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van Erp IA, van Essen T, Kompanje EJ, van der Jagt M, Moojen WA, Peul WC, van Dijck JT. Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands. BRAIN & SPINE 2024; 4:102746. [PMID: 38510637 PMCID: PMC10951765 DOI: 10.1016/j.bas.2024.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 01/03/2024] [Indexed: 03/22/2024]
Abstract
Introduction Treatment-limiting decisions (TLDs) can be inevitable severe traumatic brain injury (s-TBI) patients, but data on their use remain scarce. Research question To investigate the prevalence, timing and considerations of TLDs in s-TBI patients. Material and methods s-TBI patients between 2008 and 2017 were analysed retrospecively. Patient data, timing, location, involvement of proxies, and reasons for TLDs were collected. Baseline characteristics and in-hospital outcomes were compared between s-TBI patients with and without TLDs. Results TLDs were reported in 117 of 270 s-TBI patients (43.3%) and 95.9% of deaths after s-TBI were preceded by a TLD. The majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ-support in 64.1%. Neurosurgical intervention was withheld in 29.9%. The median time from admission to TLD was 2 days [IQR, 0-8] and 50.4% of TLDs were made within 3 days of admission. The main reason for a TLD was that the patients were perceived as unsalvageable (66.7%). Nearly all decisions were made multidisciplinary (99.1%) with proxies involvement (75.2%). The predicted mortality (CRASH-score) between patients with and without TLDs were 72.6 vs. 70.6%. The percentage of TLDs in s-TBI patients increased from 20.0% in 2008 to 42.9% in 2012 and 64.3% in 2017. Discussion and conclusion TLDs occurred in almost half of s-TBI patients and were instituted more frequently over time. Half of TLDs were made within 3 days of admission in spite of baseline prognosis between groups being similar. Future research should address whether prognostic nihilism contributes to self-fulfilling prophecies.
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Affiliation(s)
- Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - T.A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Erwin J.O. Kompanje
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
- Department of Ethics and Philosophy of Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Wouter A. Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
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2
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Vlachos S, Rubenfeld G, Menon D, Harrison D, Rowan K, Maharaj R. Early and late withdrawal of life-sustaining treatment after out-of-hospital cardiac arrest in the United Kingdom: Institutional variation and association with hospital mortality. Resuscitation 2023; 193:109956. [PMID: 37661013 DOI: 10.1016/j.resuscitation.2023.109956] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
AIM Frequency and timing of Withdrawal of Life-Sustaining Treatment (WLST) after Out-of-Hospital Cardiac Arrest (OHCA) vary across Intensive Care Units (ICUs) in the United Kingdom (UK) and may be a marker of lower healthcare quality if instituted too frequently or too early. We aimed to describe WLST practice, quantify its variability across UK ICUs, and assess the effect of institutional deviation from average practice on patients' risk-adjusted hospital mortality. METHODS We conducted a retrospective multi-centre cohort study including all adult patients admitted after OHCA to UK ICUs between 2010 and 2017. We identified patient and ICU characteristics associated with early (within 72 h) and late (>72 h) WLST and quantified the between-ICU variation. We used the ICU-level observed-to-expected (O/E) ratios of early and late-WLST frequency as separate metrics of institutional deviation from average practice and calculated their association with patients' hospital mortality. RESULTS We included 28,438 patients across 204 ICUs. 10,775 (37.9%) had WLST and 6397 (59.4%) of them had early-WLST. Both WLST types were strongly associated with patient-level demographics and pre-existing conditions but weakly with ICU-level characteristics. After adjustment, we found unexplained between-ICU variation for both early-WLST (Median Odds Ratio 1.59, 95%CrI 1.49-1.71) and late-WLST (MOR 1.39, 95%CrI 1.31-1.50). Importantly, patients' hospital mortality was higher in ICUs with higher O/E ratio of early-WLST (OR 1.29, 95%CI 1.21-1.38, p < 0.001) or late-WLST (OR 1.39, 95%CI 1.31-1.48, p < 0.001). CONCLUSIONS Significant variability exists between UK ICUs in WLST frequency and timing. This matters because unexplained higher-than-expected WLST frequency is associated with higher hospital mortality independently of timing, potentially signalling prognostic pessimism and lower healthcare quality.
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Affiliation(s)
- Savvas Vlachos
- King's College London, School of Cardio-Vascular Medicine and Sciences, Strand, London WC2R 2LS, UK.
| | - Gordon Rubenfeld
- University of Toronto, Interdepartmental Division of Critical Care, ON M5S Toronto, Ontario, Canada
| | - David Menon
- University of Cambridge, Department of Medicine, CB2 1TN Cambridge, UK
| | - David Harrison
- Intensive Care National Audit & Research Centre, Department of Statistics, WC1V 6AZ London, UK
| | - Kathryn Rowan
- National Institute for Health and Care Research, W1T 7HA London, UK
| | - Ritesh Maharaj
- London School of Economics and Political Science, Department of Health Policy and Health Economics, WC2A 2AE London, UK
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3
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Birch J. Medical AI, inductive risk and the communication of uncertainty: the case of disorders of consciousness. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109424. [PMID: 37979975 DOI: 10.1136/jme-2023-109424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/28/2023] [Indexed: 11/20/2023]
Abstract
Some patients, following brain injury, do not outwardly respond to spoken commands, yet show patterns of brain activity that indicate responsiveness. This is 'cognitive-motor dissociation' (CMD). Recent research has used machine learning to diagnose CMD from electroencephalogram recordings. These techniques have high false discovery rates, raising a serious problem of inductive risk. It is no solution to communicate the false discovery rates directly to the patient's family, because this information may confuse, alarm and mislead. Instead, we need a procedure for generating case-specific probabilistic assessments that can be communicated clearly. This article constructs a possible procedure with three key elements: (1) A shift from categorical 'responding or not' assessments to degrees of evidence; (2) The use of patient-centred priors to convert degrees of evidence to probabilistic assessments; and (3) The use of standardised probability yardsticks to convey those assessments as clearly as possible.
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Affiliation(s)
- Jonathan Birch
- Centre for Philosophy of Natural and Social Science, LSE, London, UK
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4
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Miranda SP, Morris RS, Rabas M, Creutzfeldt CJ, Cooper Z. Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations. Neurocrit Care 2023; 39:284-293. [PMID: 37349599 DOI: 10.1007/s12028-023-01764-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 05/11/2023] [Indexed: 06/24/2023]
Abstract
Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 15 South Tower, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Rachel S Morris
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mackenzie Rabas
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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5
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Lazaridis C. Informed Consent and Decision-Making for Patients with Acquired Cognitive Impairment. Neurol Clin 2023; 41:433-442. [PMID: 37407097 DOI: 10.1016/j.ncl.2023.03.001] [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: 07/07/2023]
Abstract
Informed consent (IC) is an ethical and legal requirement grounded in the principle of autonomy. Cognitive impairment may often interfere with decision-making capacity necessitating alternative models of ethically sound deliberation. In cases where the patient lacks decision-making capacity, one must determine the appropriate decision-maker and the criteria used in making a medical decision appropriate for the patient. In this article, I critically discuss the traditional approaches of IC, advance directives, substituted judgment, and best interests. A further suggestion is that thinking about sufficient reasons for or against a course of action is a conceptual enrichment in addition to the concepts of interests and well-being. Finally, I propose another model of collective consensus-seeking decision-making.
