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Gula AL, Walter JK, Morrison W, Kirschen MP. Exploring Ethical Dimensions in Neuropalliative Care. Semin Neurol 2024. [PMID: 38914125 DOI: 10.1055/s-0044-1787775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
Neurologic illnesses can be challenging to diagnose, involve changes in consciousness, and are often complicated by prognostic uncertainty. These disorders can affect how individuals interact with their environment, and as a result, many ethical concerns may arise related to their medical care. Key ethical issues in neuropalliative care include shared decision-making, evolving autonomy and capacity, best interest and harm principles, beneficence and nonmaleficence, futile and inappropriate care, justice and equity, and ableism. The four core principles of medical ethics, beneficence, nonmaleficence, justice, and autonomy, are foundational in considering approaches to these ethical challenges. Shared decision-making is rooted in the principle of autonomy. Evolving autonomy and capacity evoke autonomy, beneficence, and nonmaleficence. The best interest and harm principles are rooted in beneficence and nonmaleficence. Questions of futility and inappropriate care are founded in the principles of nonmaleficence, autonomy, and justice. Ableism invokes questions of nonmaleficence, autonomy, and justice. Practitioners of neurology will encounter ethical challenges in their practice. Framing decisions around the core ethical principles of beneficence, nonmaleficence, autonomy, and justice will help clinicians navigate challenging situations while acknowledging and respecting each patient's individual story.
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Affiliation(s)
- Annie L Gula
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer K Walter
- Department of Medical Ethics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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Turner K, Brummett A, Salter E. On What Grounds? A Pilot Study of References Used in Clinical Ethics Consultation and Education. HEC Forum 2024:10.1007/s10730-024-09532-7. [PMID: 38819603 DOI: 10.1007/s10730-024-09532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/01/2024]
Abstract
In accordance with standards published by the American Society for Bioethics and Humanities (ASBH), ethics consultants are expected to provide recommendations that align with scholarly literature, professional society statements, law, and policy. However, there are no studies to date that characterize the specific references that ethics consultants and educators use to inform their work. To address this gap, a convenience sample of clinical ethics consultants and educators was surveyed online through two major listservs for clinical ethics, the ASBH Clinical Ethics Consultation Affinity Group (CECAG) and the Association of Bioethics Program Directors (ABPD). Ninety-five ethics consultants and/or educators with diverse educational background, credentials, and experience provided responses. In total, 451 references, 315 of which were unique, were reported. These references were broken into 6 categories after analysis: bioethics literature (divided into articles and books), professional society documents (divided into professional society statements and codes of ethics), federal/state/uniform/case law, hospital/health system policies, official religious teachings, and other. We found extensive variation and minimal overlap in the references respondents used for ethics consultation and education, even when referring to the same topics. Future research directions should include conducting more systematic efforts to characterize the references used by ethics consultants across the US; determining whether demographic characteristics of consultants influence the references used; and ascertaining whether the variation in references used reflects genuine disagreements in consultants' and educators' bioethical analysis or recommendations.
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Affiliation(s)
- Kelly Turner
- Gnaegi Center for Health Care Ethics, Saint Louis University, Saint Louis, MO, USA.
| | - Abram Brummett
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
- Corewell Health, William Beaumont University Hospital, Rochester, USA
| | - Erica Salter
- Gnaegi Center for Health Care Ethics, Saint Louis University, Saint Louis, MO, USA
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Kelly D, Barrett J, Brand G, Leech M, Rees C. Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review. Aust Crit Care 2024:S1036-7314(24)00049-3. [PMID: 38609749 DOI: 10.1016/j.aucc.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
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Affiliation(s)
- Diane Kelly
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia.
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Hospital, Richmond, VIC, Australia; Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia
| | - Gabrielle Brand
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Frankston, VIC, Australia
| | - Michelle Leech
- Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; Monash Medical Centre, Clayton, VIC 3168, Australia
| | - Charlotte Rees
- Monash Centre for Scholarship in Health Education, Faculty of Medicine Nursing & Health Sciences, Monash University, Clayton, VIC, Australia; School of Health Sciences, College of Medicine, Nursing & Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Ramadan OE, Mady AF, Al-Odat MA, Balshi AN, Aletreby AW, Stephen TJ, Diolaso SR, Gano JQ, Aletreby WT. Diagnostic accuracy of ePOS score in predicting DNR labeling after ICU admission: A prospective observational study (ePOS-DNR). JOURNAL OF INTENSIVE MEDICINE 2024; 4:216-221. [PMID: 38681789 PMCID: PMC11043627 DOI: 10.1016/j.jointm.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/28/2023] [Accepted: 09/14/2023] [Indexed: 05/01/2024]
Abstract
Background Resuscitation can sometimes be futile and making a do-not-resuscitate (DNR) decision is in the best interest of the patient. The electronic poor outcome screening (ePOS) score was developed to predict 6-month poor outcomes of critically ill patients. We explored the diagnostic accuracy of the ePOS score in predicting DNR decisions in the intensive care unit (ICU). Methods This study was conducted at the ICU of a tertiary referral hospital in Saudi Arabia between March and May 2023. Prospectively, we calculated ePOS scores for all eligible consecutive admissions after 48 h in the ICU and recorded the DNR orders. The ability of the score to predict DNR was explored using logistic regression. Youden's ideal cut-off value was calculated using the DeLong method, and different diagnostic accuracy measures were generated with corresponding 95 % confidence intervals (CIs). Results We enrolled 857 patients, 125 received a DNR order and 732 did not. The average ePOS score of DNR and non-DNR patients was 28.2±10.7 and 15.2±9.7, respectively. ePOS score, as a predictor of DNR order, had an area under receiver operator characteristic (AUROC) curve of 81.8 % (95% CI: 79.0 to 84.3, P <0.001). Youden's ideal cut-off value >17 was associated with a sensitivity of 87.2 (95% CI: 80.0 to 92.5, P <0.001), specificity of 63.9 (95% CI: 60.3 to 67.4, P <0.001), positive predictive value of 29.2 (95% CI: 24.6 to 33.8, P <0.001), negative predictive value of 96.7 (95% CI: 95.1 to 98.3, P <0.001), and diagnostic odds ratio 12.1 (95% CI: 7.0 to 20.8, P <0.001). Conclusions In this study, the ePOS score performed well as a diagnostic test for patients who will be labeled as DNR during their ICU stay. A cut-off score >17 may help guide clinical decisions to withhold or commence resuscitative measures.
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Affiliation(s)
- Omar E. Ramadan
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Anesthesia Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed F. Mady
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Anesthesia Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Ahmed N. Balshi
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Taisy J. Stephen
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Nursing Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Sheena R. Diolaso
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Nursing Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Jennifer Q. Gano
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Nursing Department, King Saud Medical City, Riyadh, Saudi Arabia
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West ED, Ricks TN. What nurses must understand about the ethics of assisted dying. Nurs Open 2024; 11:e2129. [PMID: 38491839 PMCID: PMC10943369 DOI: 10.1002/nop2.2129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/18/2024] Open
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Glover J, Bock M, Reynolds R, Zaretsky M, Vemulakonda V. Prenatally-diagnosed renal failure: an ethical framework for decision-making. J Perinatol 2024; 44:333-338. [PMID: 37735209 DOI: 10.1038/s41372-023-01779-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 08/31/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
The Children's Hospital Working Group has developed an ethical framework to guide patient care and research for prenatally diagnosed severe renal anomalies. It identifies ethical challenges in communication, timing of decisions and scarce resources. Key elements include shared decision-making, establishing a trusting relationship, and managing disagreement. The ethical framework will be used to develop a clinical pathway that operationalizes the key values of trust, honesty, transparency, beneficence, nonmaleficence, respecting parental authority, professional integrity, and justice.
