-making, particularly about end-of-life issues.

DESIGN

Prospective multicenter study.

SETTING

Forty-three French intensive care units (37 adult and six pediatric); each unit included 15 patients admitted for longer than 2 days.

PATIENTS

Six hundred thirty-seven patients and 920 family members.

INTERVENTIONS

Intensive care unit characteristics and data on the patient and family members were collected. Family members completed the Hospital Anxiety and Depression Scale to allow evaluation of the prevalence and potential factors associated with symptoms of anxiety and depression.

MEASUREMENTS AND MAIN RESULTS

Of 920 Hospital Anxiety and Depression Scale questionnaires that were completed by family members, all items were completed in 836 questionnaires, which formed the basis for this study. The prevalence of symptoms of anxiety and depression in family members was 69.1% and 35.4%, respectively. Symptoms of anxiety or depression were present in 72.7% of family members and 84% of spouses. Factors associated with symptoms of anxiety in a multivariate model included patient-related factors (absence of chronic disease), family-related factors (spouse, female gender, desire for professional psychological help, help being received by general practitioner), and caregiver-related factors (absence of regular physician and nurse meetings, absence of a room used only for meetings with family members). The multivariate model also identified three groups of factors associated with symptoms of depression: patient-related (age), family-related (spouse, female gender, not of French descent), and caregiver-related (no waiting room, perceived contradictions in the information provided by caregivers).

CONCLUSIONS

More than two-thirds of family members visiting patients in the intensive care unit suffer from symptoms of anxiety or depression. Involvement of anxious or depressed family members in end-of-life decisions should be carefully discussed.

Chinese seniors' perspectives on end-of-life decisions

Making end-of-life decisions is a painful and difficult process; one that can be intensified by cultural differences between physicians and their patients. The objective of this study was to examine attitudes of Chinese seniors towards end-of-life decisions. We conducted a qualitative survey in a Chinese community centre in Toronto, Canada. Face-to-face interviews, in Cantonese, were conducted with 40 Chinese seniors 65 years of age or older. Respondents based their end-of-life decision making on the following factors: hope, suffering and burden, the future, emotional harmony, the life cycle, respect for doctors, and the family. Respondents rejected advance directives. Respondents' attitudes toward end-of-life decision making can be understood through the lens of values from Confucianist, Buddhist and Taoist traditions. Health care workers can best achieve quality end-of-life care--and address the cultural differences that may arise--by focusing primarily on understanding the perspectives of patients and their families, and by continually striving for balanced and open communication at all stages of the caregiving process.

Meeting the needs of intensive care unit patient families: a multicenter study

Intensive care unit (ICU) caregivers should seek to develop collaborative relationships with their patients' family members, based on an open exchange of information and aimed at helping family members cope with their distress and allowing them to speak for the patient if necessary. We conducted a prospective multicenter study of family member satisfaction evaluated using the Critical Care Family Needs Inventory. Forty-three French ICUs participated in the study. ICU characteristics, patient and family member demographics, and data on satisfaction were collected. Factors associated with satisfaction were identified using a Poisson regression model. A total of 637 patients were included in the study, and 920 family members completed the questionnaire. Seven predictors of family satisfaction were found: one family-related factor, namely, family of French descent and six caregiver-related factors, namely, no perceived contradictions in information given by caregivers; information provided by a junior physician; patient to nurse ratio </= 3; knowledge of the specific role of each caregiver; help from the family's own doctor; and sufficient time spent giving information. Predictors of satisfaction are amenable to intervention and deserve to be investigated further with the goal of improving the satisfaction of ICU patients' family members.

Ethical decision making and patient autonomy: a comparison of physicians and patients in Japan and the United States

BACKGROUND

Patient-centered decision making, which in the United States is typically considered to be appropriate, may not be universally endorsed, thereby harboring the potential to complicate the care of patients from other cultural backgrounds in potentially unrecognized ways. This study compares the attitudes toward ethical decision making and autonomy issues among academic and community physicians and patients of medical center outpatient clinics in Japan and the United States.

METHODS

A questionnaire requesting judgments about seven clinical vignettes was distributed (in English or Japanese) to sample groups of Japanese physicians (n = 400) and patients (n = 65) as well as US physicians (n = 120) and patients (n = 60) that were selected randomly from academic institutions and community settings in Japan (Tokyo and the surrounding area) and the United States (the Stanford/Palo Alto, CA, area). Responses were obtained from 273 Japanese physicians (68%), 58 Japanese patients (89%), 98 US physicians (82%), and 55 US patients (92%). Physician and patient sample groups were compared on individual items, and composite scores were derived from subsets of items relevant to patient autonomy, family authority, and physician authority.

RESULTS

A majority of both US physicians and patients, but only a minority of Japanese physicians and patients, agreed that a patient should be informed of an incurable cancer diagnosis before their family is informed and that a terminally ill patient wishing to die immediately should not be ventilated, even if both the doctor and the patient's family want the patient ventilated (Japanese physicians and patients vs US physicians and patients, p < 0.001). A majority of respondents in both Japanese sample groups, but only a minority in both US sample groups, agreed that a patient's family should be informed of an incurable cancer diagnosis before the patient is informed and that the family of an HIV-positive patient should be informed of this disease status despite the patient's opposition to such disclosure (Japanese physicians and patients vs US physicians and patients, p < 0.001). Physicians in both Japan and the United States were less likely than patients in their respective countries to agree with physician assistance in the suicide of a terminally ill patient (Japanese physicians and patients vs US physicians and patients, p < 0.05). Across various clinical scenarios, all four respondent groups accorded greatest authority to the patient, less to the family, and still less to the physician when the views of these persons conflicted. Japanese physicians and patients, however, relied more on family and physician authority and placed less emphasis on patient autonomy than the US physicians and patients sampled. Younger respondents placed less emphasis on family and physician authority.

CONCLUSIONS

Family and physician opinions are accorded a larger role in clinical decision making by the Japanese physicians and patients sampled than by those in the United States, although both cultures place a greater emphasis on patient preferences than on the preferences of the family or physician. Our results are consistent with the view that cultural context shapes the relationship of the patient, the physician, and the patient's family in medical decision making. The results emphasize the need for clinicians to be aware of these issues that may affect patient and family responses in different clinical situations, potentially affecting patient satisfaction and compliance with therapy.