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Lissak IA, Young MJ. Limitation of life sustaining therapy in disorders of consciousness: ethics and practice. Brain 2024; 147:2274-2288. [PMID: 38387081 PMCID: PMC11224617 DOI: 10.1093/brain/awae060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Michael J Young
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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2
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Laurenceau T, Marcou Q, Agostinucci JM, Martineau L, Metzger J, Nadiras P, Michel J, Petrovic T, Adnet F, Lapostolle F. Quantifying physician's bias to terminate resuscitation. The TERMINATOR Study. Resuscitation 2023; 188:109818. [PMID: 37150394 DOI: 10.1016/j.resuscitation.2023.109818] [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: 12/26/2022] [Revised: 04/12/2023] [Accepted: 04/27/2023] [Indexed: 05/09/2023]
Abstract
Context Deciding on "termination of resuscitation" (TOR) is a dilemma for any physician facing cardiac arrest. Due to the lack of evidence-based criteria and scarcity of the existing guidelines, crucial arbitration to interrupt resuscitation remains at the practitioner's discretion. AIM Evaluate with a quantitative method the existence of a physician internal bias to terminate resuscitation. METHOD We extracted data concerning OHCAs managed between January 2013 and September 2021 from the RéAC registry. We conducted a statistical analysis using generalized linear mixed models to model the binary TOR decision. Utstein data were used as fixed effect terms and a random effect term to model physicians personal bias towards TOR. RESULTS 5,144 OHCAs involving 173 physicians were included. The cohort's average age was 69 (SD 18) and was composed of 62% of women. Median no-flow and low-flow times were respectively 6 (IQR [0,12]) and 18 (IQR [10,26]) minutes. Our analysis showed a significant (p<0.001) physician effect on TOR decision. Odds ratio for the "doctor effect" was 2.48 [2.13-2.94] for a doctor one SD above the mean, lower than that of dependency for activities of daily living (41.18 [24.69-65.50]), an age of more than 85 years (38.60 [28.67-51.08]), but higher than that of oncologic, cardiovascular, respiratory disease or no-flow duration between 10 to 20 minutes (1.60 [1.26-2.00]). CONCLUSIONS We demonstrate the existence of individual physician biases in their decision about TOR. The impact of this bias is greater than that of a no-flow duration lasting ten to twenty minutes. Our results plead in favor developing tools and guidelines to guide physicians in their decision.
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Affiliation(s)
- T Laurenceau
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - Q Marcou
- Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 27 boulevard Jean Moulin, 13005, Marseille, France.
| | - J M Agostinucci
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - L Martineau
- SMUR, Urgences Centre hospitalier intercommunal Robert Ballanger, Boulevard Robert Ballanger, 93600 Aulnay-sous-Bois, France.
| | - J Metzger
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - P Nadiras
- SMUR Groupe hospitalier intercommunal Le Raincy-Montfermeil, 10, rue du Général Leclerc, 93370 Montfermeil, France.
| | - J Michel
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - T Petrovic
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - F Adnet
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
| | - F Lapostolle
- SAMU 93, UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942. Hôpital Avicenne, APHP, 125, rue de Stalingrad, 93009 Bobigny, France.
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Damps M, Gajda M, Kowalska M, Kucewicz-Czech E. Limitation of Futile Therapy in the Opinion of Nursing Staff Employed in Polish Hospitals-Results of a Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16975. [PMID: 36554855 PMCID: PMC9778965 DOI: 10.3390/ijerph192416975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
The debate on limiting futile therapy in the aspect of End of Life (EoL) care has been going on in Poland over the last decade. The growing demand for EoL care resulting from the aging of societies corresponds to the expectation of a satisfactory quality of life and self-determination. The authors designed a cross-sectional study using a newly designed questionnaire to assess the opinions of 190 nurses employed in intensive care units (ICUs) on futile therapy, practices, and the respondents' approach to the issue. The problem of futile therapy and its clinical implications are known to the nursing community. Among the most common reasons for undertaking futile therapy in adult patients, the respondents declared fear of legal liability for not taking such actions (71.58%), as well as fear of being accused of unethical conduct (56.32%), and fear of talking to the patient/patient's family and their reaction (43.16%). In the case of adult patients, the respondents believed that discontinuation of futile therapy should be decided by the patient (84.21%), followed by a doctor (64.21%). As for paediatric patients, two-thirds of the respondents mentioned a doctor and a court (64.74% and 64.21%, respectively). Overall, 65.26% of the respondents believe and agree that the comfort of the patient's last days is more important than the persistent continuation of therapy and prolonging life at all costs. The presented results clearly show the attitude of the respondents who defend the patient's dignity and autonomy.
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Affiliation(s)
- Maria Damps
- Department of Anaesthesiology and Intensive Care, Upper Silesian Child Health Centre, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 16, 40-752 Katowice, Poland
| | - Maksymilian Gajda
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Malgorzata Kowalska
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Ewa Kucewicz-Czech
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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Mohyuddin GR, Sinnarajah A, Gayowsky A, Chan KKW, Seow H, Mian H. Quality of end-of-life care in multiple myeloma: A 13-year analysis of a population-based cohort in Ontario, Canada. Br J Haematol 2022; 199:688-695. [PMID: 35949180 DOI: 10.1111/bjh.18401] [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: 04/21/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
Optimizing end-of-life (EOL) care for multiple myeloma (MM) represents an unmet need. An administrative cohort in Ontario, Canada was analysed between 2006 and 2018. Aggressive care was defined as two or more emergency-department visits in the last 30 days before death, or at least two new hospitalizations within 30 days of death, or an intensive care unit (ICU) admission within the last 30 days of life. Supportive care was defined as a physician house-call in the last two weeks before death, or a palliative nursing or personal support visit at home in the last 30 days before death. Among 5095 patients, 23.2% of patients received chemotherapy at EOL and 55.6% of patients died as inpatient. A minority received aggressive care at EOL [28.3%: autologous stem cell transplant (ASCT), 20.4%: non-ASCT], and a majority received supportive care at EOL (65.4%: ASCT, 61.5%: non-ASCT). Supportive care was less likely to be received by those aged over 80 years and in lower-income neighbourhoods. Supportive care at EOL increased from 56.0% in 2006 to 70.3% in 2018. Despite improvements, many patients with MM experience aggressive care at EOL. Even in a publicly funded health care system, disparities based on age, income and community size are present.