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Affiliation(s)
- Jacqueline Glover
- Pediatrics, Center for Bioethics and Humanities, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA.
| | - Margret Bock
- Pediatrics, Nephrology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Regina Reynolds
- Pediatrics, Neonatology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael Zaretsky
- OB, GYN, Maternal-Fetal Medicine, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
| | - Vijaya Vemulakonda
- Surgery, Pediatric Urology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO, USA
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Kruser JM, Ashana DC, Courtright KR, Kross EK, Neville TH, Rubin E, Schenker Y, Sullivan DR, Thornton JD, Viglianti EM, Costa DK, Creutzfeldt CJ, Detsky ME, Engel HJ, Grover N, Hope AA, Katz JN, Kohn R, Miller AG, Nabozny MJ, Nelson JE, Shanawani H, Stevens JP, Turnbull AE, Weiss CH, Wirpsa MJ, Cox CE. Defining the Time-limited Trial for Patients with Critical Illness: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2024; 21:187-199. [PMID: 38063572 PMCID: PMC10848901 DOI: 10.1513/annalsats.202310-925st] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
In critical care, the specific, structured approach to patient care known as a "time-limited trial" has been promoted in the literature to help patients, surrogate decision makers, and clinicians navigate consequential decisions about life-sustaining therapy in the face of uncertainty. Despite promotion of the time-limited trial approach, a lack of consensus about its definition and essential elements prevents optimal clinical use and rigorous evaluation of its impact. The objectives of this American Thoracic Society Workshop Committee were to establish a consensus definition of a time-limited trial in critical care, identify the essential elements for conducting a time-limited trial, and prioritize directions for future work. We achieved these objectives through a structured search of the literature, a modified Delphi process with 100 interdisciplinary and interprofessional stakeholders, and iterative committee discussions. We conclude that a time-limited trial for patients with critical illness is a collaborative plan among clinicians and a patient and/or their surrogate decision makers to use life-sustaining therapy for a defined duration, after which the patient's response to therapy informs the decision to continue care directed toward recovery, transition to care focused exclusively on comfort, or extend the trial's duration. The plan's 16 essential elements follow four sequential phases: consider, plan, support, and reassess. We acknowledge considerable gaps in evidence about the impact of time-limited trials and highlight a concern that if inadequately implemented, time-limited trials may perpetuate unintended harm. Future work is needed to better implement this defined, specific approach to care in practice through a person-centered equity lens and to evaluate its impact on patients, surrogates, and clinicians.
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Sarpal A, Miller MR, Martin CM, Sibbald RW, Speechley KN. Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers. Front Pediatr 2024; 12:1272648. [PMID: 38304746 PMCID: PMC10830678 DOI: 10.3389/fped.2024.1272648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024] Open
Abstract
Background Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited. Objectives Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate. Methods Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale. Results Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty. Conclusions While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.
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Affiliation(s)
- Amrita Sarpal
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Michael R. Miller
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Claudio M. Martin
- Lawson Health Research Institute, London, ON, Canada
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Robert W. Sibbald
- Department of Ethics, London Health Sciences Centre, London, ON, Canada
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kathy N. Speechley
- Department of Paediatrics, Children's Hospital – London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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10
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Kon AA. Parents Have a Right to Refuse Brain Death Testing, Including Apnea Testing. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:106-108. [PMID: 38236892 DOI: 10.1080/15265161.2023.2278575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Alexander A Kon
- Community Children's and the University of Washington School of Medicine
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11
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Savel RH, Shiloh AL. Trajectory After Tracheostomy: Sobering Data for Decision Makers. Crit Care Med 2023; 51:1834-1837. [PMID: 37971341 DOI: 10.1097/ccm.0000000000006044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Richard H Savel
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ
| | - Ariel L Shiloh
- Critical Care Consult Service, Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
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12
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Mehta AB, Matlock DD, Shorr AF, Douglas IS. Healthcare Trajectories and Outcomes in the First Year After Tracheostomy Based on Patient Characteristics. Crit Care Med 2023; 51:1727-1739. [PMID: 37638787 DOI: 10.1097/ccm.0000000000006029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVES To define healthcare trajectories after tracheostomy to inform shared decision-making efforts for critically ill patients. DESIGN Retrospective epidemiologic cohort study. SETTING California Patient Discharge Database 2018-2019. PATIENTS Patients who received a tracheostomy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We tracked 1-year outcomes after tracheostomy, including survival and time alive in and out of a healthcare facility (HCF. Patients were stratified based on surgical status (did the patient require a major operating room procedure or not), age (65 yr old or older and less than 65 yr), pre-ICU comorbid states (frailty, chronic organ dysfunction, cancer, and robustness), and the need for dialysis during the tracheostomy admission. We identified 4,274 nonsurgical adults who received a tracheostomy during the study period with 50.9% being 65 years old or older. Among adults 65 years old or older, median survival after tracheostomy was less than 3 months for individuals with frailty, chronic organ dysfunction, cancer, or dialysis. Median survival was 3 months for adults younger than 65 years with cancer or dialysis. Most patients spent the majority of days alive after a tracheostomy in an HCF in the first 3 months. Older adults had very few days alive and out of an HCF in the first 3 months after tracheostomy. Most patients who ultimately died in the first year after tracheostomy spent almost all days alive in an HCF. CONCLUSIONS Cumulative mortality and median survival after a tracheostomy were very poor across most ages and groups. Older adults and several subgroups of younger adults experienced high rates of prolonged hospitalization with few days alive and out of an HCF. This information may aid some patients, surrogates, and providers in decision-making.
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Affiliation(s)
- Anuj B Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Veteran's Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Aurora, CO
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Daniel D Matlock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
- Veteran's Affairs Eastern Colorado Geriatric Research, Education and Clinical Center, Aurora, CO
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Andrew F Shorr
- Department of Medicine, Medstar Washington Hospital Center, Washington, DC
| | - Ivor S Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health and Hospital Authority, Denver, CO
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
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13
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Wasserman JA, Brummett AL, Navin MC, Menkes DL. Conscientious Objection to Aggressive Interventions for Patients in a Vegetative State. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-12. [PMID: 38032547 DOI: 10.1080/15265161.2023.2280099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of "futility", but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment.