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Affiliation(s)
- Christos Lazaridis
- Department of Neurology, University of Chicago, IL, USA; Department of Neurosurgery, University of Chicago, IL, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, IL.
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6
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van Beinum A. Challenging the logic of lifesaving in the intensive care unit. Soc Sci Med 2023; 321:115769. [PMID: 36809699 DOI: 10.1016/j.socscimed.2023.115769] [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: 11/14/2022] [Revised: 01/17/2023] [Accepted: 02/10/2023] [Indexed: 02/19/2023]
Abstract
Intensive care units are considered life-saving medical services and a vital component of healthcare systems. These specialized hospital wards contain the life support machines and technical expertise to sustain seriously ill and injured bodies. However, as the COVID-19 pandemic has demonstrated, intensive care is an expensive, finite resource which is not necessarily available to all citizens, and which may be unjustly rationed. As a result, the intensive care unit may contribute more towards biopolitical narratives of investment in lifesaving than measurable improvements in population health. Drawing from ethnographic fieldwork and a decade of involvement in clinical research, this paper examines everyday activities of lifesaving in the intensive care unit and interrogates epistemological assumptions upon which they are organized. A closer look at how healthcare professionals, medical devices, patients, and families accept, refuse, and modify imposed boundaries of bodily finitude reveals how activities of lifesaving often lead to uncertainty and may even impose harm when they deny possibilities for desired death. Refiguring death as a personal ethical threshold, rather than inherently tragic ending, challenges the power of the logic of lifesaving and instead insists on greater attention towards improving conditions for living.
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Affiliation(s)
- Amanda van Beinum
- Department of Sociology and Anthropology, Carleton University, Ottawa, Ontario, Canada; Centre for Health Law, Policy and Ethics, University of Ottawa, Ottawa, Ontario, Canada.
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7
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Spataro R, La Bella V. The role of ethical attitudes on mortality of patients with disorders of consciousness. Eur J Neurol 2022; 29:3473-3474. [DOI: 10.1111/ene.15510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 06/18/2022] [Accepted: 07/06/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Rossella Spataro
- IRCCS Centro Neurolesi Bonino Pulejo Palermo Italy
- ALS Clinical Research Center University of Palermo Palermo Italy
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8
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Steinberg A, Hudoba C, Hwang DY, Kramer NM, Mehta AK, Muehlschlegel S, Jones CA, Besbris J. Top Ten Tips Palliative Care Clinicians Should Know About Disorders of Consciousness: A Focus on Traumatic and Anoxic Brain Injury. J Palliat Med 2022; 25:1571-1578. [PMID: 35639356 DOI: 10.1089/jpm.2022.0202] [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: 11/13/2022] Open
Abstract
Palliative care (PC) teams commonly encounter patients with disorders of consciousness (DOC) following anoxic or traumatic brain injury (TBI). Primary teams may consult PC to help surrogates in making treatment choices for these patients. PC clinicians must understand the complexity of predicting neurologic outcomes, address clinical nihilism, and appropriately guide surrogates in making decisions that are concordant with patients' goals. The purpose of this article was to provide PC providers with a better understanding of caring for patients with DOC, specifically following anoxic or TBI. Many of the tips acknowledge the uncertainty of DOC and provide strategies to help tackle this dilemma.
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Affiliation(s)
- Alexis Steinberg
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christine Hudoba
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Neha M Kramer
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA.,Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Anesthesia/Critical Care, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA.,Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University Hospital, Durham, North Carolina, USA
| | - Jessica Besbris
- Department of Internal Medicine and Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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9
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Goss AL, Creutzfeldt CJ. Prognostication, Ethical Issues, and Palliative Care in Disorders of Consciousness. Neurol Clin 2022; 40:59-75. [PMID: 34798975 PMCID: PMC8672806 DOI: 10.1016/j.ncl.2021.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Research advances in recent years have shown that some individuals with vegetative state or minimally conscious state can emerge to higher states of consciousness even years after injury. A minority of behaviorally unresponsive patients with vegetative state have also been shown to follow commands, or even communicate, using neuroimaging or electrophysiological techniques. These advances raise ethical questions that have important implications for clinical care. In this article, the authors argue that adopting a neuropalliative care approach can help clinicians provide ethical, compassionate care to these patients and their caregivers.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143, USA.
| | - Claire J Creutzfeldt
- Department of Neurology, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA
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10
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Perrigault PF, Greco F. Ethical issues in neurocritical care. Rev Neurol (Paris) 2022; 178:57-63. [PMID: 34998525 DOI: 10.1016/j.neurol.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/14/2021] [Indexed: 11/16/2022]
Abstract
Medicine has always tried to push the limits of life. The technological and scientific progress made in resuscitation now makes it possible to keep patients who are more and more severely affected alive, by compensating for organ failure. The management of the brain-damaged patient poses specific ethical problems in intensive care. Most in-hospital deaths of patients with severe acute brain injury occur after a decision to withhold or withdraw life-sustaining treatments. In these patients, a problem is the difficulty in predicting outcome at an early stage. Our reasoning in the management of brain-damaged patients in the intensive care is based on the four main principles of medical ethics: autonomy, beneficence, non-maleficence and distributive justice. In the case of a patient suffering from cerebral palsy, consent is most often impossible to obtain. The respect of this autonomy, can be done by means of advance directives or testimonies of the support person and family. Non-malficence in the resuscitated brain-damaged patient consists of avoiding unreasonable obstinacy. Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient's medical condition. A determination of medical futility can be made either in the presence of a vanishingly small probability of physiological effect or an exceedingly poor quality of outcome. However, a distinction must be made between loss of autonomy and unreasonable obstinacy. French law specifies that the physician must use collegial procedure in situations that may concern a brain-damaged patient. In terms of ethical decision-making, the concept of "window of opportunity" is often mentioned. The temporal approach taken is the guarantee of an absence of "a rush". It is important for the health care team and the family to share the progress of the treatment so that everyone understands the evolution of what is happening and the risks taken for the patient. The resuscitation of the brain-damaged patient poses specific and difficult ethical problems. One of the challenges is to be able to assume our decisions, understand them and defend them. It is also to maintain the coherence of our actions and the cohesion of our teams necessary for the good care of our patients.