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Affiliation(s)
| | | | | | - Kelvin K W Chan
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.,Canadian Centre for Applied Research in Cancer Control, Vancouver, British Columbia, Canada
| | - Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Hira Mian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
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Eleven-year retrospective study characterizing patients with severe brain damage and poor neurological prognosis -role of physicians' attitude toward life-sustaining treatment. BMC Palliat Care 2022; 21:79. [PMID: 35581603 PMCID: PMC9115963 DOI: 10.1186/s12904-022-00975-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Background Severe brain hemorrhage/infarction and cardiac arrest constitute the most critical situations leading to poor neurological prognosis. Characterization of these patients is required to offer successful end-of-life care, but actual practice is affected by multiple confounding factors, including ethicolegal issues, particular in Japan and Asia. The aim of this study is to evaluate the clinical courses of patients with severe brain damage and to assess the preference of end-of-life care for these patients in Japanese hospitals. Methods A retrospective observational study was conducted between 2008 and 2018. All intracranial hemorrhage/infarction and cardiac arrest out-patients (n = 510) who were admitted to our two affiliated hospitals and survived but with poor neurologic outcomes were included. Demographic characteristics as well as prognosis and treatment policies were also assessed. Results Patients were divided into two categories; cases with absent brainstem reflex (BSR) (BSR[-]) and those with preserved BSR (BSR[ +]). The survival rate was higher and the length of hospitalization was longer in patients with BSR[ +] than in those with BSR[-]. Among three life-sustaining policies (i.e., aggressive treatment, withdrawal of treatment, and withholding of treatment), withholding of treatment was adopted to most patients. In BSR[-], the proportion of three treatment policies performed at the final decision did not differ from that at the initial diagnosis on neurological status (p = 0.432). In contrast, this proportion tended to be altered in BSR[ +] (p = 0.072), with a decreasing tendency of aggressive treatment and a modest increasing tendency of withdrawal of treatment. Furthermore, the requests from patients’ families to withdraw life-sustaining treatment, including discontinuation of mechanical ventilation, increased, but actual implementation of withdrawal by physicians was less than half of the requests. Conclusions BSR constitutes a crucial determinant of mortality and length of hospitalization in comatose patients with severe brain damage. Although the number of withdrawal of life-sustaining treatment tends to increase over time in BSR[ +] patients, there are many more requests from patients’ families for withdrawal. Since physicians has a tendency to desist from withdrawing life-sustaining treatment, more in-depth communication between medical staff and patients’ families will facilitate mutual understanding over ethicolegal and religious issues and may thus improve end-of-life care.
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Palma A, Aliaga-Castillo V, Bascuñan L, Rojas V, Ihl F, Medel JN. An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile. Am J Crit Care 2022; 31:24-32. [PMID: 34972854 DOI: 10.4037/ajcc2022585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist. OBJECTIVES To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients. METHODS A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done. RESULTS Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication. CONCLUSION These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.
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Affiliation(s)
- Alejandra Palma
- Alejandra Palma is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Verónica Aliaga-Castillo
- Verónica Aliaga-Castillo is a physical therapist, Departamento de Kinesiología, Facultad de Medicina, Univer sidad de Chile, Santiago, Chile
| | - Luz Bascuñan
- Luz Bascuñan is a psychologist, Departamento de Bioética y Humanidades Médicas, Facultad de Medicina, Universidad de Chile
| | - Verónica Rojas
- Verónica Rojas is a licensed nurse, Departamento de Medicina Interna Norte, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, and Proyecto Internacional de Investigación para la Humaniza ción de los Cuidados Intensivos (Proyecto HU-CI), España
| | - Fernando Ihl
- Fernando Ihl is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Juan Nicolás Medel
- Juan Nicolás Medel is a critical care physician, Departa mento de Medicina Interna Norte, Unidad de Pacientes Críti cos, Hospital Clínico Universidad de Chile
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Zaaqoq AM, Pottash M, Ahlstrom E, Brodie D. Postcardiotomy Extracorporeal Membrane Oxygenation: Narrative Review Navigating the Ethical Issues. J Cardiothorac Vasc Anesth 2021; 36:2628-2635. [PMID: 34763977 DOI: 10.1053/j.jvca.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/18/2021] [Accepted: 10/08/2021] [Indexed: 11/11/2022]
Abstract
Postcardiotomy shock (PCS) is an uncommon and life-threatening surgical complication. Extracorporeal membrane oxygenation (ECMO) is the first line of mechanical circulatory support for treating PCS when medical therapies are insufficient. Reaching a "therapeutic ceiling" or a "bridge to nowhere" is a common clinical scenario in which medical avenues for recovery have been exhausted. These situations pose emotional and ethical challenges for patients, their surrogates, and clinicians. To shed light on these ethically challenging situations in PCS and potential approaches, the authors conducted a narrative review of the literature. Publications were utilized to describe current trends in the diagnosis and management of the patient with PCS, with particular emphasis on the therapeutic ceiling for life support. Most of the recommendations came from practice parameters or expert opinions to support specific interventions. The authors proposed a stepwise multidisciplinary approach to reduce PCS-associated ethical and emotional challenges. Their proposed algorithm was based on the likelihood of the need for ECMO support based on the mortality risk stratification of cardiac surgery. They suggested focused discussions around the commencement of ECMO or other life-sustaining therapies-ideally preoperatively at the time of consent-through shared decision-making and, subsequently, proactive multidisciplinary education and updates to the surrogate decision-makers relying on realistic prognosis and consideration of the patient wishes during the ECMO run.
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Affiliation(s)
- Akram M Zaaqoq
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC.
| | - Michael Pottash
- Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Division of Palliative Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Eric Ahlstrom
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC; Department of Medicine, MedStar Washington Hospital Center, Georgetown University, Washington, DC
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York
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Jiao K, Chow AY, Wang J, Chan II. Factors facilitating positive outcomes in community-based end-of-life care: A cross-sectional qualitative study of patients and family caregivers. Palliat Med 2021; 35:1181-1190. [PMID: 33947292 DOI: 10.1177/02692163211007376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Delivery of community-based end-of-life care for patients and family members has been recognized as an important public health care approach. Despite differences in different healthcare settings and the significance of a person-centered approach, little research has investigated facilitators of community-based end-of-life care from the perspective of service recipients. In particular, there has been limited exploration of strategies to ensure positive outcomes at an operational level. AIM To explore factors facilitating positive end-of-life care provision in community-based settings and how these are achieved in practice, from the perspectives of patients and family caregivers. DESIGN A qualitative cross-sectional descriptive study was undertaken through semi-structured interviews with patients and family caregivers subjected to thematic analysis. SETTING/PARTICIPANTS Ten patients and 16 family caregivers were recruited from an end-of-life community care program provided by four non-governmental organizations in Hong Kong. RESULTS Seven core themes were identified: positive emotions about the relationship, positive appraisals of the relationship, care through inquiring about recipients' circumstances, instrumentality of care (i.e. information, coaching on care, practical help, psychological support, multiple activities), comprehensiveness of care (i.e. diversity, post-death care, family-level wellbeing), structure of care (i.e. timely follow-up, well-developed system), and qualities of workers. CONCLUSIONS Improvement in service quality might be achieved through alternating the perceptions or emotional reactions of care recipients toward care providers and increased use of sensitive inquiry. Comprehensive care and positive outcomes might be facilitated by addressing the dualities of care by providing diverse choices in pre-death and post-death care.