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Affiliation(s)
- Jason Adam Wasserman
- Oakland University William Beaumont School of Medicine
- Corewell Health - East
- Oakland University Center for Moral Values in Health and Medicine
| | - Abram L Brummett
- Oakland University William Beaumont School of Medicine
- Corewell Health - East
- Oakland University Center for Moral Values in Health and Medicine
| | - Mark Christopher Navin
- Corewell Health - East
- Oakland University Center for Moral Values in Health and Medicine
- Oakland University
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14
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Enck G, Condley B. Agent-Regret in Healthcare. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023:1-15. [PMID: 37962933 DOI: 10.1080/15265161.2023.2276166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
For healthcare professionals and organizations, there is an emphasis on addressing moral distress and compassion fatigue among clinicians. While addressing these issues is vital, this paper suggests that the philosophical concept of agent-regret is a relevant but overlooked issue in healthcare. To experience agent-regret is to regret your harmful but not wrongful actions. This person's action results in someone being killed or significantly injured, but it was ethically faultless. Despite being faultless, agent-regret is an emotional response concerning one's agency in a situation that results in death or significant harm. In healthcare, many clinicians are likely to experience regret for faultless actions that significantly harm or cause the death of a patient. The recognition of agent-regret in healthcare is significant because it differs, conceptually and practically, from moral distress and compassion fatigue. Building on the work of Wojtowicz (2022), we should strive to understand clinicians' agent-regret by recognizing their agency in the situation, not lessening or removing it.
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Affiliation(s)
- Gavin Enck
- The University of Texas MD Anderson Cancer Center
| | - Beth Condley
- ; The University of Oklahoma Health Sciences Center
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15
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Rodriquez J. Becoming futile: the emotional pain of treating COVID-19 patients. FRONTIERS IN SOCIOLOGY 2023; 8:1231638. [PMID: 38024788 PMCID: PMC10663339 DOI: 10.3389/fsoc.2023.1231638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023]
Abstract
Introduction The COVID-19 pandemic has had a profoundly detrimental impact on the emotional wellbeing of health care workers. Numerous studies have shown that their rates of the various forms of work-related distress, which were already high before the pandemic, have worsened as the demands on health care workers intensified. Yet much less is known about the specific social processes that have generated these outcomes. This study adds to our collective knowledge by focusing on how one specific social process, the act of treating critically ill COVID-19 patients, contributed to emotional pain among health care workers. Methods This article draws from 40 interviews conducted with intensive care unit (ICU) staff in units that were overwhelmed with COVID-19 patients. The study participants were recruited from two suburban community hospitals in Massachusetts and the interviews were conducted between January and May 2021. Results The results show that the uncertainty over how to treat critically ill COVID-19 patients, given the absence of standard protocols combined with ineffective treatments that led to an unprecedented number of deaths caused significant emotional pain, characterized by a visceral, embodied experience that signaled moral distress, emotional exhaustion, depersonalization, and burnout. Furthermore, ICU workers' occupational identities were undermined as they confronted the limits of their own abilities and the limits of medicine more generally. Discussion The inability to save incurable COVID-19 patients while giving maximal care to such individuals caused health care workers in the ICU an immense amount of emotional pain, contributing to our understanding of the social processes that generated the well-documented increase in moral distress and related measures of work-related psychological distress. While recent studies of emotional socialization among health care workers have portrayed clinical empathy as a performed interactional strategy, the results here show empathy to be more than dramaturgical and, in this context, entailed considerable risk to workers' emotional wellbeing.
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Affiliation(s)
- Jason Rodriquez
- Department of Sociology, University of Massachusetts Boston, Boston, MA, United States
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16
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Chichra A, Tickoo M, Honiden S. Managing the Chronically Ventilated Critically Ill Population. J Intensive Care Med 2023:8850666231203601. [PMID: 37787184 DOI: 10.1177/08850666231203601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Advances in intensive care over the past few decades have significantly improved the chances of survival for patients with acute critical illness. However, this progress has also led to a growing population of patients who are dependent on intensive care therapies, including prolonged mechanical ventilation (PMV), after the initial acute period of critical illness. These patients are referred to as the "chronically critically ill" (CCI). CCI is a syndrome characterized by prolonged mechanical ventilation, myoneuropathies, neuroendocrine disorders, nutritional deficiencies, cognitive and psychiatric issues, and increased susceptibility to infections. It is associated with high morbidity and mortality as well as a significant increase in healthcare costs. In this article, we will review disease burden, outcomes, psychiatric effects, nutritional and ventilator weaning strategies as well as the role of palliative care for CCI with a specific focus on those requiring PMV.
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Affiliation(s)
- Astha Chichra
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mayanka Tickoo
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Shyoko Honiden
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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17
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Robertson-Preidler J, Kaplan H. "But my mom still blinks when I talk to her." Understanding the concept of social death to avoid bias and improve goals-of-care discussions at the end of life. J Eval Clin Pract 2023; 29:1083-1089. [PMID: 37525563 DOI: 10.1111/jep.13907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
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18
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Hornor M, Khan U, Cripps MW, Cook Chapman A, Knight-Davis J, Puzio TJ, Joseph B. Futility in acute care surgery: first do no harm. Trauma Surg Acute Care Open 2023; 8:e001167. [PMID: 37780455 PMCID: PMC10533797 DOI: 10.1136/tsaco-2023-001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/25/2023] [Indexed: 10/03/2023] Open
Abstract
The consequences of the delivery of futile or potentially ineffective medical care and interventions are devastating on the healthcare system, our patients and their families, and healthcare providers. In emergency situations in particular, determining if escalating invasive interventions will benefit a frail and/or severely critically ill patient can be exceedingly difficult. In this review, our objective is to define the problem of potentially ineffective care within the specialty of acute care surgery and describe strategies for improving the care of our patients in these difficult situations.
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Affiliation(s)
- Melissa Hornor
- Surgery, Loyola University Chicago, Maywood, Illinois, USA
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
| | - Uzer Khan
- Surgery, Texas Christian University, Fort Worth, Texas, USA
| | - Michael W Cripps
- Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Allyson Cook Chapman
- Medicine and Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Knight-Davis
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, The Ohio State University College of Medicine and Public Health, Columbus, Ohio, USA
| | - Thaddeus J Puzio
- General Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Bellal Joseph
- American Association for the Surgery of Trauma, AAST Geriatric Trauma Committee, Chicago, IL, USA
- Surgery, University of Arizona Medical Center—University Campus, Tucson, Arizona, USA
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19
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Rubin EB, Robinson EM, Cremens MC, McCoy TH, Courtwright AM. Declining to Provide or Continue Requested Life-Sustaining Treatment: Experience With a Hospital Resolving Conflict Policy. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:457-466. [PMID: 37380828 DOI: 10.1007/s11673-023-10270-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/31/2022] [Indexed: 06/30/2023]
Abstract
In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.
