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Ajzenberg H, Dainty KN, O'Connor E. Recommendation-making in the emergency department: A qualitative study of how Canadian emergency physicians guide treatment decisions about resuscitation in critically ill patients. J Am Coll Emerg Physicians Open 2023; 4:e12962. [PMID: 37229184 PMCID: PMC10204169 DOI: 10.1002/emp2.12962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/06/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Study Objective Emergency physicians are frequently responsible for making time-sensitive decisions around the provision of life-sustaining treatment. These decisions can involve goals of care or code status discussion, which will often substantially alter a patient's care pathway. A central part of these conversations that has received relatively little attention are recommendations for care. By proposing a best course of action or treatment via a recommendation, a clinician can ensure that their patients receive care that is concordant with their values. The objective of this study is to explore emergency physicians' attitudes toward recommendations about resuscitation in critically ill patients in the emergency department (ED). Methods We recruited Canadian emergency physicians via multiple recruitment strategies to ensure maximum variation sampling. Semi-structured qualitative interviews were conducted until thematic saturation occurred. Participants were asked about their perspectives and experiences with respect to recommendation-making in critically ill patients and to identify areas for improvement in this process in the ED. We used a qualitative descriptive approach and thematic analysis to identify themes around recommendation-making in the ED for critically ill patients. Results Sixteen emergency physicians agreed to participate. We identified four themes and multiple subthemes. Major themes included identification of the roles and responsibilities of the emergency physician (EP) with respect to making a recommendation, the logistics or process of making a recommendation, barriers to making a recommendation, and how to improve recommendation-making and goals of care conversations in the ED. Conclusion Emergency physicians provided a range of perspectives on the role of recommendation-making in critically ill patients in the ED. Several barriers to the inclusion of a recommendation were identified and many physicians provided ideas on how to improve goals of care conversations, the recommendation-making process, and ensure that critically ill patients receive care that is concordant with their values.
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Affiliation(s)
- Henry Ajzenberg
- Division of Emergency MedicineUniversity of TorontoTorontoOntarioCanada
| | - Katie N. Dainty
- North York General Hospital, Institute of Health Policy Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Erin O'Connor
- Divisions of Emergency Medicine and Palliative MedicineDepartment of MedicineUniversity of TorontoTorontoOntarioCanada
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Gould JB. Why Intellectual Disability is Not Mere Difference. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:495-509. [PMID: 35679004 PMCID: PMC9179217 DOI: 10.1007/s11673-022-10190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/11/2022] [Indexed: 06/15/2023]
Abstract
A key question in disability studies, philosophy, and bioethics concerns the relationship between disability and well-being. The mere difference view, endorsed by Elizabeth Barnes, claims that physical and sensory disabilities by themselves do not make a person worse off overall-any negative impacts on welfare are due to social injustice. This article argues that Barnes's Value Neutral Model does not extend to intellectual disability. Intellectual disability is (1) intrinsically bad-by itself it makes a person worse off, apart from a non-accommodating environment; (2) universally bad-it lowers quality of life for every intellectually disabled person; and (3) globally bad-it reduces a person's overall well-being. While people with intellectual disabilities are functionally disadvantaged, this does not imply that they are morally inferior-lower quality of life does not mean lesser moral status. No clinical implications concerning disability-based selective abortion, denial of life-saving treatment, or rationing of scarce resources follow from the claim that intellectual disability is bad difference.
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Affiliation(s)
- James B Gould
- Emeritus Faculty, Department of Philosophy, McHenry County College, Crystal Lake, Illinois, USA.
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Robbins AJ, Ingraham NE, Sheka AC, Pendleton KM, Morris R, Rix A, Vakayil V, Chipman JG, Charles A, Tignanelli CJ. Discordant Cardiopulmonary Resuscitation and Code Status at Death. J Pain Symptom Manage 2021; 61:770-780.e1. [PMID: 32949762 PMCID: PMC8052631 DOI: 10.1016/j.jpainsymman.2020.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT One fundamental way to honor patient autonomy is to establish and enact their wishes for end-of-life care. Limited research exists regarding adherence with code status. OBJECTIVES This study aimed to characterize cardiopulmonary resuscitation (CPR) attempts discordant with documented code status at the time of death in the U.S. and to elucidate potential contributing factors. METHODS The Cerner Acute Physiology and Chronic Health Evaluation (APACHE) outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant CPR at death. Multivariable logistic regression models were used to identify patient-level and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score). RESULTS A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received CPR at death, and associated factors included black race, higher APACHE III score, or treatment in small or nonteaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive CPR at death, and associated factors included higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year. CONCLUSION At the time of death, 1.6% of patients received or did not undergo CPR in a manner discordant with their documented code statuses. Race and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
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Affiliation(s)
- Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.