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Affiliation(s)
- Keyuan Jiao
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China
| | - Amy Ym Chow
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China.,Jockey Club End-of-life Community Project (JCECC), Faculty of Social Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - Juan Wang
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong SAR, China
| | - Iris Ik Chan
- Jockey Club End-of-life Community Project (JCECC), Faculty of Social Sciences, The University of Hong Kong, Hong Kong SAR, China
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Ding CQ, Zhang YP, Wang YW, Yang MF, Wang S, Cui NQ, Jin JF. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland. World J Emerg Med 2020; 11:231-237. [PMID: 33014219 DOI: 10.5847/wjem.j.1920-8642.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Zhang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Wei Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min-Fei Yang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sa Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Nian-Qi Cui
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing-Fen Jin
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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10
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Khaki AR, Xu Y, Cheung WY, Li L, Fedorenko C, Grivas P, Ramsey S, Shankaran V. Comparison of Health Care Utilization at the End of Life Among Patients With Cancer in Alberta, Canada, Versus Washington State. JCO Oncol Pract 2020; 16:e1543-e1552. [PMID: 32804586 DOI: 10.1200/op.20.00217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Aggressive care at the end of life (EOL) can lead to unnecessary suffering and health care costs for patients with cancer. Despite geographic proximity and cultural similarities, we hypothesize that EOL care is more intense in the United States multipayer system versus the Canadian single-payer system. We compared health care utilization at EOL among patients with cancer in Alberta, Canada, with those in Washington state in the United States. METHODS Adult patients with American Joint Committee on Cancer stage II to IV solid tumors who died between 2014 and 2016 in Alberta and between 2015 and 2017 in Washington were identified from regional population-based cancer registries linked to treatment and hospitalization records (Alberta) and health claims from major regional insurance plans (Washington). The proportion of patients receiving chemotherapy and having multiple emergency department (ED) visits, or intensive care unit (ICU) admissions in the last 30, 60, and 90 days of life (DOL) in Alberta and Washington were determined and compared using two-sample z-test and multivariable logistic regression (α = .006 after Bonferroni correction). RESULTS Of patients, 11,177 in Alberta and 12,807 in Washington were included. Patients were similar in age (median, 71 v 72 year), with more patients in Washington with no comorbidities. More patients in Washington were treated with chemotherapy (12.6% v 6.6%; adjusted OR [aOR], 2.74), had multiple ED visits (16.2% v 12.1%; aOR, 1.40), and ICU admissions (23.7% v 3.9%; aOR, 14.27) in the last 30 DOL. Utilization was also higher in Washington in the last 60 and 90 DOL and among those with stage IV disease and those age 65 years and older. CONCLUSION Utilization of chemotherapy, ED visits, and ICU admissions near EOL was higher in Washington versus Alberta. Future studies to characterize drivers of aggressive EOL care may help improve cancer care for patients in the United States and Canada.
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Affiliation(s)
- Ali Raza Khaki
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.,Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yuan Xu
- Department of Community health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Winson Y Cheung
- Department of Community health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Li Li
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Catherine Fedorenko
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Petros Grivas
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Scott Ramsey
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.,Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Veena Shankaran
- Division of Oncology, Department of Medicine, University of Washington, Seattle, WA.,Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA
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11
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Stretti F, Klinzing S, Ehlers U, Steiger P, Schuepbach R, Krones T, Brandi G. Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital. Anesth Analg 2019; 127:698-703. [PMID: 29649031 DOI: 10.1213/ane.0000000000003375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.
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Affiliation(s)
- Federica Stretti
- From the Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | | | | | | | | | - Tanja Krones
- Clinical Ethics, University Hospital of Zurich, Zurich, Switzerland
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Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T, Taito S, Nakamura K, Unoki T, Kawai Y, Kenmotsu Y, Saito M, Yamakawa K, Nishida O. Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg 2019; 6:233-246. [PMID: 31304024 PMCID: PMC6603316 DOI: 10.1002/ams2.415] [Citation(s) in RCA: 246] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
Expanding elderly populations are a major social challenge in advanced countries worldwide and have led to a rapid increase in the number of elderly patients in intensive care units (ICUs). Innovative advances in medical technology have enabled lifesaving of patients in ICUs, but there remain various problems to improve their long-term prognoses. Post-intensive care syndrome (PICS) refers to physical, cognition, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients. Its concept also applies to pediatric patients (PICS-p) and the mental status of their family (PICS-F). Intensive care unit-acquired weakness, a syndrome characterized by acute symmetrical limb muscle weakness after ICU admission, belongs to physical impairments in three domains of PICS. Prevention of PICS requires performance of the ABCDEFGH bundle, which incorporates the prevention of delirium, early rehabilitation, family intervention, and follow-up from the time of ICU admission to the time of discharge. Diary, nutrition, nursing care, and environmental management for healing are also important in the prevention of PICS. This review outlines the pathophysiology, prevention, and future directions of PICS.
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Affiliation(s)
- Shigeaki Inoue
- Department of Disaster and Emergency and Critical Care Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine Yokohama City Minato Red Cross Hospital Yokohama Kanagawa Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine Juntendo University Urayasu Hospital Urayasu Chiba Japan
| | - Toru Hifumi
- Emergency and Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Hideaki Sakuramoto
- Department of Adult Health Nursing College of Nursing Ibaraki Christian University Hitachi Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care Shizuoka Children's Hospital Shizuoka Japan
| | - Shunsuke Taito
- Department of Clinical Practice and Support Division of Rehabilitation Hiroshima University Hospital Hiroshima Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine Hitachi General Hospital Hitachi Ibaraki Japan
| | - Takeshi Unoki
- Department of Adult Health Nursing School of Nursing Sapporo City University Sapporo Japan
| | - Yusuke Kawai
- Department of Nursing Fujita Health University Hospital Toyoake Aichi Japan
| | - Yuji Kenmotsu
- Department of Nursing Tokai University Hachioji Hospital Hachioji Tokyo Japan
| | - Masafumi Saito
- Department of Disaster and Emergency and Critical Care Medicine Kobe University Graduate School of Medicine Kobe Hyogo Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care Osaka General Medical Center Osaka City Osaka Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine Fujita Health University School of Medicine Toyoake Aichi Japan
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Fuseya Y, Muro S, Sato S, Sato A, Tanimura K, Hasegawa K, Uemasu K, Hamakawa Y, Takahashi Y, Nakayama T, Sakai N, Fukui M, Kita H, Mio T, Mishima M, Hirai T. Perspectives on End-of-Life Treatment among Patients with COPD: A Multicenter, Cross-sectional Study in Japan. COPD 2019; 16:75-81. [PMID: 30788987 DOI: 10.1080/15412555.2019.1573888] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality. Since patients with severe COPD may experience exacerbations and eventually face mortality, advanced care planning (ACP) has been increasingly emphasized in the recent COPD guidelines. We conducted a multicenter, cross-sectional study to survey the current perspectives of Japanese COPD patients toward ACP. "High-risk" COPD patients and their attending physicians were consecutively recruited. The patients' family configurations, understanding of COPD pathophysiology, current end-of-life care communication with physicians and family members, and preferences for invasive life-sustaining treatments including mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) were evaluated using a custom-made, structured, self-administered questionnaire. Attending physicians were also interviewed, and we evaluated the patient-physician agreement. Among the 224 eligible "high-risk" patients, 162 participated. Half of the physicians (54.4%) thought they had communicated detailed information; however, only 19.4% of the COPD patients thought the physicians did so (κ score = 0.16). Less than 10% of patients wanted to receive invasive treatment (MV, 6.3% and CPR, 9.4%); interestingly, more than half marked their decision as "refer to the physician" (MV 42.5% and CPR 44.4%) or "refer to family" (MV, 13.8% and CPR, 14.4%). Patients with less knowledge of COPD were less likely to indicate that they had already made a decision. Although ACP is necessary to cope with severe COPD, Japanese "high-risk" COPD patients were unable to make a decision on their preferences for invasive treatments. Lack of disease knowledge and communication gaps between patients and physicians should be addressed as part of these patients' care.