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Affiliation(s)
- Emily B Rubin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, Bullfinch Building, Boston, MA, 02114, USA.
| | - Ellen M Robinson
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Patient Care Services, Massachusetts General Hospital, Boston, MA, USA
| | - M Cornelia Cremens
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry Massachusetts General Hospital, Boston, MA, USA
| | - Thomas H McCoy
- Optimum Care Committee, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry Massachusetts General Hospital, Boston, MA, USA
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20
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Piscitello GM, Tyker A, Schenker Y, Arnold RM, Siegler M, Parker WF. Disparities in Unilateral Do Not Resuscitate Order Use During the COVID-19 Pandemic. Crit Care Med 2023; 51:1012-1022. [PMID: 36995088 PMCID: PMC10526631 DOI: 10.1097/ccm.0000000000005863] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVES A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic. DESIGN We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021. SETTING Two academic medical centers in the Chicago metropolitan area. PATIENTS Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7). CONCLUSIONS In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Albina Tyker
- Division of Respirology, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mark Siegler
- Department of Medicine, University of Chicago, Chicago, IL
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| | - William F Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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Kon AA. Withdrawal of ECMO Support over the Objections of a Capacitated Patient can be Appropriate. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:30-32. [PMID: 37220383 DOI: 10.1080/15265161.2023.2201218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Alexander A Kon
- Community Children's
- University of Washington School of Medicine
- University of California San Diego School of Medicine
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22
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Morrison W, Moynihan K. Personalizing Care and Communication at the Limits of Technology. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:41-43. [PMID: 37220364 DOI: 10.1080/15265161.2023.2201207] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Wynne Morrison
- The Children's Hospital of Philadelphia
- University of Pennsylvania
| | - Katie Moynihan
- Harvard Medical School
- Boston Children's Hospital
- The University of Sydney
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23
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Childress A, Bibler T, Moore B, Nelson RH, Robertson-Preidler J, Schuman O, Malek J. From Bridge to Destination? Ethical Considerations Related to Withdrawal of ECMO Support over the Objections of Capacitated Patients. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:5-17. [PMID: 35616323 DOI: 10.1080/15265161.2022.2075959] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention-a bridge to recovery or transplant-not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of withdrawal, including distributive justice, quality of life, patients' rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned.
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Batten JN, Dzeng E, Finder S, Blythe JA, Nurok M. When Critically Ill Patients with Decision Making Capacity and No Further Therapeutic Options Request Indefinite Life Support. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:21-23. [PMID: 37220368 DOI: 10.1080/15265161.2023.2201208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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25
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Frader J, Paquette E, Michelson K, Morgan E. Bridge or Destination: Ethical Complexity, Emotional Unrest. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:44-46. [PMID: 37220376 DOI: 10.1080/15265161.2023.2201211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Joel Frader
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - Erin Paquette
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - Kelly Michelson
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - Elaine Morgan
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
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Derse AR. The ECMO Bridge and 5 Paths. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:1-4. [PMID: 37220356 DOI: 10.1080/15265161.2023.2202611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Beil M, de Lange D, Leaver S, Szczeklik W, Fjolner J, Nachshon A, van Heerden PV, Joskowicz L, Jung C, Hyams G, Sviri S. The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU. Ann Intensive Care 2023; 13:40. [PMID: 37162595 PMCID: PMC10170430 DOI: 10.1186/s13613-023-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. METHODS This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. RESULTS The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. CONCLUSIONS Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, service MIR, Paris, France
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Akiva Nachshon
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Christian Jung
- Division of Cardiology, Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
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Affirming the Existence and Legitimacy of Secular Bioethical Consensus, and Rejecting Engelhardt's Alternative: A Reply to Nick Colgrove and Kelly Kate Evans. HEC Forum 2023; 35:95-109. [PMID: 34156607 DOI: 10.1007/s10730-021-09452-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
One of the most significant and persistent debates in secular clinical ethics is the question of ethics expertise, which asks whether ethicists can make justified moral recommendations in active patient cases. A critical point of contention in the ethics expertise debate is whether there is, in fact, a bioethical consensus upon which secular ethicists can ground their recommendations and whether there is, in principle, a way of justifying such a consensus in a morally pluralistic context. In a series of recent articles in this journal, Janet Malek defends a positive view of ethics expertise, claiming that secular ethicists should comport their recommendations with bioethical consensus. In response, Nick Colgrove and Kelly Kate Evans deny the existence of a secular bioethical consensus; question why, even if it did exist, consensus should be considered a reliable way of resolving bioethical questions; and recommend a friendlier approach to clinical ethics based on the thought of H. Tristram Engelhardt Jr. In this article, I respond to Colgrove and Evans on all three points. In part one, I show there is a secular bioethical consensus but note it could be better consolidated and created through a more systematic and inclusive process. In part two, I argue that bioethical consensus is morally justified but note that this justification cannot be plausibly based upon claims that it only invokes moral principles available to or shared by all. In part three, I argue Engelhardt's approach cannot be described as "friendlier" to clinical ethics because it is incompatible with many current healthcare laws and policies.
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Harting MT, Munson D, Linebarger J, Hirshberg E, Gow KW, Malek MM, Robbins AJ, Turnbull J. Ethical Considerations in Critically Ill Neonatal and Pediatric Patients. J Pediatr Surg 2023; 58:1059-1073. [PMID: 36948932 DOI: 10.1016/j.jpedsurg.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/03/2023] [Indexed: 02/19/2023]
Abstract
The care of critically ill neonates and pediatric patients can be particularly emotionally and ethically challenging. Emerging evidence suggests that we can improve the patient, family, and care team experience in the critical care setting through a better understanding and application of ethical frameworks and communication strategies. We conducted a multidisciplinary panel session at the American Academy of Pediatrics National Conference and Exhibition in the fall of 2022 wherein we explored a myriad of ethical and communication considerations in this unique patient population, with congenital diaphragmatic hernia (CDH) as the congenital anomaly/disease framework. In this review, we will cover state of the art topics in ethics, communication, and palliative care including basic terminology, communication strategies such as trauma-informed communication, establishing/evolving goals of care, futility, medically inappropriate treatment, ethical frameworks, parental discretion, establishing milestones, internal/external intentions, and re-direction of care. These topics will be helpful to many specialties who are involved in the care of critically ill neonates and children including maternal fetal medicine, pediatrics, neonatology, pediatric critical care, palliative care, and pediatric surgery, along with the pediatric surgical subspecialties. We use a theoretical CDH case as an example and include the live audience responses from the interactive session. This primer provides overarching educational principles, as well as practical communication concepts, that can cultivate compassionate multidisciplinary teams, equipped to optimize family-centered, evidence-based compassionate communication and care.