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Affiliation(s)
- P F Perrigault
- Department of Anesthesiology and Intensive Care Medicine, Gui de Chauliac University Hospital, Montpellier University, School of Medicine, avenue Augustin-Fliche, 34295 Montpellier, France.
| | - F Greco
- Department of Anesthesiology and Intensive Care Medicine, Gui de Chauliac University Hospital, Montpellier University, School of Medicine, avenue Augustin-Fliche, 34295 Montpellier, France
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11
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Zulato E, Montali L, Bauer MW. Understanding a liminal condition: Comparing emerging representations of the “vegetative state”. EUROPEAN JOURNAL OF SOCIAL PSYCHOLOGY 2021. [DOI: 10.1002/ejsp.2794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Edoardo Zulato
- Department of Psychology University of Milano‐Bicocca Milano Italy
| | - Lorenzo Montali
- Department of Psychology University of Milano‐Bicocca Milano Italy
| | - Martin W. Bauer
- Department of Psychological and Behavioural Science London School of Economics and Political Science (LSE) London UK
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12
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Graham M. Residual Cognitive Capacities in Patients With Cognitive Motor Dissociation, and Their Implications for Well-Being. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2021; 46:729-757. [PMID: 34655220 PMCID: PMC8643594 DOI: 10.1093/jmp/jhab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Patients with severe disorders of consciousness are thought to be unaware of themselves or their environment. However, research suggests that a minority of patients diagnosed as having a disorder of consciousness remain aware. These patients, designated as having “cognitive motor dissociation” (CMD), can demonstrate awareness by imagining specific tasks, which generates brain activity detectable via functional neuroimaging. The discovery of consciousness in these patients raises difficult questions about their well-being, and it has been argued that it would be better for these patients if they were allowed to die. Conversely, I argue that CMD patients may have a much higher level of well-being than is generally acknowledged. It is far from clear that their lives are not worth living, because there are still significant gaps in our understanding of how these patients experience the world. I attempt to fill these gaps, by analyzing the neuroscientific research that has taken place with these patients to date. Having generated as comprehensive a picture as possible of the capacities of CMD patients, I examine this picture through the lens of traditional philosophical theories of well-being. I conclude that the presumption that CMD patients do not have lives worth living is not adequately supported.
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13
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Lou W, Granstein JH, Wabl R, Singh A, Wahlster S, Creutzfeldt CJ. Taking a Chance to Recover: Families Look Back on the Decision to Pursue Tracheostomy After Severe Acute Brain Injury. Neurocrit Care 2021; 36:504-510. [PMID: 34476722 PMCID: PMC8412876 DOI: 10.1007/s12028-021-01335-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022]
Abstract
Background Tracheostomy represents one important and value-laden treatment decision after severe acute brain injury (SABI). Whether to pursue this life-sustaining treatment typically hinges on intense conversations between family and clinicians. The aim of this study was, among a cohort of patient who had undergone tracheostomy after SABI, to explore the long-term reflections of patients and their families as they look back on this decision. Methods For this qualitative study, we reviewed the electronic medical records of patients with SABI who underwent tracheostomy. We included all patients who were admitted to our 30-bed neuro-intensive care unit with SABI and underwent tracheostomy between November 2017 and October 2019. Using purposive sampling, we invited survivors and family members to participate in telephone interviews greater than 3 months after SABI until thematic saturation was reached. Interviews were audiotaped, transcribed, and analyzed by using thematic analysis. Results Overall, 38 patients with SABI in the neuro-intensive care unit underwent tracheostomy. The mean age of patients was 49 (range 18–81), with 19 of 38 patients diagnosed with traumatic brain injury and 19 of 38 with stroke. We interviewed 20 family members of 18 of 38 patients at a mean of 16 (SD 9) months after hospitalization. The mean patient age among those with an interview was 50 (range 18–76); the mean modified Rankin Scale score (mRS) was 4.7 (SD 0.8) at hospital discharge. At the time of the interview, ten patients lived at home and two in a skilled nursing facility and had a mean mRS of 2.6 (SD 0.9), and six had died. As families reflected on the decision to proceed with a tracheostomy, two themes emerged. First, families did not remember tracheostomy as a choice because the uncertain chance of recovery rendered the certain alternative of death unacceptable or because they valued survival above all and therefore could not perceive an alternative to life-sustaining treatment. Second, families identified a fundamental need to receive supportive, consistent communication centering around compassion, clarity, and hope. When this need was met, families were able to reflect on the tracheostomy decision with peace, regardless of their loved one’s eventual outcome. Conclusions After SABI, prognostic uncertainty almost transcends the concept of choice. Families who proceeded with a tracheostomy saw it as the only option at the time. High-quality communication may mitigate the stress surrounding this high-stakes decision. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01335-9.
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Affiliation(s)
- William Lou
- Harborview Medical Center, Department of Neurology, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Justin H Granstein
- Harborview Medical Center, Department of Neurology, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Rafael Wabl
- Harborview Medical Center, Department of Neurology, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Amita Singh
- Harborview Medical Center, Department of Neurology, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Sarah Wahlster
- Harborview Medical Center, Department of Neurology, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Department of Neurology, University of Washington, 325 Ninth Avenue, Box 359775, Seattle, WA, 98104, USA.
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14
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Young MJ, Bodien YG, Giacino JT, Fins JJ, Truog RD, Hochberg LR, Edlow BL. The neuroethics of disorders of consciousness: a brief history of evolving ideas. Brain 2021; 144:3291-3310. [PMID: 34347037 DOI: 10.1093/brain/awab290] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/11/2021] [Accepted: 07/10/2021] [Indexed: 11/12/2022] Open
Abstract
Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant, and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically-responsible care in this domain are especially timely given recent surges in critically ill patients with unusually prolonged disorders of consciousness associated with coronavirus disease 2019 (COVID-19) around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness, and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and up until the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery, and ethical issues that arise within the context of caring for persons with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.
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Affiliation(s)
- Michael J Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA 02138, USA
| | - Yelena G Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Spaulding Rehabilitation Hospital, Charlestown, MA 02129, USA
| | | | - Joseph J Fins
- Division of Medical Ethics, Weill Cornell Medical College, New York, NY 10021, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, MA 02115, USA
| | - Leigh R Hochberg
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,School of Engineering and Carney Institute for Brain Science, Brown University, Providence, RI 02906, USA.,VA RR&D Center for Neurorestoration and Neurotechnology, Department of Veterans Affairs Medical Center, Providence, RI 02908, USA
| | - Brian L Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114,USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA 02129, USA
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15
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Peterson A, Webster F, Gonzalez-Lara LE, Munce S, Owen AM, Weijer C. Caregiver reactions to neuroimaging evidence of covert consciousness in patients with severe brain injury: a qualitative interview study. BMC Med Ethics 2021; 22:105. [PMID: 34320966 PMCID: PMC8320067 DOI: 10.1186/s12910-021-00674-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Severe brain injury is a leading cause of death and disability. Diagnosis and prognostication are difficult, and errors occur often. Novel neuroimaging methods can improve diagnostic and prognostic accuracy, especially in patients with prolonged disorders of consciousness (PDoC). Yet it is currently unknown how family caregivers understand this information, raising ethical concerns that disclosure of neuroimaging results could result in therapeutic misconception or false hope. Methods To examine these ethical concerns, we conducted semi-structured interviews with caregivers of patients with PDoC who were enrolled in a concurrent neuroimaging research program designed to detect covert consciousness following severe brain injury. Caregivers held surrogate decision-making status for a patient. Interviews were conducted at two time points for each caregiver. The first interview occurred before the disclosure of neuroimaging results. The second occurred after disclosure. Descriptive analysis was applied to the data of four interview topics: (1) expectations for neuroimaging; (2) reactions to evidence of preserved cognition; (3) reactions to null results; and (4) understanding of the results and study. Results Twelve caregivers participated in the study; two caregivers shared surrogate decision-making status for one patient with PDoC. Twenty-one interviews were completed; one caregiver declined to participate in the post-disclosure interview. Three patients with PDoC associated with the study displayed evidence of covert consciousness. Overall, caregivers understood the neuroimaging research and results. Caregivers who received results of covert consciousness were generally pleased. However, there was some variation in expectations and reactions to these data and null results. Conclusion This study, for the first time, reveals caregiver expectations for and reactions to neuroimaging evidence of covert consciousness in patients with PDoC. Caregivers understood the neuroimaging research and results, casting doubt on speculative ethical concerns regarding therapeutic misconception and false hope. However, disclosure of neuroimaging result could be improved. Pre-disclosure consultations might assist professionals in shaping caregiver expectations. Standardization of disclosure might also improve comprehension of the results. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00674-8.