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Affiliation(s)
- Yoshinori Fuseya
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan.,b Department of Respiratory Medicine , Japanese Red Cross Otsu Hospital , Otsu , Shiga , Japan
| | - Shigeo Muro
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan.,c Department of Respiratory Medicine , Nara Medical University , Kashihara , Nara , Japan
| | - Susumu Sato
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Atsuyasu Sato
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Kazuya Tanimura
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Koichi Hasegawa
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Kiyoshi Uemasu
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Yoko Hamakawa
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Yoshimitsu Takahashi
- d Department of Health Informatics , Kyoto University School of Public Health , Kyoto , Japan
| | - Takeo Nakayama
- d Department of Health Informatics , Kyoto University School of Public Health , Kyoto , Japan
| | - Naoki Sakai
- b Department of Respiratory Medicine , Japanese Red Cross Otsu Hospital , Otsu , Shiga , Japan
| | - Motonari Fukui
- e Division of Respiratory Medicine , Respiratory Disease Center, Kitano Hospital , Osaka , Japan
| | - Hideo Kita
- f Department of Respiratory Medicine , Takatsuki Red Cross Hospital , Takatsuki , Osaka , Japan
| | - Tadashi Mio
- g Department of Respiratory Disease , National Hospital Organization Kyoto Medical Center , Kyoto , Japan
| | - Michiaki Mishima
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
| | - Toyohiro Hirai
- a Department of Respiratory Medicine, Graduate School of Medicine , Kyoto University , Kyoto , Japan
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Chan CWH, Wong MMH, Choi KC, Chan HYL, Chow AYM, Lo RSK, Sham MMK. Prevalence, Perception, and Predictors of Advance Directives among Hong Kong Chinese: A Population-based Survey. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16030365. [PMID: 30696082 PMCID: PMC6388376 DOI: 10.3390/ijerph16030365] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 11/16/2022]
Abstract
Advance directives (AD) can be used for the communication of healthcare decisions that may be required in the future when individuals have lost their capacity to make such decisions. The aim of this study is to examine the prevalence, perception, and predictors of AD completion in the Hong Kong general population with a diverse culture. Through random-digit dialing, a population-based telephone survey was conducted with participants aged 18 or above. Socio-demographic characteristics, self-perception and health status, prevalence of AD, and perceptions related to AD were assessed. The acceptance on completing AD was measured by the summed score on the level of agreement in making AD. In total, 2002 participants completed the survey, with only 0.5% having made AD. However, the majority of those who had heard about AD had made or intended to make AD (80.2%). Multivariable regression analysis showed that being religious, being optimistic, and agreeing to respect patients' wishes are independently associated with higher AD acceptance. Being a student is associated with lower AD acceptance. The extremely low completion rate of AD, but high acceptance of AD urges for more active promotion of AD to the public and education on end-of-life care among university students.
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Affiliation(s)
- Carmen W H Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
| | - Martin M H Wong
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
| | - Kai Chow Choi
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
| | - Helen Y L Chan
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
| | - Amy Y M Chow
- Department of Social Work and Social Administration, University of Hong Kong, Hong Kong.
| | - Raymond S K Lo
- Geriatrics and Palliative Medicine, Shatin Hospital, Hong Kong.
- Bradbury Hospice, Hong Kong.
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15
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Ho KM, Liang J. Withholding and Withdrawal of Therapy in New Zealand Intensive Care Units (ICUs): A Survey of Clinical Directors. Anaesth Intensive Care 2019; 32:781-6. [PMID: 15648988 DOI: 10.1177/0310057x0403200609] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Withdrawing and withholding life-support therapy in patients who are unlikely to survive despite treatment are common practices in intensive care units (ICUs). The literature suggests there is a large variation in practice between different ICUs in different parts of the world. We conducted a postal survey among all public ICUs in New Zealand to investigate the pattern of practice in withholding and withdrawal of therapy. Nineteen ICUs responded to this survey and they represented 74% of all the public ICU beds and 83% of the annual ICU admissions. The percentage of ICU admissions with therapy withdrawn or withheld was less than 10% in most ICUs. Only a small percentage (21%) of ICUs had a formal policy in withholding and withdrawal of therapy. The timing of making the decision to withhold or withdraw therapy was very variable. The patient and/or the family, the primary medical team consultant, two or more ICU consultants, and ICU nurses were usually involved in the decision making process. ICU nurses were more commonly involved in the decision making process in smaller ICUs (5 beds vs 10 beds, P=0.03). The patient's pre-ICU quality of life, medical comorbidities, predicted mortality, predicted post-ICU quality of life, and the family's wishes were important factors in deciding whether ICU therapy would be withheld or withdrawn. Hospice ward or the patient's home was the preferred place for palliative care in 32% of the responses.
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Affiliation(s)
- K M Ho
- Department of Anaesthesia and Intensive Care, North Shore Hospital, Auckland 1309, New Zealand
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16
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17
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Differences in Utilization of Life Support and End-of-Life Care for Medical ICU Patients With Versus Without Cancer. Crit Care Med 2017; 45:e379-e383. [DOI: 10.1097/ccm.0000000000002260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jegede AS, Adegoke OO. Advance Directive in End of Life Decision-Making among the Yoruba of South-Western Nigeria. BEONLINE : JOURNAL OF THE WEST AFRICAN BIOETHICS TRAINING PROGRAM 2016; 3:41-67. [PMID: 28344984 PMCID: PMC5363404 DOI: 10.20541/beonline.2016.0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
End-of-life decision making is value-laden within the context of culture and bioethics. Also, ethics committee role is difficult to understand on this, thus need for ethnomethodological perspective in an expanding bioethical age. Anthropological approach was utilized to document Yoruba definition and perspective of death, cultural beliefs about end-of-life decision making, factors influencing it and ethics committee role. Interviews were conducted among selected Yoruba resident in Akinyele LGA, Oyo State, Nigeria. Content analytical approach was used for data analysis. Yoruba culture, death is socially constructed having spiritual, physical and social significance. Relationship between the dying and significant others influences decision making. Hierarchy of authority informs implementing traditional advance directive. Socialization, gender, patriarchy, religious belief and tradition are major considerations in end-of-life decision making. Awareness, resource allocation and advocacy are important ethics committees' roles. Further research into cultural diversity of end-of-life decision making will strengthen ethical practice in health care delivery.