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Affiliation(s)
- Matthew T Harting
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA.
| | - David Munson
- Department of Pediatrics, Division of Neonatology, Perelman School of Medicine at the University of Pennsylvania and the Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Linebarger
- Department of Pediatrics, University of Missouri - Kansas City and Children's Mercy Hospital, Kansas City, MO, USA
| | - Ellie Hirshberg
- Department of Pediatrics, University of Utah School of Medicine and Intermountain Healthcare, Salt Lake City, UT, USA
| | - Kenneth W Gow
- Department of Surgery, Division of Pediatric Surgery, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Marcus M Malek
- Department of Surgery, Division of Pediatric Surgery, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandria J Robbins
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA; Department of Family Medicine and Community Health, Division of Palliative Care, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Jessica Turnbull
- Department of Pediatrics and the Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
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30
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Lo JJ, Yoon S, Neo SHS, Sim DKL, Graves N. Elements of Potentially Inappropriate Interventions and Patient Prognostic Profiles at the End of Life in Cardiology: A Qualitative Analysis. J Palliat Med 2023; 26:700-703. [PMID: 36787484 DOI: 10.1089/jpm.2022.0564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background: The determination of what makes a medical treatment inappropriate is unclear with a small likelihood of consensus. Objectives: This study aimed to explore how clinicians in cardiology perceive "inappropriate treatment" and to collate the common profiles of cardiology patients receiving likely "inappropriate treatment" as perceived by clinicians in a multiethnic Asian context. Methods: A qualitative study was conducted using semistructured in-depth interviews with 32 clinicians involved in the care for cardiology patients at a large national cardiology center in Singapore. Results: Clinicians' accounts indicated that elements of potentially inappropriate treatment encompass patient-related treatment elements as well as quantitative and probability-based elements such as resource use and probability of treatment benefit. Patient prognostic profiles, characterized as likely to have received inappropriate treatment by clinicians, were organized into six categories according to demographic, clinical, and functional factors. Conclusions: The perception of inappropriateness of treatments among clinicians in cardiology was primarily focused on patient-related outcomes. Collated patient profiles may serve as meaningful indicators of patient cases receiving potentially inappropriate treatment for further research and intervention.
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Affiliation(s)
- Jamie J Lo
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Sungwon Yoon
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Shirlyn Hui Shan Neo
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | | | - Nicholas Graves
- Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
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Huwel L, Van Eessen J, Gunst J, Malbrain ML, Bosschem V, Vanacker T, Verhaeghe S, Benoit DD. What is appropriate care? A qualitative study into the perceptions of healthcare professionals in Flemish university hospital intensive care units. Heliyon 2023; 9:e13471. [PMID: 36816284 PMCID: PMC9929305 DOI: 10.1016/j.heliyon.2023.e13471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Aim This study examines when healthcare professionals consider intensive care as appropriate care. Background Despite attempts to conceptualize appropriate care in prior research, there is a lack of insight into its meaning and implementation in practice. This is an important issue because healthcare professionals as well as patients and relatives report inappropriate care in the intensive care unit (ICU) on a regular basis. Methods A qualitative study was designed, based on principles of grounded theory. Seventeen semi-structured interviews were conducted with nurses, doctors and doctors in training from three Flemish university hospitals. Analyses followed the Quagol method; insights were gained by means of the constant comparative method. Results Healthcare professionals described appropriate care as socially sustainable care, high-quality care, patient-oriented care, dignified care and meaningful care. They considered it important that care is not only proportional to the expected survival and quality of life of the patient and in line with the patient's or relatives' wishes, but also that the pursuit of the care goals is proportional to the patient's suffering.Although healthcare professionals indicated the same elements of appropriate care, they were defined and interpreted in individual and therefore different ways. This diversity lies at the basis of fields of tension and frustrations among healthcare professionals. Conclusion Appropriate care is defined and interpreted in individual and therefore different ways. In order to decide which type of care is appropriate for a specific patient, a process of open and constructive communication in a team is recommended.
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Affiliation(s)
- Lore Huwel
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
- Corresponding author.
| | - Joke Van Eessen
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Jan Gunst
- Leuven University Hospital, Department of Intensive Care Medicine; Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
- KU Leuven, Department of Cellular and Molecular Medicine, Laboratory of Intensive Care Medicine, Onderwijs & Navorsing 1 (O&N1) Building of Campus Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
| | - Manu L.N.G. Malbrain
- Brussels University Hospital, Department of Intensive Care; Brussels Health Campus, Laarbeeklaan 101, 1090 Jette, Belgium
- International Fluid Academy, iMERiT vzw, Dreef 3, 3360 Lovenjoel, Belgium
| | - Veerle Bosschem
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Tom Vanacker
- Ghent University Hospital, Department of Intensive Care Medicine, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - Sofie Verhaeghe
- Ghent University, Centre for Nursing and Midwifery, Department of Public Health and Primary Care, UZ Gent, 5K3 (entrance 42), Corneel Heymanslaan 10, 9000 Gent, Belgium
- VIVES University College Leuven, Department of Nursing, VIVES Roeselare, Wilgenstraat 32, 8800 Roeselare, Belgium
- Hasselt University, Faculty of Medicine and Life Science; Agoralaan, 3590 Diepenbeek, Belgium
| | - Dominique D. Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium
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Long RF, Kingsley DJ, Derrington DSF. The Shifting Landscape of Death by Neurologic Criteria in Pediatrics: Current Controversies and Persistent Questions. Semin Pediatr Neurol 2023; 45:101034. [PMID: 37003632 DOI: 10.1016/j.spen.2023.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
Since the concept of death by neurologic criteria (DNC) or "brain death" was articulated by the Harvard Ad Hoc Committee in 1968, efforts to establish and uphold DNC as equivalent to biologic death have been supported through federal and state legislation, professional guidelines, and hospital policies. Despite these endeavors, DNC remains controversial among bioethics scholars and clinicians and is not universally accepted by patient families and the public. In this focused review, we outline the current points of contention surrounding the diagnosis of DNC in pediatric patients. These include physiologic, legal, and philosophical inconsistencies in the definition of DNC, controversy regarding the components of the clinical exam, variability in clinical practice, and ethical concerns regarding justice and role of informed consent. By better understanding these controversies, clinicians may serve families grappling with the diagnosis of DNC more effectively, compassionately, and equitably.
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Damluji AA, Rymer JA, Nanna MG. The Heterogeneity of Old Age: Healthy Aging in Older Adults Undergoing TAVR. JACC Cardiovasc Interv 2023; 16:189-192. [PMID: 36697155 PMCID: PMC9945654 DOI: 10.1016/j.jcin.2022.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 12/05/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Fairfax, Virginia, USA; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | | | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.
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35
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Beil M, van Heerden PV, de Lange DW, Szczeklik W, Leaver S, Guidet B, Flaatten H, Jung C, Sviri S, Joskowicz L. Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care. BMC Med Inform Decis Mak 2023; 23:1. [PMID: 36609257 PMCID: PMC9818057 DOI: 10.1186/s12911-022-02094-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making. METHODS Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions. RESULTS Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree. CONCLUSIONS Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required. TRIAL REGISTRATION VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).
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Affiliation(s)
- Michael Beil
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P. Vernon van Heerden
- grid.9619.70000 0004 1937 0538Department of Anaesthesia, Intensive Care and Pain Medicine, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan W. de Lange
- grid.7692.a0000000090126352Department of Intensive Care Medicine, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Wojciech Szczeklik
- grid.5522.00000 0001 2162 9631Department of Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Susannah Leaver
- grid.451349.eIntensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Bertrand Guidet
- grid.50550.350000 0001 2175 4109Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hans Flaatten
- grid.412008.f0000 0000 9753 1393Intensive Care, Department of Clinical Medicine, Haukeland Universitetssjukehus, Bergen, Norway
| | - Christian Jung
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Sigal Sviri
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- grid.9619.70000 0004 1937 0538School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
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Ethical considerations in the management of infants with severe intraventricular hemorrhage. Semin Perinatol 2022; 46:151599. [PMID: 35450739 DOI: 10.1016/j.semperi.2022.151599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.