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Affiliation(s)
- Andrew Peterson
- Institute for Philosophy and Public Policy, George Mason University, Fairfax, USA.
| | - Fiona Webster
- Arthur Labatt Family School of Nursing, Western University, London, Canada
| | | | - Sarah Munce
- Toronto Rehabilitation Institute-University Health Network, Toronoto, Canada
| | - Adrian M Owen
- Brain and Mind Institute, Western University, London, Canada
| | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Canada
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16
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Robertsen A, Helseth E, Førde R. Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see. BMC Med Ethics 2021; 22:43. [PMID: 33849500 PMCID: PMC8043091 DOI: 10.1186/s12910-021-00612-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient's best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians' strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. METHODS Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians' strategies related to treatment-limiting decision-making. RESULTS A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital's strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team-family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The "wait-and-see" physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. CONCLUSIONS Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.
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Affiliation(s)
- Annette Robertsen
- Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Reidun Førde
- Centre of Medical Ethics, University of Oslo, Oslo, Norway
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18
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 417] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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19
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 338] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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20
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Sharma-Virk M, van Erp WS, Lavrijsen JCM, Koopmans RTCM. Intensive neurorehabilitation for patients with prolonged disorders of consciousness: protocol of a mixed-methods study focusing on outcomes, ethics and impact. BMC Neurol 2021; 21:133. [PMID: 33752631 PMCID: PMC7983203 DOI: 10.1186/s12883-021-02158-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged disorders of consciousness (PDOC) are amongst the severest sequelae of acquired brain injury. Evidence regarding epidemiology and rehabilitation outcomes is scarce. These knowledge gaps and psychological distress in families of PDOC patients may complicate clinical decision-making. The complex PDOC care and associated moral dilemmas result in high workload in healthcare professionals. Since 2019, all PDOC patients in the Netherlands have access to intensive neurorehabilitation up to 2 years post-injury provided by one rehabilitation center and four specialized nursing homes. Systematic monitoring of quantitative rehabilitation data within this novel chain of care is done in a study called DOCTOR. The optimization of tailored PDOC care, however, demands a better understanding of the impact of PDOC on patients, their families and healthcare professionals and their views on rehabilitation outcomes, end-of-life decisions and quality of dying. The True Outcomes of PDOC (TOPDOC) study aims to gain insight in the qualitative outcomes of PDOC rehabilitation and impact of PDOC on patients, their families and healthcare professionals. METHODS Nationwide multicenter prospective cohort study in the settings of early and prolonged intensive neurorehabilitation with a two-year follow-up period, involving three study populations: PDOC patients > 16 years, patients' family members and healthcare professionals involved in PDOC care. Families' and healthcare professionals' views on quality of rehabilitation outcomes, end-of-life decisions and dying will be qualitatively assessed using comprehensive questionnaires and in-depth interviews. Ethical dilemmas will be explored by studying moral deliberations. The impact of providing care to PDOC patients on healthcare professionals will be studied in focus groups. DISCUSSION To our knowledge, this is the first nationwide study exploring quality of outcomes, end-of-life decisions and dying in PDOC patients and the impact of PDOC in a novel chain of care spanning the first 24 months post-injury in specialized rehabilitation and nursing home settings. Newly acquired knowledge in TOPDOC concerning quality of outcomes in PDOC rehabilitation, ethical aspects and the impact of PDOC will enrich quantitative epidemiological knowledge and outcomes arising from DOCTOR. Together, these projects will contribute to the optimization of centralized PDOC care providing support to PDOC patients, families and healthcare professionals.
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Affiliation(s)
- Manju Sharma-Virk
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.
- PZC Dordrecht, Dordrecht, The Netherlands.
| | - Willemijn S van Erp
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- Accolade Zorg, Bosch en Duin, The Netherlands
- Libra Revalidatie & Audiologie, Tilburg, The Netherlands
| | - Jan C M Lavrijsen
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Raymond T C M Koopmans
- Radboud Institute for Health Sciences; Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
- Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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21
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Sokoliuk R, Degano G, Banellis L, Melloni L, Hayton T, Sturman S, Veenith T, Yakoub KM, Belli A, Noppeney U, Cruse D. Covert Speech Comprehension Predicts Recovery From Acute Unresponsive States. Ann Neurol 2021; 89:646-656. [PMID: 33368496 DOI: 10.1002/ana.25995] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/07/2020] [Accepted: 12/07/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients with traumatic brain injury who fail to obey commands after sedation-washout pose one of the most significant challenges for neurological prognostication. Reducing prognostic uncertainty will lead to more appropriate care decisions and ensure provision of limited rehabilitation resources to those most likely to benefit. Bedside markers of covert residual cognition, including speech comprehension, may reduce this uncertainty. METHODS We recruited 28 patients with acute traumatic brain injury who were 2 to 7 days sedation-free and failed to obey commands. Patients heard streams of isochronous monosyllabic words that built meaningful phrases and sentences while their brain activity via electroencephalography (EEG) was recorded. In healthy individuals, EEG activity only synchronizes with the rhythm of phrases and sentences when listeners consciously comprehend the speech. This approach therefore provides a measure of residual speech comprehension in unresponsive patients. RESULTS Seventeen and 16 patients were available for assessment with the Glasgow Outcome Scale Extended (GOSE) at 3 months and 6 months, respectively. Outcome significantly correlated with the strength of patients' acute cortical tracking of phrases and sentences (r > 0.6, p < 0.007), quantified by inter-trial phase coherence. Linear regressions revealed that the strength of this comprehension response (beta = 0.603, p = 0.006) significantly improved the accuracy of prognoses relative to clinical characteristics alone (eg, Glasgow Coma Scale [GCS], computed tomography [CT] grade). INTERPRETATION A simple, passive, auditory EEG protocol improves prognostic accuracy in a critical period of clinical decision making. Unlike other approaches to probing covert cognition for prognostication, this approach is entirely passive and therefore less susceptible to cognitive deficits, increasing the number of patients who may benefit. ANN NEUROL 2021;89:646-656.