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Affiliation(s)
- Ayodele Samuel Jegede
- Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
- West African Bioethics Training Program, College of Medicine, University of Ibadan, Ibadan, Nigeria
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19
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Su WH, Huang MY, Lai EY. Outcomes of Palliative Care Team Consultation for Ventilator Withdrawal from Terminally Ill Patients in the Intensive Care Unit. INT J GERONTOL 2016. [DOI: 10.1016/j.ijge.2016.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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20
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Druml C, Ballmer PE, Druml W, Oehmichen F, Shenkin A, Singer P, Soeters P, Weimann A, Bischoff SC. ESPEN guideline on ethical aspects of artificial nutrition and hydration. Clin Nutr 2016; 35:545-56. [PMID: 26923519 DOI: 10.1016/j.clnu.2016.02.006] [Citation(s) in RCA: 163] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 01/28/2016] [Accepted: 02/05/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The worldwide debate over the use of artificial nutrition and hydration remains controversial although the scientific and medical facts are unequivocal. Artificial nutrition and hydration are a medical intervention, requiring an indication, a therapeutic goal and the will (consent) of the competent patient. METHODS The guideline was developed by an international multidisciplinary working group based on the main aspects of the Guideline on "Ethical and Legal Aspects of Artificial Nutrition" published 2013 by the German Society for Nutritional Medicine (DGEM) after conducting a review of specific current literature. The text was extended and introduced a broader view in particular on the impact of culture and religion. The results were discussed at the ESPEN Congress in Lisbon 2015 and accepted in an online survey among ESPEN members. RESULTS The ESPEN Guideline on Ethical Aspects of Artificial Nutrition and Hydration is focused on the adult patient and provides a critical summary for physicians and caregivers. Special consideration is given to end of life issues and palliative medicine; to dementia and to specific situations like nursing care or the intensive care unit. The respect for autonomy is an important focus of the guideline as well as the careful wording to be used in the communication with patients and families. The other principles of Bioethics like beneficence, non-maleficence and justice are presented in the context of artificial nutrition and hydration. In this respect the withholding and withdrawing of artificial nutrition and/or hydration is discussed. Due to increasingly multicultural societies and the need for awareness of different values and beliefs an elaborated chapter is dedicated to cultural and religious issues and nutrition. Last but not least topics like voluntary refusal of nutrition and fluids, and forced feeding of competent persons (persons on hunger strike) is included in the guideline.
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Affiliation(s)
- Christiane Druml
- UNESCO Chair on Bioethics at the Medical University of Vienna, Collections and History of Medicine - Josephinum, Medical University of Vienna, Waehringerstrasse 25, A-1090 Vienna, Austria.
| | - Peter E Ballmer
- Department of Medicine, Kantonsspital Winterthur, Brauerstrasse 15, Postfach 834, 8401 Winterthur, Switzerland.
| | - Wilfred Druml
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
| | - Frank Oehmichen
- Department of Early Rehabilitation, Klinik Bavaria Kreischa, An der Wolfsschlucht 1-2, 01731 Kreischa, Germany.
| | - Alan Shenkin
- Department of Clinical Chemistry, University of Liverpool, Duncan Building, Daulby Street, Liverpool L69 3GA, UK.
| | - Pierre Singer
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Jean Leven Building, 6th Floor, Tel Aviv, Israel.
| | - Peter Soeters
- Department of Surgery, Academic Hospital Maastricht, Peter Debeyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands.
| | - Arved Weimann
- Department of General Surgery and Surgical Intensive Care, St Georg Hospital, Delitzscher Straße 141, 04129 Leipzig, Germany.
| | - Stephan C Bischoff
- Department of Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599 Stuttgart, Germany.
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Konstantara E, Vandrevala T, Cox A, Creagh-Brown BC, Ogden J. Balancing professional tension and deciding upon the status of death: Making end-of-life decisions in intensive care units. Health Psychol Open 2016; 3:2055102915622928. [PMID: 28070383 PMCID: PMC5193261 DOI: 10.1177/2055102915622928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists' role, treatment effectiveness, and patients' best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists' sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.
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Badır A, Topçu İ, Türkmen E, Göktepe N, Miral M, Ersoy N, Akın E. Turkish critical care nurses' views on end-of-life decision making and practices. Nurs Crit Care 2015; 21:334-342. [PMID: 25943254 DOI: 10.1111/nicc.12157] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/04/2014] [Accepted: 12/18/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Life-sustaining treatments are increasingly used in intensive care units (ICUs) for EOL care, but the decision to use these may cause ethical issues. AIMS AND OBJECTIVES The aim of this study was to investigate the views and practices of critical care nurses in Turkey on the end-of-life (EOL) care. DESIGN This was a cross-sectional study. METHODS The research was conducted in 32 second- and third-level ICUs of 19 Ministry of Health research hospitals in Turkey. The Views of European Nurses in Intensive Care on EOL Care tool was used for data collection. RESULTS The total sample size was 602. While half of the nurses stated that the withholding and withdrawal of life support were ethically different decisions, 40% felt both decisions were unethical. The expected quality of life as viewed by the patient, the medical team, the family and the nursing team (90·4%, 85·4%, and 83·4%, respectively) was an important factor in EOL decision making. The majority of the nurses (75·7%) were not directly involved in the EOL decision making and 78·4% of nurses were committed to family involvement in EOL decisions. When withdrawing treatment, 87·2% of ICU nurses agreed that the patient and family members should perform their final religious and spiritual duties. Further results showed that after withdrawing treatment, a majority of nurses (86%) agreed to continue pressure sore prevention, effective pain relief (85·5%), nutritional support (77·6%) and hydration (64·8%). Almost half (48·2%) indicated that keeping the patients in the ICU was unnecessary. CONCLUSION ICU nurses expressed a range of experiences and practices regarding EOL care. ICU nurses should be more involved in the decision-making process about EOL care. RELEVANCE TO CLINICAL PRACTICE Due to their unique relationship with patients, nurses should be involved in EOL care decision making; however, patients, families or nurses are not often involved in the decision-making process in Turkey.
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Affiliation(s)
- Aysel Badır
- Koc University School of Nursing, Istanbul, Turkey
| | - İbrahim Topçu
- Bezmialem Foundation University, School of Medicine, Department of Medical History and Ethics, Istanbul, Turkey
| | | | | | - Mukaddes Miral
- Department of Education & Human Resources, Health Directorate of Istanbul, Istanbul, Turkey
| | - Nermin Ersoy
- Kocaeli University School of Medicine, Department of Medical History and Ethics, Kocaeli, Turkey
| | - Esra Akın
- İzmir Katip Çelebi University, Health Sciences Faculty, Izmir, Turkey
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Abstract
OBJECTIVES The recently enacted Israeli Dying Patient Act was designed to strike balance between enhancing patient autonomy in end-of-life decision making and cultural/religious norms that are in opposition to active euthanasia and physician-assisted suicide (PAS). The current study evaluated physician attitudes regarding active and passive euthanasia, and their knowledge of specific aspects of the law. METHODS A survey was administered to a convenience sample of hospital-based physicians treating terminal patients. Physicians were queried about their attitudes regarding euthanasia and PAS. Physicians were also queried about specific aspects of the law and whether they had sufficient resources to uphold the law. RESULTS Surveys were distributed to 270 physicians and 100 were returned and evaluated (37%). Nearly all physicians supported passive euthanasia (withholding treatment), whereas over 40% maintained that active forms of euthanasia should be allowed for terminal patients in severe physical pain. Multivariate analysis showed a negative relationship between support for more active forms of euthanasia and physicians' self-reported religiosity. Physicians cited lack of time as a reason for not complying with the new law. Physicians had a familiarity with the general aspects of the new legislation, but a large proportion was not aware of the specifics of the law. CONCLUSIONS Compared with previous surveys, a larger number of physicians support passive euthanasia. A sizable percentage of physicians would be willing to participate in active euthanasia and even PAS. Attitudes toward euthanasia are influenced by religious factors.