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Lim WH, Dominguez-Gil B. Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors. Semin Nephrol 2022; 42:151269. [PMID: 36577644 DOI: 10.1016/j.semnephrol.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
With the continuing disparity between organ supply to match the increasing demand for kidney transplants in patients with renal failure, donation after the circulatory determination of death (DCDD) has become an important and increasing global source of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor kidney transplants were inferior to those obtained from donors declared dead by neurologic criteria has largely diminished because large-scale registry and single-center reports consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants, outcomes are correspondingly acceptable, although there is a greater risk of primary nonfunction. The potential of DCDD remains unrealized in many countries because of the ethical concerns and resource implications in the utilization of these donor kidneys for transplantation. In this review, we discuss the origin and definitions of DCDD donors, and examine the long-term outcomes of transplants from DCDD donor kidneys. We discuss the controversies, challenges, and ethical and legal barriers in the acceptance of DCDD, including the complexities of implementing and sustaining controlled and uncontrolled DCDD donor programs. The lessons learned from global leaders will assist a wider international recognition, acceptance, and development of DCDD transplant programs that will noticeably facilitate and address the global shortages of kidneys for transplantation, and ensure the opportunity for people who had indicated their desires to become organ donors fulfill their final wishes.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia; Internal Medicine, University of Western Australia Medical School, Perth, Australia.
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38
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Enck GG. The significance of the distinction between "having a life" vs. "being alive" in end-of-life care. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:251-258. [PMID: 35015173 DOI: 10.1007/s11019-022-10066-3] [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] [Accepted: 01/03/2022] [Indexed: 06/14/2023]
Abstract
In end-of-life care discussions, I contend that the distinction between "having a life" vs. "being alive" is an underutilized distinction. This distinction is significant in separating different states of existence conflated by patients, families, and clinicians. In the clinical setting, applying this distinction in end-of-life care discussions aids patients' and family members' decision-making by helping them understand that being alive can differ from having a life. Moreover, this distinction helps them decide which state may be the most important to them. After applying this distinction to three complex cases, I respond to the likely objection that "having a life" vs. "being alive" is less accurate and more controversial than other distinctions. I conclude by arguing that "having a life" vs. "being alive" is more accurate and less controversial than distinctions between medically indicated vs. medically inappropriate treatments, personhood, and quantity vs. quality of life.
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Affiliation(s)
- Gavin G Enck
- Department of Clinical Ethics, Ohio Health, Columbus, OH, USA.
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Wen FH, Chou WC, Chen JS, Chang WC, Hsu MH, Tang ST. Sufficient Death Preparedness Correlates to Better Mental Health, Quality of Life, and EOL Care. J Pain Symptom Manage 2022; 63:988-996. [PMID: 35192878 DOI: 10.1016/j.jpainsymman.2022.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 10/19/2022]
Abstract
CONTEXT Patients can prepare for end of life and their forthcoming death to enhance the quality of dying. OBJECTIVES We aimed to longitudinally evaluate the never-before-examined associations of cancer patients' death-preparedness states by conjoint cognitive prognostic awareness and emotional preparedness for death with psychological distress, quality of life (QOL), and end-of-life care received. METHODS In this cohort study, we simultaneously evaluated associations of four previously identified death-preparedness states (no-death-preparedness, cognitive-death-preparedness-only, emotional-death-preparedness-only, and sufficient-death-preparedness states) with anxiety symptoms, depressive symptoms, and QOL over 383 cancer patients' last six months and end-of-life care received in the last month using multivariate hierarchical linear modeling and logistic regression modeling, respectively. Minimal clinically important differences (MCIDs) have been established for anxiety- (1.3-1.8) and depressive- (1.5-1.7) symptom subscales (0-21 Likert scales). RESULTS Patients in the no-death-preparedness and cognitive-death-preparedness-only states reported increases in anxiety symptoms and depressive symptoms that exceed the MCIDs, and a decline in QOL from those in the sufficient-death-preparedness state. Patients in the emotional-death-preparedness-only state were more (OR [95% CI]=2.38 [1.14, 4.97]) and less (OR [95% CI]=0.38 [0.15, 0.94]) likely to receive chemotherapy/immunotherapy and hospice care, respectively, than those in the sufficient-death-preparedness state. Death-preparedness states were not associated with life-sustaining treatments received in the last month. CONCLUSION Conjoint cognitive and emotional preparedness for death is associated with cancer patients' lower psychological distress, better QOL, reduced anti-cancer therapy, and increased hospice-care utilization. Facilitating accurate prognostic awareness and emotional preparedness for death is justified when consistent with patient circumstances and preferences.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taiwan, China
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, China; Chang Gung University College of Medicine, Taiwan, China
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, China; Chang Gung University College of Medicine, Taiwan, China
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, China; Chang Gung University College of Medicine, Taiwan, China
| | - Mei Huang Hsu
- School of Nursing, Chang Gung University, Taiwan, China
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan, China; School of Nursing, Chang Gung University, Taiwan, China; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Taiwan, China.
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Rothschild CB, Chaiyachati BH, Finck KR, Atwood MA, Leuthner SR, Christian CW. A Venn diagram of vulnerability: The convergence of pediatric palliative care and child maltreatment a narrative review, and a focus on communication. CHILD ABUSE & NEGLECT 2022; 128:105605. [PMID: 35367899 PMCID: PMC11000825 DOI: 10.1016/j.chiabu.2022.105605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 06/14/2023]
Abstract
Child maltreatment and end-of-life care independently represent two of the most emotion-laden and uncomfortable aspects of pediatric patient care. Their overlap can be uniquely distressing. This review explores ethical and legal principles in such cases and provides practical advice for clinicians. The review focuses on three archetypal scenarios of overlap: life-limiting illness in a child for whom parental rights have been terminated; life-threatening injury under CPS investigation; and complex end-of-life care which may warrant CPS involvement. While each scenario presents unique challenges, one consistent theme is the centrality of effective communication. This includes empathic communication with families and thoughtful communication with providers and community stakeholders. In almost all cases, everyone genuinely wants to do what is in the best interest of the child in these unthinkable circumstances. Transparent and collaborative communication can ensure that broad perspectives are considered to ensure that each child gets the best possible care in a manner adherent with ethical and legal standards, as they apply to each case.
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Affiliation(s)
| | - Barbara H Chaiyachati
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kara R Finck
- Interdisciplinary Child Advocacy Clinic, University of Pennsylvania Carey Law School, Philadelphia, PA, USA
| | - Melissa A Atwood
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven R Leuthner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cindy W Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Martínez-Sellés M, Grodzicki T. Modification of Cardiovascular Drugs in Advanced Heart Failure: A Narrative Review. Front Cardiovasc Med 2022; 9:883669. [PMID: 35677686 PMCID: PMC9167993 DOI: 10.3389/fcvm.2022.883669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Advanced heart failure (HF) is a complex entity with a clinical course difficult to predict. However, most patients have a poor prognosis. This document addresses the modification of cardiovascular drugs in patients with advanced HF that are not candidates to heart transplantation or ventricular assist device and are in need of palliative care. The adjustment of cardiovascular drugs is frequently needed in these patients. The shift in emphasis from life-prolonging to symptomatic treatments should be a progressive one. We establish a series of recommendations with the aim of adjusting drugs in these patients, in order to adapt treatment to the needs and wishes of each patient. This is frequently a difficult process for patients and professionals, as drug discontinuing needs to balance treatment benefit with the psychological adaption to having a terminal illness. We encourage the use of validated assessment tools to assess prognosis and to use this information to take clinical decisions regarding drug withdrawal and therapeutic changes. The golden rule is to stop drugs that are harmful or non-essential and to continue the ones that provide symptomatic improvement.