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Affiliation(s)
- Rodika Sokoliuk
- School of Psychology, University of Birmingham, Birmingham, UK.,Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Giulio Degano
- School of Psychology, University of Birmingham, Birmingham, UK.,Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Leah Banellis
- School of Psychology, University of Birmingham, Birmingham, UK.,Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Lucia Melloni
- Department of Neuroscience, Max Planck Institute for Empirical Aesthetics, Frankfurt, Germany.,Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Tom Hayton
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK
| | - Steve Sturman
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK
| | - Tonny Veenith
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Kamal M Yakoub
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK
| | - Antonio Belli
- Centre for Human Brain Health, University of Birmingham, Birmingham, UK.,Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Birmingham, UK
| | - Uta Noppeney
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Damian Cruse
- School of Psychology, University of Birmingham, Birmingham, UK.,Centre for Human Brain Health, University of Birmingham, Birmingham, UK
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22
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Gonzalez-Lara LE, Munce S, Christian J, Owen AM, Weijer C, Webster F. The multiplicity of caregiving burden: a qualitative analysis of families with prolonged disorders of consciousness. Brain Inj 2021; 35:200-208. [PMID: 33385307 DOI: 10.1080/02699052.2020.1865565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: To understand the multiple and sometimes conflicting roles substitute decision makers (SDMs) of individuals in a vegetative state (VS), minimally conscious state (MCS), or with locked-in syndrome (LIS) perform while caring for a loved one and the competing priorities derived from these roles.Methods: We conducted semi-structured qualitative interviews using a constructive-grounded theory design. Twelve SDMs, who were also family members for 11 patients, were interviewed at two time points (except one) for a total of 21 in-depth interviews.Results: Participants described that caregiving is often the central role which they identify as their top priority and around which they coordinate and to some extent subordinate their other roles. In addition to caregiving, they participated in a wide variety of roles, which were sometimes in conflict, as they became caregivers for a loved one with chronic and complex needs. SDMs described the caregiver role as complex and intense that lead to physical, emotional, social, and economic burdens.Conclusion: SDMs report high levels of burdens in caring for a person with a prolonged disorder of consciousness. Lack of health system support that recognized the broader context of SDMs lives, including their multiple competing priorities, was a major contributing factor.
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Affiliation(s)
| | - Sarah Munce
- Toronto Rehabilitation Institute - University Health Network
| | | | - Adrian M Owen
- The Brain and Mind Institute, Western University, London, Ontario, Canada
| | | | - Fiona Webster
- Labatt Family School of Nursing, Western University, London, Ontario, Canada
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23
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Goudarzi F, Abedi H, Zarea K. Information Seeking Experiences of Family Caregivers of Patients with Persistent Vegetative State: A Qualitative Study. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2020; 25:393-400. [PMID: 33344210 PMCID: PMC7737835 DOI: 10.4103/ijnmr.ijnmr_187_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/02/2019] [Accepted: 06/27/2020] [Indexed: 02/03/2023]
Abstract
Background: Providing care for patients in Persistent Vegetative State (PVS) by family caregivers without enough training and knowledge may be problematic both for the patients and for the caregivers. Therefore, the present study tries to explain the experiences of family caregivers of patients with PVS of seeking information needed to provide adequate care. Materials and Methods: Twenty two participants, including 17 family caregivers and 5 professional caregivers were enrolled by purposive sampling into this qualitative content analysis study, carried out between 2013 and 2015. Unstructured interviews and field notes were used to gather the data. Data collection was stopped when data saturation was achieved. Data analysis was performed by content analysis based on Graneheim and Lundman's approach. Results: As a result of the analysis of the collected data a main theme emerged labeled as “Seeking constructive education” with three categories including “Neglected requisite education,” “Greedy search for useful education” and “Dynamic independence in care.” Conclusions: In this study, information seeking by family caregivers of patients with PVS was constructive. Family caregivers insistently sought needed information from various sources. Ultimately, they found these insistent efforts beneficial and fruitful, because their efforts made them independent in providing care for their patients.
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Affiliation(s)
- Fateme Goudarzi
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Heidarali Abedi
- Faculty of Nursing and Midwifery, Isfahan (Khorasgan) Branch, Islamic Azad University , Isfahan, Iran
| | - Kourosh Zarea
- Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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24
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From Awareness to Prognosis: Ethical Implications of Uncovering Hidden Awareness in Behaviorally Nonresponsive Patients. Camb Q Healthc Ethics 2020; 28:616-631. [PMID: 31526429 DOI: 10.1017/s0963180119000550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking-including decisions about life-sustaining treatment-even though the prognostic value of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: (1) Surrogate decisionmakers may misinterpret results; (2) Results may create false hope about the prospects of recovery; (3) There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care.
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25
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Chartrand L. Dying on television versus dying in intensive care units following withdrawal of life support: how normative frames may traumatise the bereaved. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:1155-1170. [PMID: 32304256 DOI: 10.1111/1467-9566.13089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
While treatment is often withdrawn from patients in intensive care units (ICUs), few people outside the healthcare profession have witnessed a death under such circumstances. Family members who have made the decision to withdraw treatment may have expectations about the dying process, what constitutes a good death and how they should behave in an ICU based on popular prime-time television series. An inductive comparative thematic coding strategy is therefore used to examine how death following treatment withdrawal as depicted in a US medical drama (Grey's Anatomy) differs from realities observed for 6 months fieldwork at an ICU in Canada. Three common frames (privacy, emotional control and memorialising) help patients' intimates normalise the unfamiliar experience and guide their behaviour during the event. However, discrepancies between media representations and experiences in the ICU, especially around the frames of timing of death and the physicality of the unbounded body (incontinence and agonal breathing), can traumatise them. The bereaved may be left viewing ventilator withdrawal and dying as chaotic processes and believing their loved one suffered through a bad death. Understanding these normative and discrepant frames should help healthcare professionals better prepare the public to witness death.
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26
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van Erp WS, Lavrijsen JCM, Vos PE, Laureys S, Koopmans RTCM. Unresponsive wakefulness syndrome: Outcomes from a vicious circle. Ann Neurol 2020; 87:12-18. [PMID: 31675139 PMCID: PMC6972677 DOI: 10.1002/ana.25624] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/13/2019] [Accepted: 10/14/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Willemijn S. van Erp
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenthe Netherlands
- Coma Science Group, GIGA Consciousness, University of LiègeLiègeBelgium
| | - Jan C. M. Lavrijsen
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health SciencesNijmegenthe Netherlands
| | - Pieter E. Vos
- Department of NeurologySlingeland HospitalDoetinchemthe Netherlands
| | - Steven Laureys
- Coma Science Group, GIGA ConsciousnessUniversity of LiègeLiègeBelgium
| | - Raymond T. C. M. Koopmans
- Department of Primary and Community CareRadboud University Medical Center, Radboud Institute for Health Sciences, and Joachim en Anna Center for Specialized Geriatric CareNijmegenthe Netherlands
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Huxtable R. Dying too soon or living too long? Withdrawing treatment from patients with prolonged disorders of consciousness after Re Y. BMC Med Ethics 2019; 20:91. [PMID: 31884958 PMCID: PMC6936052 DOI: 10.1186/s12910-019-0424-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/07/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached. MAIN BODY There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default. CONCLUSION Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.
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Affiliation(s)
- Richard Huxtable
- Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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Edlow BL, Fins JJ. Assessment of Covert Consciousness in the Intensive Care Unit: Clinical and Ethical Considerations. J Head Trauma Rehabil 2019; 33:424-434. [PMID: 30395042 PMCID: PMC6317885 DOI: 10.1097/htr.0000000000000448] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To propose a practical ethical framework for how task-based functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) may be used in the intensive care unit (ICU) to identify covert consciousness in patients with acute severe traumatic brain injury (TBI). METHODS We present 2 clinical scenarios in which investigational task-based fMRI and EEG were performed in critically ill patients with acute severe TBI who appeared unconscious on the bedside behavioral assessment. From these cases, we consider the clinical and ethical challenges that emerge and suggest how to reconcile them. We also provide recommendations regarding communication with families about ICU patients with covert consciousness. RESULTS Covert consciousness was detected acutely in a patient who died in the ICU due to withdrawal of life-sustaining therapy, whereas covert consciousness was not detected in a patient who subsequently recovered consciousness, communication, and functional independence. These cases raise ethical challenges about how assessment of covert consciousness in the ICU might inform treatment decisions, prognostication, and perceptions about the benefits and burdens of ongoing care. CONCLUSIONS Given that covert consciousness can be detected acutely in the ICU, we recommend that clinicians reconsider evaluative norms for ICU patients. As our clinical appreciation of covert consciousness evolves and its ethical import unfolds, we urge prognostic humility and transparency when clinicians communicate with families in the ICU about goals of care.