| | - Nicholas E Ingraham
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adam C Sheka
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Kathryn M Pendleton
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rachel Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alexander Rix
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Victor Vakayil
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jeffrey G Chipman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher J Tignanelli
- Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA; Department of Surgery, North Memorial Health Hospital, Robbinsdale, Minnesota, USA; Institute for Health Informatics, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
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Nelson RH, Ram B, Majumder MA. Disability and Contingency Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:190-192. [PMID: 32716778 DOI: 10.1080/15265161.2020.1779863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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Duivenbode R, Hall S, Padela AI. Assessing Relationships Between Muslim Physicians’ Religiosity and End-of-Life Health-Care Attitudes and Treatment Recommendations: An Exploratory National Survey. Am J Hosp Palliat Care 2019; 36:780-788. [DOI: 10.1177/1049909119833335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: Research demonstrates that the attitudes of religious physicians toward end-of-life care treatment can differ substantially from their nonreligious colleagues. While there are various religious perspectives regarding treatment near the end of life, the attitudes of Muslim physicians in this area are largely unknown. Objective: This article attempts to fill in this gap by presenting American Muslim physician attitudes toward end-of-life care decision-making and by examining associations between physician religiosity and these attitudes. Methods: A randomized national sample of 626 Muslim physicians completed a mailed questionnaire assessing religiosity and end-of-life care attitudes. Religiosity, religious practice, and bioethics resource utilization were analyzed as predictors of quality-of-life considerations, attitudes regarding withholding and withdrawing life-sustaining treatment, and end-of-life treatment recommendations at the bivariate and multivariable level. Results: Two-hundred fifty-five (41% response rate) respondents completed surveys. Most physicians reported that religion was either very or the most important part of their life (89%). Physicians who reported consulting Islamic bioethics literature more often had higher odds of recommending active treatment over hospice care in an end-of-life case vignette. Physicians who were more religious had higher odds of viewing withdrawal of life-sustaining treatment more ethically and psychologically challenging than withholding it and had lower odds of agreeing that one should always comply with a competent patient’s request to withdraw life-sustaining treatment. Discussion: Religiosity appears to impact Muslim physician attitudes toward various aspects of end-of-life health-care decision-making. Greater research is needed to evaluate how this relationship manifests itself in patient care conversations and shared clinical decision-making in the hospital.
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Affiliation(s)
- Rosie Duivenbode
- Initiative on Islam and Medicine, The University of Chicago, Chicago, IL, USA
| | - Stephen Hall
- Initiative on Islam and Medicine, The University of Chicago, Chicago, IL, USA
- Department of Medicine, Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
| | - Aasim I. Padela
- Initiative on Islam and Medicine, The University of Chicago, Chicago, IL, USA
- Department of Medicine, Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
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What Has Religion Got to Do With It? Crit Care Med 2018; 44:2109-2110. [PMID: 27755072 DOI: 10.1097/ccm.0000000000001920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Frush BW, Brauer SG, Yoon JD, Curlin FA. Physician Decision-Making in the Setting of Advanced Illness: An Examination of Patient Disposition and Physician Religiousness. J Pain Symptom Manage 2018; 55:906-912. [PMID: 29109001 DOI: 10.1016/j.jpainsymman.2017.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