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Affiliation(s)
- Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
- *Correspondence: Manuel Martínez-Sellés
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, Krakow, Poland
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Van Raemdonck D, Ceulemans LJ, Neyrinck A, Levvey B, Snell GI. Donation After Circulatory Death in lung transplantation. Thorac Surg Clin 2022; 32:153-165. [PMID: 35512934 DOI: 10.1016/j.thorsurg.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The continuing shortage of pulmonary grafts from donors after brain death has led to a resurgence of interest in lung transplantation from donors after circulatory death (DCD). Most lungs from donors after withdrawal from life-sustaining therapy can be recovered rapidly and transplanted directly without ex-vivo assessment in case functional warm ischemic time is limited to 30 to 60 min. The potential of the DCD lung pool is still underutilized and should be maximized in countries with existing legislation. Countries lacking a DCD pathway should be encouraged to develop national ethical, professional, and legal frameworks to address public and professional concerns.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Chronic Diseases and Metabolism, KU Leuven University, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, UZ Gasthuisberg, Herestraat 49, Leuven B-3000, Belgium; Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Bronwyn Levvey
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Gregory I Snell
- Lung Transplant Service, The Alfred Hospital and Monash University, 55 Commercial Road, Melbourne, Victoria 3004, Australia
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Guerin RM. Mechanisms of defense in clinical ethics consultation. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:119-130. [PMID: 34741698 DOI: 10.1007/s11019-021-10057-w] [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] [Accepted: 11/01/2021] [Indexed: 06/13/2023]
Abstract
Clinical ethics consultants respond to a multitude of issues, ranging from the cognitive to the emotional. As such, ethics consultants must be prepared to analyze as well as empathize. And yet, there remains a paucity of research and training on the interpersonal and emotional aspects of clinical ethics consultations-the so-called skills in "advanced ethics facilitation." This article is a contribution to the need for further understanding and practical knowledge in the emotional aspects of ethics consultation. In particular, I draw attention to defense mechanisms: what they are, why they exist, and how we might work with them in the setting of ethics consultation.
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Affiliation(s)
- Robert M Guerin
- Cleveland Medical Center, University Hospitals, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
- Department of Bioethics, School of Medicine, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH, 44106, USA.
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Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, Doble B, Dullie L, Durie R, Finkelstein EA, Guglani S, Hodson M, Husebø BS, Kellehear A, Kitzinger C, Knaul FM, Murray SA, Neuberger J, O'Mahony S, Rajagopal MR, Russell S, Sase E, Sleeman KE, Solomon S, Taylor R, Tutu van Furth M, Wyatt K. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet 2022; 399:837-884. [PMID: 35114146 PMCID: PMC8803389 DOI: 10.1016/s0140-6736(21)02314-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Afsan Bhadelia
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Yali Cong
- Peking University Health Science Center, Beijing, China
| | | | | | | | | | | | | | | | | | | | | | | | - Julia Neuberger
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eriko Sase
- Georgetown University, Washington, DC, USA
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Utilisation of goals of care discussions and palliative care prior to image-guided procedures near the end of life. Clin Radiol 2022; 77:345-351. [PMID: 35177227 DOI: 10.1016/j.crad.2022.01.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/19/2022] [Indexed: 11/03/2022]
Abstract
AIM To characterise image-guided procedures performed near the end of life and the use of goals of care discussions (GOC) and palliative care consultation (PCC) prior to these procedures. MATERIALS AND METHODS Retrospective chart review of 3,714 consecutive inpatient procedures performed for 2,351 patients and 8,206 outpatient procedures performed for 5,225 patients within a suburban medical system. Data were collected on demographics, procedures performed, mortality, and use of GOC or PCC prior to the procedures. Procedures near the end of life were classified as emergent, elective, or palliative. Logistic regression was used to assess for demographic disparities in care. RESULTS Nine percent of inpatients died within 30 days of their procedure, 57% of which were within the same hospitalisation. Of these patients, 59% had a documented GOC and 35% had a PCC. Similarly, 7% of outpatients died within 6 months of their procedure. A minority of these patients had a documented GOC (37%) or PCC (13%). There were few statistically significant demographic disparities in this care and the associated odds ratios were small. CONCLUSION A wide array of image-guided procedures is performed near the end of life. GOC and PCC are underutilised prior to these procedures. Few demographic disparities exist in this care.
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Soliman IW, Leaver S, Flaatten H, Fjølner J, Wernly B, Bruno RR, Artigas A, Bollen Pinto B, Schefold JC, Beil M, Sviri S, van Heerden PV, Szczeklik W, Elhadi M, Joannidis M, Oeyen S, Zafeiridis T, Wollborn J, Banzo MJA, Fuest K, Marsh B, Andersen FH, Moreno R, Boumendil A, Guidet B, Jung C, De Lange DW. Health-related quality of life in older patients surviving ICU treatment for COVID-19: results from an international observational study of patients older than 70 years. Age Ageing 2022; 51:6523677. [PMID: 35136896 PMCID: PMC8825757 DOI: 10.1093/ageing/afab278] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/03/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND health-related quality of life (HRQoL) is an important patient-centred outcome in patients surviving ICU admission for COVID-19. It is currently not clear which domains of the HRQoL are most affected. OBJECTIVE to quantify HRQoL in order to identify areas of interventions. DESIGN prospective observation study. SETTING admissions to European ICUs between March 2020 and February 2021. SUBJECTS patients aged 70 years or older admitted with COVID-19 disease. METHODS collected determinants include SOFA-score, Clinical Frailty Scale (CFS), number and timing of ICU procedures and limitation of care, Katz Activities of Daily Living (ADL) dependence score. HRQoL was assessed at 3 months after ICU admission with the Euro-QoL-5D-5L questionnaire. An outcome of ≥4 on any of Euro-QoL-5D-5L domains was considered unfavourable. RESULTS in total 3,140 patients from 14 European countries were included in this study. Three months after inclusion, 1,224 patients (39.0%) were alive and the EQ-5D-5L from was obtained. The CFS was associated with an increased odds ratio for an unfavourable HRQoL outcome after 3 months; OR 1.15 (95% confidence interval (CI): 0.71-1.87) for CFS 2 to OR 4.33 (95% CI: 1.57-11.9) for CFS ≧ 7. The Katz ADL was not statistically significantly associated with HRQoL after 3 months. CONCLUSIONS in critically ill old intensive care patients suffering from COVID-19, the CFS is associated with the subjectively perceived quality of life. The CFS on admission can be used to inform patients and relatives on the risk of an unfavourable qualitative outcome if such patients survive.