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Affiliation(s)
- Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown (Dr Edlow); and Division of Medical Ethics and Consortium for the Advanced Study of Brain Injury, Weill Cornell Medical College, New York, and The Rockefeller University, New York, and the Solomon Center for Health Law and Policy, Yale Law School, New Haven, Connecticut (Dr Fins)
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Ursin LØ. Withholding and Withdrawing Life-Sustaining Treatment: Ethically Equivalent? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:10-20. [PMID: 30896350 DOI: 10.1080/15265161.2018.1561961] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Withholding and withdrawing treatment are widely regarded as ethically equivalent in medical guidelines and ethics literature. Health care personnel, however, widely perceive moral differences between withholding and withdrawing. The proponents of equivalence argue that any perceived difference can be explained in terms of cognitive biases and flawed reasoning. Thus, policymakers should clear away any resistance to accept the equivalence stance by moral education. To embark on such a campaign of changing attitudes, we need to be convinced that the ethical analysis is correct. Is it? In this article, I take a closer look at the moral relation between withholding and withdrawing. My conclusion is that withholding and withdrawing are not in general ethically equivalent. Thus, medical guidelines should be rewritten, and rather than being "educated" away from their sound judgments, medical professionals and patients should have nuanced medico-ethical discussions regarding withholding and withdrawing treatment.
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Withdrawal of Life-Sustaining Treatments in Perceived Devastating Brain Injury: The Key Role of Uncertainty. Neurocrit Care 2019; 30:33-41. [PMID: 30143963 DOI: 10.1007/s12028-018-0595-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Withdrawal of life-sustaining treatment (WOLST) is the leading proximate cause of death in patients with perceived devastating brain injury (PDBI). There are reasons to believe that a potentially significant proportion of WOLST decisions, in this setting, are premature and guided by a number of assumptions that falsely confer a sense of certainty. METHOD This manuscript proposes that these assumptions face serious challenges, and that we should replace unwarranted certainty with an appreciation for the great degree of multi-dimensional uncertainty involved. The article proceeds by offering a taxonomy of uncertainty in PDBI and explores the key role that uncertainty as a cognitive state, may play into how WOLST decisions are reached. CONCLUSION In order to properly share decision-making with families and surrogates of patients with PDBI, we will have to acknowledge, understand, and be able to communicate the great degree of uncertainty involved.
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Kitzinger C, Wood M. Story completion, methodological innovation, epistemology and social change: Matthew Wood in conversation with Celia Kitzinger. QUALITATIVE RESEARCH IN PSYCHOLOGY 2018. [DOI: 10.1080/14780887.2018.1536383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Boyer F, Audibert G, Baumann C, Colnat-Coulbois S, Pinelli C, Claudot F, Baumann A. [Decision-making regarding treatment limitation after severe traumatic brain injury: A survey of French neurosurgeons]. Neurochirurgie 2018; 64:401-409. [PMID: 30424955 DOI: 10.1016/j.neuchi.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 06/11/2018] [Accepted: 07/27/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND/INTRODUCTION In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury. AIM OF THE STUDY The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons. METHODS A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016. RESULTS Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age. CONCLUSIONS Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making.
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Affiliation(s)
- F Boyer
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France
| | - G Audibert
- Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France; Service d'anesthésie réanimation chirurgicale, CHRU de Nancy, hôpital central, 54000 Nancy, France
| | - C Baumann
- UMDS, CHRU de Nancy-hôpitaux de Brabois, plateforme d'aide à la recherche clinique (PARC), 54505 Vandœuvre-lès-Nancy, France
| | - S Colnat-Coulbois
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France
| | - C Pinelli
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France
| | - F Claudot
- UMDS, CHRU de Nancy-hôpitaux de Brabois, plateforme d'aide à la recherche clinique (PARC), 54505 Vandœuvre-lès-Nancy, France; EA4360 APEMAC, université de Lorraine, 54000 Nancy, France
| | - A Baumann
- EA4360 APEMAC, université de Lorraine, 54000 Nancy, France; Département d'anesthésie réanimation, hôpitaux universitaires Paris-Sud, hôpital Bicêtre, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.
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Goudarzi F, Abedi H, Zarea K, Ahmadi F, Hosseinigolafshani SZ. The Resilient Care of Patients with Vegetative State at Home: a Grounded Theory. J Caring Sci 2018; 7:163-175. [PMID: 30283762 PMCID: PMC6163151 DOI: 10.15171/jcs.2018.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 04/18/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction: The care of patients in vegetative state at
home is difficult because they need continuous medical interventions and extensive care.
The present study aims to explain the process of home care of patients in vegetative state
at home. Methods: This study was a qualitative research with a
grounded theory approach. The participants were 22 people (included 17 family caregivers
and 5 professional caregivers) who were enrolled in a purposive sampling. Data was
gathered through unstructured interviews, observations and field notes. Data collection
was continued to saturation. Data analysis was performed through the Strauss and Corbin
1998 approach. The MAXQDA10 software was used to facilitate data analysis. Results: The data analysis led to emerge four main concepts
included "erosive care", "erosive expenditures", "seeking solver education" and "lasting
hope" as the axes of the study. Participants' experiences showed that the main concern of
family caregivers of vegetative patients was "playing an inevitable role in care", in
which they did not hesitate to make any effort, and they tolerated all the problems and
issues. Therefore, "resilient care" was extracted as the underlying idea of this
study. Conclusion: The process of resilient care of vegetative
patients at home showed planning by policy makers in health system is very important and
underscored the necessity for supporting families and family caregivers of these patients.
So some changes in the health system for this goal might include considering home care and
supporting them in various aspects, especially information, financial and emotional
dimensions.