CONTEXT Little is known about patient and physician factors that affect decisions to pursue more or less aggressive treatment courses for patients with advanced illness. OBJECTIVES This study sought to determine how patient age, patient disposition, and physician religiousness affect physician recommendations in the context of advanced illness. METHODS A survey was mailed to a stratified random sample of U.S. physicians, which included three vignettes depicting advanced illness scenarios: 1) cancer, 2) heart failure, and 3) dementia with acute infection. One vignette included experimental variables to test how patient age and patient disposition affected physician recommendations. After each vignette, physicians indicated their likelihood to recommend disease-directed medical care vs. hospice care. RESULTS Among eligible physicians (n = 1878), 62% (n = 1156) responded. Patient age and stated patient disposition toward treatment did not significantly affect physician recommendations. Compared with religious physicians, physicians who reported that religious importance was "not applicable" were less likely to recommend chemotherapy (adjusted odds ratio [OR] 0.39, 95% CI 0.23-0.66) and more likely to recommend hospice (OR 1.90, 95% CI 1.15-3.16) for a patient with cancer. Compared with physicians who ever attended religious services, physicians who never attended were less likely to recommend left ventricular assist device placement for a patient with congestive heart failure (OR 0.57, 95% CI 0.35-0.92). In addition, Asian ethnicity was independently associated with recommending chemotherapy (OR 1.72, 95% CI 1.13-2.61) and being less likely to recommend hospice (OR 0.59, 95% CI 0.40-0.91) for the patient with cancer; and it was associated with recommending antibiotics for the patient with dementia and pneumonia (OR 1.64, 95% CI 1.08-2.50). CONCLUSION This study provides preliminary evidence that patient disposition toward more and less aggressive treatment in advanced illness does not substantially factor into physician recommendations. Non-religious physicians appear less likely to recommend disease-directed medical treatment in the setting of advanced illness, although this finding was not uniform and deserves further research.
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Affiliation(s)
- Benjamin W Frush
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA; Duke Divinity School, Durham, North Carolina, USA.
| | - Simon G Brauer
- Duke University Sociology Department, Durham, North Carolina, USA
| | - John D Yoon
- MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, Illinois, USA; Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Farr A Curlin
- Duke Divinity School, Durham, North Carolina, USA; Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina, USA; Duke Palliative Care, Division of General Internal Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
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Oeyen S, Vermeulen K, Benoit D, Annemans L, Decruyenaere J. Development of a prediction model for long-term quality of life in critically ill patients. J Crit Care 2017; 43:133-138. [PMID: 28892669 DOI: 10.1016/j.jcrc.2017.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/22/2017] [Accepted: 09/02/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE We developed a prediction model for quality of life (QOL) 1 year after intensive care unit (ICU) discharge based upon data available at the first ICU day to improve decision-making. METHODS The database of a 1-year prospective study concerning long-term outcome and QOL (assessed by EuroQol-5D) in critically ill adult patients consecutively admitted to the ICU of a university hospital was used. Cases with missing data were excluded. Utility indices at baseline (UIb) and at 1 year (UI1y) were surrogates for QOL. For 1-year non-survivors UI1y was set at zero. The grouped lasso technique selected the most important variables in the prediction model. R2 and adjusted R2 were calculated. RESULTS 1831 of 1953 cases (93.8%) were complete. UI1y depended significantly on: UIb (P<0.001); solid tumor (P<0.001); age (P<0.001); activity of daily living (P<0.001); imaging (P<0.001); APACHE II-score (P=0.001); ≥80 years (P=0.001); mechanical ventilation (P=0.006); hematological patient (P=0.007); SOFA-score (P=0.008); tracheotomy (P=0.018); admission diagnosis surgical P<0.001 (versus medical); and comorbidity (P=0.049). Only baseline health status and surgical patients were positively associated with UI1y. R2 was 0.3875 and adjusted R2 0.3807. CONCLUSION Although only 40% of variability in long-term QOL could be explained, this prediction model can be helpful in decision-making.
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Affiliation(s)
- Sandra Oeyen
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Karel Vermeulen
- Faculty of Bioscience Engineering, Department of Mathematical Modelling, Statistics and Bioinformatics, Ghent University, Coupure Links 653, 9000 Ghent, Belgium.
| | - Dominique Benoit
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Lieven Annemans
- Faculty of Medicine and Health Sciences, Department of Public Health, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Johan Decruyenaere
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
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Putman MS, D’Alessandro A, Curlin FA, Yoon JD. Unilateral Do Not Resuscitate Orders. Chest 2017; 152:224-225. [DOI: 10.1016/j.chest.2017.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 03/30/2017] [Indexed: 11/26/2022] Open
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