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Walczak A, Henselmans I, Tattersall MHN, Clayton JM, Davidson PM, Young J, Bellemore FA, Epstein RM, Butow PN. A qualitative analysis of responses to a question prompt list and prognosis and end-of-life care discussion prompts delivered in a communication support program. Psychooncology 2014; 24:287-93. [PMID: 25079976 DOI: 10.1002/pon.3635] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 07/02/2014] [Accepted: 07/06/2014] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Discussing end-of-life (EOL) care is challenging when death is not imminent, contributing to poor decision-making and EOL quality-of-life. A communication support program (CSP) targeting these issues may facilitate discussions. We aimed to qualitatively explore responses to a nurse-led CSP, incorporating a question prompt list (QPL-booklet of questions patients/caregivers can ask clinicians), promoting life expectancy and EOL-care discussions. METHODS Participants met a nurse-facilitator to explore an EOL-focussed QPL. Prognosis and advance care planning (ACP) QPL content was highlighted. Thirty-one transcribed meetings were analysed using thematic text analysis before reaching data saturation. RESULTS Thirty-one advanced cancer patients (life expectancy <12 months) and 11 family caregivers were recruited from six medical oncology clinics in Sydney, Australia. Intent to use the QPL related to information needs, involvement in care and readiness to discuss EOL issues. Many participants did not want life expectancy estimates, citing unreliable estimates, unknown treatment outcomes, or coping by not looking ahead. Most displayed interest in ACP, often motivated by a loved one's EOL experiences, clear treatment preferences, concerns about caregivers or recognition that ACP is valuable regardless of life expectancy. Timing emerged as a reason not to discuss EOL issues; many maintaining it was too early. CONCLUSION Patients and caregivers appear ambivalent about acknowledging approaching death by discussing life expectancy but value ACP. Given heterogeneity in responses, individualised approaches are required to guide EOL discussion conduct and content. Further exploration of the role of prognostic discussion in ACP is warranted.
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Affiliation(s)
- Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, Australia
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Dargin JM, Mackey CG, Lei Y, Liesching TN. Resource utilization and end-of-life care in a US hospital following medical emergency team-implemented do not resuscitate orders. J Hosp Med 2014; 9:372-8. [PMID: 24604884 DOI: 10.1002/jhm.2183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/29/2014] [Accepted: 02/19/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN Retrospective review. SETTING Single, tertiary care center. PATIENTS Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS None. RESULTS We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.
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Affiliation(s)
- James M Dargin
- Department of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts; Tufts University School of Medicine, Boston, Massachusetts
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Abstract
Critical care medicine in China has made great advances in recent decades. This has led to an unavoidable issue: end-of-life ethics. With advances in medical technology and therapeutics allowing the seemingly limitless maintenance of life, the exact time of death of an individual patient is often determined by the decision to limit life support. How to care for patients at the end of life is not only a medical problem but also a social, ethical, and legal issue. A lot of factors, besides culture, come into play in determining a person’s ethical attitudes or behaviors, such as experience, education, religion, individual attributes, and economic considerations. Chinese doctors face ethical problems similar to those of their Western counterparts; however, since Chinese society is different from that of Western countries in cultural traditions, customs, religious beliefs, and ethnic backgrounds, there is a great difference between China and the Western world in regard to ethics at the end of life, and there is also a huge controversy within China.
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Hernández-Tejedor A. [A review of bioethics in the Intensive Care Unit: The autonomy and role of relatives and legal representatives]. Med Intensiva 2013; 38:104-10. [PMID: 23810273 DOI: 10.1016/j.medin.2013.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 04/05/2013] [Accepted: 04/15/2013] [Indexed: 11/27/2022]
Abstract
In recent decades we have witnessed a change in mentality in which patient autonomy has reached significant preponderance, with informed consent as the prime example. The approach in situations where the patient cannot make decisions varies from one country to another, affording greater or lesser importance to the wishes of the family when a surrogate has not been designated. Several studies show discrepancies between the decisions of patients and that the decisions which their surrogates have taken for them. We review concepts such as greatest benefit, evaluate the potential limitations of advance care directives, and consider different options when the action or treatment proposed by professionals comes into conflict with the ideas expressed by the patient's family or surrogates, and which has led to different legally sanctioned solutions in some regions.
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Affiliation(s)
- A Hernández-Tejedor
- Unidad de Cuidados Críticos, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
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Al-Jahdali H, Baharoon S, Al Sayyari A, Al-Ahmad G. Advance medical directives: a proposed new approach and terminology from an Islamic perspective. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2013; 16:163-169. [PMID: 24571002 DOI: 10.1007/s11019-012-9382-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Advance directives are specific competent consumers' wishes about future medical plans in the event that they become incompetent. Awareness of a patient's autonomy particularly, in relation to their right to refuse or withdraw treatment, a right for the patient to die from natural causes and interest in end of life issues were among the main reasons for developing and legalizing advance medical directives in developed countries. However, in many circumstances cultural and religious aspects are among many factors that can hamper implementation of advance directives. Islam and Muslims in general have a good understanding of death and dying. Islam allows the withholding or withdrawal of treatments in some cases where the intervention is considered futile. However, there is lack of literature and debate about such issues from an Islamic point of view. This article provides the Islamic perspective with regards to advance medical directive with the hope that it will generate more thoughts and evoke further discussion on this important topic.
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Laguna J, Enguídanos S, Siciliano M, Coulourides-Kogan A. Racial/ethnic minority access to end-of-life care: a conceptual framework. Home Health Care Serv Q 2012; 31:60-83. [PMID: 22424307 DOI: 10.1080/01621424.2011.641922] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Minority underutilization of hospice care has been well-documented; however, explanations addressing disparities have failed to examine the scope of factors in operation. Drawing from previous health care access models, a framework is proposed in which access to end-of-life care results from an interaction between patient-level, system-level, and societal-level barriers with provider-level mediators. The proposed framework introduces an innovative mediating factor missing in previous models, provider personal characteristics, to better explain care access disparities. This article offers a synthesis of previous research and proposes a framework that is useful to researchers and clinicians working with minorities at end of life.
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Affiliation(s)
- Jeff Laguna
- University of Southern California, Davis School of Gerontology, Los Angeles, California 90089-0191, USA.