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Affiliation(s)
- Fateme Goudarzi
- Social Determinants of Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran.,Department of Nursing, Nursing and Midwifery Faculty, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Heidarali Abedi
- Department of Nursing, Nursing and Midwifery Faculty, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran
| | - Kourosh Zarea
- Nursing Care Research Center in Chronic Diseases, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Kitzinger J, Kitzinger C. Deaths after feeding-tube withdrawal from patients in vegetative and minimally conscious states: A qualitative study of family experience. Palliat Med 2018; 32:1180-1188. [PMID: 29569993 PMCID: PMC6041738 DOI: 10.1177/0269216318766430] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Families of patients in vegetative or minimally conscious states are often horrified by the suggestion of withdrawing a feeding tube, even when they believe that their relative would not have wanted to be maintained in their current condition. Very little is known about what it is like to witness such a death. AIM To understand these families' experience of their relatives' deaths. DESIGN Qualitative study using in-depth narrative interviews analyzed inductively with thematic analysis. PARTICIPANTS A total of 21 people (from 12 families) whose vegetative or minimally conscious relative died following court-authorized withdrawal of artificial nutrition and hydration. All had supported treatment withdrawal. FINDINGS Interviewees were usually anxious in advance about the nature of the death and had sometimes confronted resistance from, and been provided with misinformation by, healthcare staff in long-term care settings. However, they overwhelmingly described deaths as peaceful and sometimes even as a "good death." There was (for some) a significant "burden of witness" associated with the length of time it took the person to die and/or distressing changes in their appearance. Most continued to voice ethical objections to the manner of death while considering it "the least worst" option in the circumstances. CONCLUSION Staff need to be aware of the distinctive issues around care for this patient group and their families. It is important to challenge misinformation and initiate honest discussions about feeding-tube withdrawal and end-of-life care for these patients. Families (and staff) need better support in managing the "burden of witness" associated with these deaths.
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Affiliation(s)
- Jenny Kitzinger
- School of Journalism, Media and Culture, Cardiff University, Cardiff, UK
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Lemos Dekker N. Moral frames for lives worth living: Managing the end of life with dementia. DEATH STUDIES 2018; 42:322-328. [PMID: 29281562 DOI: 10.1080/07481187.2017.1396644] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Narratives that frame the end of life with dementia as undignified reveal moral claims on which lives are considered worth living. These claims are deeply rooted in the medicalization of death and its appeal to dignity. Drawing from ethnographic fieldwork in nursing homes for people with dementia in The Netherlands, I demonstrate how the end of life with dementia is managed through such moral frames. Specifically, I elaborate on the production of lives (not) worth living and explore how family members welcomed the death of a loved one with dementia. I argue that the welcoming of death is not an act of indifference but can be seen as a form of care.
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Affiliation(s)
- Natashe Lemos Dekker
- a Centre for Social Science and Global Health , University of Amsterdam , Amsterdam
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Wade DT. Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management. JOURNAL OF MEDICAL ETHICS 2018; 44:336-342. [PMID: 28912289 DOI: 10.1136/medethics-2017-104244] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 06/07/2023]
Abstract
Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.
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Understanding Early Decisions to Withdraw Life-Sustaining Therapy in Cardiac Arrest Survivors. A Qualitative Investigation. Ann Am Thorac Soc 2018; 13:1115-22. [PMID: 27073975 DOI: 10.1513/annalsats.201511-751oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Early withdrawal of life-sustaining therapy contributes to the majority of deaths following out-of-hospital cardiac arrest (OHCA), despite current recommendations for delayed neurological prognostication (≥72 h) after treatment with targeted temperature management. Little is known about clinicians' experiences of early withdrawal of life support decisions in patients with OHCA. OBJECTIVES To explore clinicians' experiences and perceptions of early withdrawal of life support decisions and barriers to guideline-concordant neurological prognostication in comatose survivors of OHCA treated with targeted temperature management. METHODS We conducted qualitative interviews with intensive care unit (ICU) physicians and nurses following withdrawal of life support in comatose patients with OHCA treated with targeted temperature management. The study was carried out across 18 academic and community hospitals participating in a multicenter, stepped-wedge, cluster-randomized controlled trial designed to improve quality-of-care processes for patients after OHCA in Ontario, Canada. We used a focused thematic analysis to capture barriers to guideline-concordant neurological prognostication and used these barriers to identify potentially modifiable issues. MEASUREMENTS AND MAIN RESULTS The core thematic finding was a high emotional burden of ICU family-team communication in which strong feelings inhibited information transfer and delayed decision making following OHCA. Four subthemes describing sources of communication strain were identified: (1) requests from family members to provide early outcome predictions, (2) incomplete family comprehension of critical care, (3) family requests for early withdrawal of life support based on their understanding of patients' preferences and values, and (4) family-team communication gaps related to prognostic uncertainty. Participants worried that gaps in timely and clear prognostic information contributed to surrogates' perceptions of a poor outcome and to inappropriately early decisions to withdraw life support. CONCLUSIONS Family-team communication difficulties may be an underestimated factor leading to early withdrawal of life support in ICUs for individuals who initially survive OHCA.
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Kitzinger J, Kitzinger C, Cowley J. When 'Sanctity of Life' and 'Self-Determination' clash: Briggs versus Briggs [2016] EWCOP 53 - implications for policy and practice. JOURNAL OF MEDICAL ETHICS 2017; 43:446-449. [PMID: 28642353 PMCID: PMC5520012 DOI: 10.1136/medethics-2016-104118] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 05/07/2017] [Accepted: 05/16/2017] [Indexed: 05/30/2023]
Abstract
In a landmark judgment in the English Court of Protection, the judge (Charles J) found it to be in the best interests of a minimally conscious patient for clinically assisted nutrition and hydration (CANH) to be withdrawn, with the inevitable consequence that the patient would die. In making this judgment, it was accepted that the patient's level of consciousness - if CANH were continued and rehabilitation provided - might improve, and that he might become capable of expressing emotions and making simple choices. The decision to withdraw treatment relied on a best interests decision, which gave great weight to the patient's past wishes, feelings, values and beliefs, and brought a 'holistic' approach to understanding what this particular patient would have wanted. We draw on our own experience of supporting families, advocating for patients and training healthcare professionals in similar situations to consider the implications of the published judgment for policy and practice with patients in prolonged disorders of consciousness and their families.
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Affiliation(s)
- Jenny Kitzinger
- School of Journalism, Media and Cultural Studies, Cardiff University, Cardiff, UK
| | | | - Jakki Cowley
- Empowerment Matters, Liscard Business Centre, The Old School, Liscard, UK
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Kitzinger J, Kitzinger C. Causes and consequences of delays in treatment-withdrawal from PVS patients: a case study of Cumbria NHS Clinical Commissioning Group v Miss S and Ors [2016] EWCOP 32. JOURNAL OF MEDICAL ETHICS 2017; 43:459-468. [PMID: 27663784 PMCID: PMC5520014 DOI: 10.1136/medethics-2016-103853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/08/2016] [Accepted: 09/16/2016] [Indexed: 05/25/2023]
Abstract
Life-extending treatment, in the form of artificial nutrition and hydration, is often provided to people in permanent vegetative states (PVS) in England and Wales for many years, even when their family believes the patient would not want it and despite the fact that no court in the UK has ever found in favour of continuing such treatment for a patient with a confirmed PVS diagnosis. The first half of this article presents a close analysis of the recent case of Cumbria NHS Clinical Commissioning Group v Miss S and Ors [2016] EWCOP 32. It examines the causes of delay in bringing this case to court and reaching a final judgment. It draws not only on the published judgment, but also on the two authors' involvement in supporting the family (before, during and subsequent to the court hearings) as a result of their academic and policy-related work in this area. This includes conversations with the family and with members of the clinical and legal teams, and observations in court. The second part of the article draws out the ethical and practical implications of the findings for theory and policy and suggests ways forward in relation to (a) the provision and inspection of care for these patients; (b) legal practice in relation to 'best interests' and (c) the perceived requirement under English law for a court application before life-prolonging treatment can be withdrawn from PVS patients-even in the absence of any 'in principle' opposition.