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Affiliation(s)
- Ivo W Soliman
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, the Netherlands
| | - Susannah Leaver
- General Intensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Department of Anaestesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Bernhard Wernly
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Raphael R Bruno
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | | | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | | | - Jakob Wollborn
- Department of Anesthesiolgy, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Havard Medical School, Boston, MA, USA
| | - Maria Jose Arche Banzo
- Servicio de Medicina Intensiva, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Kristina Fuest
- Department of Anesthesiology and Intensive Care, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Brian Marsh
- Department of Anesthesia and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocríticos e Trauma. Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
| | - Ariane Boumendil
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, F-75012 Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, F-75012 Paris, France
| | - Bertrand Guidet
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, F-75012 Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, F-75012 Paris, France
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, University Duesseldorf, Duesseldorf, Germany
| | - Dylan W De Lange
- Address correspondence to: D. W. de Lange, Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. Tel: +31 88 75 585 61; Fax: +31 88 75 556 77.
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Moynihan KM, Lelkes E, Kumar RK, DeCourcey DD. Is this as good as it gets? Implications of an asymptotic mortality decline and approaching the nadir in pediatric intensive care. Eur J Pediatr 2022; 181:479-487. [PMID: 34599379 DOI: 10.1007/s00431-021-04277-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/06/2021] [Accepted: 09/26/2021] [Indexed: 10/20/2022]
Abstract
Despite advances in medicine, some children will always die; a decline in pediatric intensive care unit (PICU) mortality to zero will never be achieved. The mortality decline is correspondingly asymptotic, yet we remain preoccupied with mortality outcomes. Are we at the nadir, and are we, thus, as good as we can get? And what should we focus to benchmark our units, if not mortality? In the face of changing case-mix and rising complexity, dramatic reductions in PICU mortality have been observed globally. At the same time, survivors have increasing disability, and deaths are often characterized by intensive life-sustaining therapies preceded by prolonged admissions, emphasizing the need to consider alternate outcome measures to evaluate our successes and failures. What are the costs and implications of reaching this nadir in mortality outcomes? We highlight the failings of our fixation with survival and an imperative to consider alternative outcomes in our PICUs, including the costs for both patients that survive and die, their families, healthcare providers, and society including perspectives in low resource settings. We describe the implications for benchmarking, research, and training the next generation of providers.Conlusion: Although survival remains a highly relevant metric, as PICUs continue to strive for clinical excellence, pushing boundaries in research and innovation, with endeavors in safety, quality, and high-reliability systems, we must prioritize outcomes beyond mortality, evaluate "costs" beyond economics, and find novel ways to improve the care we provide to all of our pediatric patients and their families. What is Known: • The fall in PICU mortality is asymptotic, and a decline to zero is not achievable. Approaching the nadir, we challenge readers to consider implications of focusing on medical and technological advances with survival as the sole outcome of interest. What is New: • Our fixation with survival has costs for patients, families, staff, and society. In the changing PICU landscape, we advocate to pivot towards alternate outcome metrics. • By considering the implications for benchmarking, research, and training, we may better care for patients and families, educate trainees, and expand what it means to succeed in the PICU.
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Affiliation(s)
- Katie M Moynihan
- Pediatric Intensive Care, Westmead Children's Hospital, Sydney, Australia.
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Efrat Lelkes
- Department of Pediatrics, Benioff Children's Hospital, University of California, CA, San Francisco, USA
| | - Raman Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Cochin, Kerala, India
| | - Danielle D DeCourcey
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
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Bauck P. Practicing Neighbor Love: Empathy, Religion, and Clinical Ethics. HEC Forum 2022:10.1007/s10730-021-09466-4. [PMID: 35031900 DOI: 10.1007/s10730-021-09466-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
The role of religion in clinical ethics consultations is contested. The religion of the ethics consultant can be an important part of the consultation process and improve the quality of a consultation. Practicing neighbor love leads to empathy, which not only can improve the quality of ethics consultations but also creates a space for religion to be part of, but not imposed on, the consultation. The practice of empathy will build trust, rapport, and an intersubjective connection that improves the quality of the consultation. (The views expressed are the author's and not representative of any institution or employer).
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Romero-García M, Delgado-Hito P, Gálvez-Herrer M, Antonio Ángel-Sesmero J, Raquel Velasco-Sanz T, Benito-Aracil L, Heras-La Calle G. Moral distress, emotional impact and coping in intensive care units staff during the outbreack of COVID-19. Intensive Crit Care Nurs 2022; 70:103206. [PMID: 35120794 PMCID: PMC8776502 DOI: 10.1016/j.iccn.2022.103206] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 01/13/2022] [Accepted: 01/16/2022] [Indexed: 12/27/2022]
Abstract
Background From the beginning, the COVID-19 pandemic increased ICU workloads and created exceptionally difficult ethical dilemmas. ICU staff around the world have been subject to high levels of moral stress, potentially leading to mental health problems. There is only limited evidence on moral distress levels and coping styles among Spanish ICU staff, and how they influenced health professionals’ mental health during the pandemic. Objectives To assess moral distress, related mental health problems (anxiety and depression), and coping styles among ICU staff during the first wave of the COVID-19 pandemic in Spain. Design Cross-sectional. Settings and participants The study setting consisted of intensive care unit and areas converted into intensive care units in public and private hospitals. A total of 434 permanent and temporary intensive care staff (reassigned due to the pandemic from other departments to units) answered an online questionnaire between March and June 2020. Methods Sociodemographic and job variables, moral distress, anxiety, depression, and coping mechanisms were anonymously evaluated through a self-reported questionnaire. Descriptive and correlation analyses were conducted and multivariate linear regression models were developed to explore the predictive ability of moral distress and coping on anxiety and depression. Results Moral distress during the pandemic is determined by situations related to the patient and family, the intensive care unit, and resource management of the organisations themselves. intensive care unit staff already reached moderate levels of moral distress, anxiety, and depression during the first wave of the pandemic. Temporary staff (redeployed from other units) obtained higher scores in these variables (p = 0.04, p = 0.038, and p = 0.009, respectively) than permanent staff, as well as in greater intention to leave their current position (p = 0.03). This intention was also stronger in health staff working in areas converted into intensive care units (45.2%) than in normal intensive care units (40.2%) (p = 0.02). Moral distress, coupled with primarily avoidance-oriented coping styles, explains 37% (AdR2) of the variance in anxiety and 38% (AdR2) of the variance in depression. Conclusions Our study reveals that the emotional well-being of intensive care unit staff was already at risk during the first wave of the pandemic. The moral distress they experienced was related to anxiety and depression issues, as well as the desire to leave the profession, and should be addressed, not only in permanent staff, but also in temporary staff, redeployed to these units as reinforcement workers.
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Nortje M, Haque S, Nortje N. The Benefits of Informed Non-Dissent when Families have Difficulty Making a Decision. CANADIAN JOURNAL OF BIOETHICS 2022. [DOI: 10.7202/1094702ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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