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31
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Meñaca A, Evans N, Andrew EV, Toscani F, Finetti S, Gómez-Batiste X, Higginson IJ, Harding R, Pool R, Gysels M. End-of-life care across Southern Europe: A critical review of cultural similarities and differences between Italy, Spain and Portugal. Crit Rev Oncol Hematol 2012; 82:387-401. [DOI: 10.1016/j.critrevonc.2011.06.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 05/27/2011] [Accepted: 06/09/2011] [Indexed: 12/14/2022] Open
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Cohen J, Van Wesemael Y, Smets T, Bilsen J, Deliens L. Cultural differences affecting euthanasia practice in Belgium: one law but different attitudes and practices in Flanders and Wallonia. Soc Sci Med 2012; 75:845-53. [PMID: 22682367 DOI: 10.1016/j.socscimed.2012.04.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 04/11/2012] [Accepted: 04/13/2012] [Indexed: 11/24/2022]
Abstract
Since 2002, Belgium has had a national law legalising euthanasia. The law prescribes several substantive due care requirements and two procedural due care requirements, i.e. consultation with an independent physician and reporting of euthanasia to a Federal Control Committee. A large discrepancy in reporting rates between the Dutch-speaking (Flanders) and the French-speaking (Wallonia) parts of Belgium has led to speculation about cultural differences affecting the practice of euthanasia in both regions. Using Belgian data from the European Values Study conducted in 2008 among a representative sample of the general public and data from a large-scale mail questionnaire survey on euthanasia of 480 physicians from Flanders and 305 from Wallonia (conducted in 2009), this study presents empirical evidence of differences between both regions in attitudes towards and practice of euthanasia. Acceptance of euthanasia by the general population was found to be slightly higher in Flanders than in Wallonia. Compared with their Flemish counterparts, Walloon physicians held more negative attitudes towards performing euthanasia and towards the reporting obligation, less often labelled hypothetical cases correctly as euthanasia, and less often defined a case of euthanasia having to be reported. A higher proportion of Flemish physicians had received a euthanasia request since the introduction of the law. In cases of a euthanasia request, Walloon physicians consulted less often with an independent physician. Requests were more often granted in Flanders than in Wallonia (51% vs 38%), and performed euthanasia cases were more often reported (73% vs 58%). The study points out some significant differences between Flanders and Wallonia in practice, knowledge and attitudes regarding euthanasia and its legal requirements which are likely to explain the discrepancy between Wallonia and Flanders in the number of euthanasia cases reported. Cultural factors seem to play an important role in the practice of (legal) euthanasia and the extent to which legal safeguards are followed.
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Affiliation(s)
- Joachim Cohen
- End-of Life Care Research Group, Ghent University and Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium.
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33
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Forte DN, Vincent JL, Velasco IT, Park M. Association between education in EOL care and variability in EOL practice: a survey of ICU physicians. Intensive Care Med 2012; 38:404-12. [PMID: 22222566 DOI: 10.1007/s00134-011-2400-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 08/29/2011] [Indexed: 11/24/2022]
Abstract
PURPOSE This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU. METHODS Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics. RESULTS The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy. CONCLUSIONS Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.
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Affiliation(s)
- Daniel Neves Forte
- Intensive Care Unit, Emergency Department, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil.
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Damghi N, Belayachi J, Aggoug B, Dendane T, Abidi K, Madani N, Zekraoui A, Belabes AB, Zeggwagh AA, Abouqal R. Withholding and withdrawing life-sustaining therapy in a Moroccan Emergency Department: an observational study. BMC Emerg Med 2011; 11:12. [PMID: 21838861 PMCID: PMC3199862 DOI: 10.1186/1471-227x-11-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 08/12/2011] [Indexed: 11/18/2022] Open
Abstract
Background Withdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions. Method A survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record. Results 177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases. Conclusion Life-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.
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Affiliation(s)
- Nada Damghi
- Medical Emergency Department, Ibn Sina University Hospital, 10000, Rabat, Morocco
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35
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Abstract
Ethical problems in medicine are common, especially when caring for patients at the end of life. However, many of these issues are not adequately identified in the outpatient setting. Primary care providers are in a unique and privileged position to identify ethical issues, prevent future conflicts, and help patients make medical decisions that are consistent with their individual values and preferences. This article describes some of the more common ethical issues faced by primary care physicians caring for patients with life-limiting illness.
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Affiliation(s)
- Danielle N Ko
- Division of General Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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36
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Yapp KA. Culture and end-of-life care: an epidemiological evaluation of physicians. Am J Hosp Palliat Care 2011; 29:106-11. [PMID: 21613304 DOI: 10.1177/1049909111410294] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Beneficence is a fundamental concept of medicine, which embodies the notion above all, do no harm. While this principle illustrates the health care professional's duty to contribute to the patient's welfare, the principle becomes convoluted when the wishes of the patient directly conflict with that of the physician. The purpose of the study was to determine the degree to which cultural beliefs influence a physician's decision to introduce the concept of hospice to terminally ill patients. This phenomenological study explored the perceptions of 14 physicians practicing medicine in Mercer County, New Jersey. Analysis of the textural data revealed the following 5 themes: (a) physician personal perspectives, (b) physician perspectives on culture, (c) perspectives on hospice care, (d) communication with patients, and (e) training and experience.
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Affiliation(s)
- Karleen A Yapp
- Legacy Counseling & Consulting, LLC, Marlton, NJ 08053, USA.
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Zubek L, Szabó L, Diószeghy C, Gál J, Elö G. End-of-life decisions in Hungarian intensive care units. Anaesth Intensive Care 2011; 39:116-21. [PMID: 21375101 DOI: 10.1177/0310057x1103900119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The awareness of local practice of end-of-life decisions in accordance with the law and ethical principles is essential for intensive care physicians in all countries. The first step for the required social dialogue is to investigate local practice. We performed the first Hungarian survey with the aim of better understanding local practice in end-of-life decisions in intensive care units. Questionnaires were sent out electronically to 743 members of the Hungarian Society of Anaesthesiology and Intensive Care. Respecting anonymity, we have statistically evaluated 103 replies (response rate 13.8%) and compared the results to data from other European countries. The results show that the practice of intensive care physicians in Hungary is rather paternalistic. Intensive care physicians generally make their decisions alone (3.75/5 points) without considering the opinion of the patient (2.57/5 points), the relatives (2.14/5 points) or other medical staff (2.37/5 points). Furthermore, they prefer not to start a form of treatment rather than to withdraw an ongoing one. Nevertheless, the frequency of end-of-life decisions (3 to 9% of intensive care unit patients) made in Hungarian intensive care units is less than in other European countries. End-of-life decisions are part of medical practice. Since the legal and ethical framework is unclear practice varies between locations and mostly depends on individual decisions rather than established protocols or guidance. For end-of-life decisions, self-determination must be supported and a dialogue must be established between lawmakers and physicians.
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Affiliation(s)
- L Zubek
- Department ofAnaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
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38
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Abstract
Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.
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Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
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39
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Hawryluck LA. Palliative Care in the Intensive Care Unit. Palliat Care 2011. [DOI: 10.1016/b978-1-4377-1619-1.00035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Zubek L, Szabó L, Gál J, Ollos A, Elo G. [Practice of treatment restriction in Hungarian intensive care units]. Orv Hetil 2010; 151:1530-6. [PMID: 20826377 DOI: 10.1556/oh.2010.28950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED End of life decisions affect most of patients in intensive care units, thus, it is important to know both local and international practice in accordance with law and ethical principles for intensive care physicians. AIM To search for local customs of end of life decisions (withholding or withdrawing the therapy, shortening of the dying process), and to compare the data with the international literature. METHODS In 2007-2008 the first Hungarian survey was performed with the purpose to learn more about local practice of end of life decisions. Questionnaires were sent out electronically to 743 registered members of Hungarian Society of Anesthesiology and Intensive Care. Respecting anonymity, 103 replies were statistically evaluated (response rate was 13.8%) and compared with data from other European countries. RESULTS As expected, it turned out from replies that the practice of domestic intensive care physicians is very paternal and this is promoted by legal regulations that share a similar character. Intensive care physicians generally make their decisions alone (3.75/5 point) without respecting the opinion of the patient (2.57/5 point) the relatives (2.14/5 point) or other medical personnel (2.37/5 point). Furthermore, they prefer not to start a therapy rather than withdraw an ongoing treatment. Nevertheless, the frequency of end of life decisions (3-9% of ICU patients) is smaller than other European countries. CONCLUSIONS There is a need for the expansion of patients' right in our country. For end of life decisions, self determinations must be supported and a dialogue must be established between lawmakers and physicians, in order to improve the legal support of this medical practice.
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Affiliation(s)
- László Zubek
- Semmelweis Egyetem, Altalános Orvostudományi Kar, Aneszteziológiai és Intenzív Terápiás Klinika, Budapest.
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41
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Zamperetti N, Piccinni P. Intensivists managing end-of-life care: dwarfs without giants' shoulders to stand upon. Intensive Care Med 2010; 36:1985-7. [PMID: 20689936 DOI: 10.1007/s00134-010-1958-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 06/30/2010] [Indexed: 10/19/2022]
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Iltis AS, Cherry MJ. Death Revisited: Rethinking Death and the Dead Donor Rule. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2010; 35:223-41. [DOI: 10.1093/jmp/jhq017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wunsch H, Linde-Zwirble WT, Harrison DA, Barnato AE, Rowan KM, Angus DC. Use of Intensive Care Services during Terminal Hospitalizations in England and the United States. Am J Respir Crit Care Med 2009; 180:875-80. [DOI: 10.1164/rccm.200902-0201oc] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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44
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The Practice of and Documentation on Withholding and Withdrawing Life Support: A Retrospective Study in Two Dutch Intensive Care Units. Anesth Analg 2009; 109:841-6. [DOI: 10.1213/ane.0b013e3181acc64a] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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45
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de Graaff FM, Francke AL. Barriers to home care for terminally ill Turkish and Moroccan migrants, perceived by GPs and nurses: a survey. BMC Palliat Care 2009; 8:3. [PMID: 19171066 PMCID: PMC2640378 DOI: 10.1186/1472-684x-8-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 01/26/2009] [Indexed: 12/03/2022] Open
Abstract
Background Previous qualitative research proved that relatives of elderly terminally ill Turkish and Moroccan immigrants experience several barriers to the use of Dutch professional home care. The aim of this study was to explore how general practitioners and home care nurses perceive the home care for terminally ill Turkish and Moroccan migrants and their families in the Netherlands. Methods Questionnaires were sent to home care organizations and GPs working in areas where most of these migrants are living. 93 nurses and 78 GPs provided information about their experiences and opinions regarding home care for this group of patients. The data were analyzed by descriptive statistics. Results GPs refer relatively few patients from these migrant groups to home care. They often find it difficult to assess the needs of these patients and their families. In 40% of the GPs' cases in which terminally ill Turkish and Moroccan migrants were not referred to home care, the GP regretted this afterwards: the patients had not received sufficient qualified care, and their informal carers had often become overburdened. In addition, home care nurses often express dissatisfaction with the home care given to terminally ill Turkish or Moroccan patients, because of communication problems, the patients' lack of knowledge of the disease, or difficulties in making suitable appointments with the patient or with the family. Conclusion Nurses and GPs cite chiefly similar factors influencing access to and use of home care as family members did in a previous study. However, according to GPs and nurses, the main barrier to the use of home care concerns communication problems, while relatives cited the preference for family care as the main reason for abstaining from the use of home care.
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Affiliation(s)
- Fuusje M de Graaff
- Amsterdam School for Social Science Research, University of Amsterdam, Kloveniersburgwal 48, 1012 CX Amsterdam, The Netherlands.
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46
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Reply to Rubolotta et al.: End-of-life: still a legal international dilemma. Intensive Care Med 2008. [DOI: 10.1007/s00134-008-1365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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47
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Azoulay É, Metnitz B, Sprung CL, Timsit JF, Lemaire F, Bauer P, Schlemmer B, Moreno R, Metnitz P. End-of-life practices in 282 intensive care units: data from the SAPS 3 database. Intensive Care Med 2008; 35:623-30. [DOI: 10.1007/s00134-008-1310-6] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2007] [Accepted: 09/20/2008] [Indexed: 10/21/2022]
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Abstract
Managing end-of-life care can be difficult because of the particular nature of intensive care support, which can separate the biological and the biographical aspects of life. Artificial organ support can temporarily delay death but, at the same time, may fail to restore a quality of life that the patient judges acceptable. For this reason, two concepts must be considered: that the mission of the healthcare system should be to care for patients according to their interests and wishes and that quality of care is related above all to the careful commitment of healthcare workers to the patient's best interests. Keeping these concepts in mind, the rule of the five Cs (competence, collegiality, communication, continuity of care and compassion) might be helpful in the management of end-of-life care. Unfortunately, neither the rule of the five Cs nor the careful use of moral principles in order to promote the patients' dignity can assure a universally acceptable decision. A reasonable level of 'moral certainty', however, might be achieved using a deliberative approach, which provides for the inclusion of all the different subjects involved in the decision-making process (patient, family, doctors, nurses and other carers), in order to reach the best possible decision in a specific situation.
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Burden of psychological symptoms and illness in family of critically ill patients: what is the relevance for critical care clinicians? Crit Care Med 2008; 36:1955-6. [PMID: 18520648 DOI: 10.1097/ccm.0b013e31817616c0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Sibbald R, Downar J, Hawryluck L. Perceptions of "futile care" among caregivers in intensive care units. CMAJ 2007; 177:1201-8. [PMID: 17978274 PMCID: PMC2043060 DOI: 10.1503/cmaj.070144] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of "futile care" or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources. METHODS Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach. RESULTS From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines. INTERPRETATION ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.
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Affiliation(s)
- Robert Sibbald
- Department of Ethics, London Health Sciences Centre, London, Ont
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