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Affiliation(s)
- Jenny Kitzinger
- School of Journalism, Media and Cultural Studies, Cardiff University, Cardiff, UK
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Wade D. Back to the bedside? Making clinical decisions in patients with prolonged unconsciousness. JOURNAL OF MEDICAL ETHICS 2017; 43:457-458. [PMID: 27501786 DOI: 10.1136/medethics-2015-103140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/07/2016] [Accepted: 07/17/2016] [Indexed: 05/11/2023]
Abstract
In 1993, the UK High Court decided that Tony Bland was unaware of himself and his environment, had no interest in medical treatment and allowed withdrawal of treatment. Subsequently, the court has reviewed all cases of stopping feeding and hydration in people with a prolonged disorder of consciousness. Their focus has been on determining whether the person is in the permanent vegetative state, because this avoids considering what is in a person's Best Interests. Consequently, much resource is spent distinguishing the vegetative state from the minimally conscious state and often clinical decisions are delayed or not made because of the requirement to go to court. In this paper, I argue that the neurophysiological basis of consciousness is unknown, and one cannot test whether the necessary structures are functioning. Unconscious people have responsiveness which varies; they may even have brief behaviours suggestive of awareness. No single clinical sign or investigation nor assessment battery can prove the presence (or absence) of consciousness or its permanence. The diagnosis of consciousness is clinical. Furthermore, awareness varies across a spectrum. There is no separate vegetative state. People simply have very limited or absent awareness. Even if there were such a state, it cannot be identified. The ethical and legal issues associated with decisions on treatment of unconscious people are no different from similar decisions in other patients. All decisions should be taken within the Best Interests framework and process. There should be no requirement to take any particular decision to court in this patient group.
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Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role. Behav Sci (Basel) 2017; 7:bs7020036. [PMID: 28590407 PMCID: PMC5485466 DOI: 10.3390/bs7020036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/12/2017] [Accepted: 06/02/2017] [Indexed: 11/18/2022] Open
Abstract
End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.
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Kitzinger C, Kitzinger J. Grief, anger and despair in relatives of severely brain injured patients: responding without pathologising. Clin Rehabil 2017; 28:627-31. [PMID: 24920582 DOI: 10.1177/0269215514527844] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The training and expertise of healthcare professionals in diagnosing and treating pathology can mean that every situation is treated as an instance of illness or abnormality requiring treatment. This medicalised perspective is often evident in clinical approaches to family members of people with prolonged disorders of consciousness. This editorial was stimulated by reviewing an article (final version now published in this issue) concerning the distress of families with severely brain injured relatives,(2) and by reading the larger body of literature to which that article contributes. It was also prompted by the recent publication of national clinical guidelines in the UK about the management of prolonged disorders of consciousness. In this editorial we highlight the depth and range of emotional reactions commonly experienced by families with a severely brain injured relative. We suggest that clinicians should understand such emotions as normal responses to a terrible situation, and consider the ways in which clinical practice can be adapted to avoid contributing to family trauma.
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Chandler JA, Sun JA, Racine E. Online public reactions to fMRI communication with patients with disorders of consciousness: Quality of life, end-of-life decision making, and concerns with misdiagnosis. AJOB Empir Bioeth 2017; 8:40-51. [PMID: 28949872 DOI: 10.1080/23294515.2016.1226199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Recently, the news media have reported on the discovery of covert awareness and the establishment of limited communication using a functional magnetic resonance imaging (fMRI) neuroimaging technique with several brain-injured patients thought to have been in a vegetative state. This discovery has raised many ethical, legal, and social questions related to quality of life, end-of-life decision making, diagnostic and prognostic accuracy in disorders of consciousness, resource allocation, and other issues. This project inquires into the public responses to these discoveries. METHODS We conducted a thematic analysis of online comments (n = 779) posted in response to 15 news articles and blog posts regarding the case of a Canadian patient diagnosed for 12 years as in a vegetative state, but who was reported in 2012 as having been able to communicate via fMRI. The online comments were coded using an iteratively refined codebook structured around 14 main themes. RESULTS Among the most frequent public reactions revealed in the online comments were discussions of the quality of life of patients with disorders of consciousness, whether life-sustaining treatment should be withdrawn (and whether the fMRI communication technique should be used to ask patients about this), and misgivings about the accuracy of diagnosis in disorders of consciousness and brain death. CONCLUSIONS These public perspectives are relevant to the obligations of clinicians, lawyers, and public policymakers to patients, families, and the public. Future work should consider how best to alleviate families' concerns as this type of research shakes their faith in diagnostic accuracy, to clarify the legal rules relating to advance directives in this context, and to address the manner in which public messaging might help to alleviate any indirect impact on confidence in the organ donation system.
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Affiliation(s)
| | | | - Eric Racine
- b Institut de Recherches Cliniques de Montreal (IRCM) , Neuroethics Research Unit
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Heywood R, Mullock A. The value of life in English law: revered but not sacred? LEGAL STUDIES (SOCIETY OF LEGAL SCHOLARS) 2016; 36:658-682. [PMID: 28111491 PMCID: PMC5216451 DOI: 10.1111/lest.12131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 03/18/2016] [Accepted: 03/29/2016] [Indexed: 06/06/2023]
Abstract
Terms such as sanctity and inviolability have failed to provide a legally coherent or ethically sound principle upon which to determine the scope of the intrinsic value of life against extrinsic, quality-of-life considerations in a medical context. In their recent work, Margaret Brazier and Suzanne Ost introduce a new term, reverence for life, which they suggest may be more appropriate when attempting to navigate the murky waters of the meaning of life and the value that should be attached to it. They suggest that reverence should be utilised as an alternative that better reflects the nuances and the realities of the dilemma. This paper explores the existing difficulties before considering how the principle of reverence might provide a principled compromise over when the presumption in favour of preserving life should be rebutted.
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Schutz REC, Coats HL, Engelberg RA, Curtis JR, Creutzfeldt CJ. Is There Hope? Is She There? How Families and Clinicians Experience Severe Acute Brain Injury. J Palliat Med 2016; 20:170-176. [PMID: 27763820 DOI: 10.1089/jpm.2016.0286] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with severe acute brain injury (SABI) raise important palliative care considerations associated with sudden devastating injury and uncertain prognosis. OBJECTIVE The goal of this study was to explore how family members, nurses, and physicians experience the palliative and supportive care needs of patients with SABI receiving care in the neuroscience intensive care unit (neuro-ICU). DESIGN Semistructured interviews were audiotaped, transcribed, and analyzed using thematic analysis. SETTING/SUBJECTS Thirty-bed neuro-ICU in a regional comprehensive stroke and level-one trauma center in the United States. We completed 47 interviews regarding 15 patients with family members (n = 16), nurses (n = 15), and physicians (n = 16). RESULTS Two themes were identified: (1) hope and (2) personhood. (1) Families linked prognostic uncertainty to a need for hope and expressed a desire for physicians to acknowledge this relationship. The language of hope varied depending on the participant: clinicians used hope as an object that can be given or taken away, generally in the process of conveying prognosis, while families expressed hope as an action that supported coping with their loved one's acute illness and its prognostic uncertainty. (2) Participants described the loss of personhood through brain injury, the need to recognize and treat the brain-injured patient as a person, and the importance of relatedness and connection, including personal support of families by clinicians. CONCLUSIONS Support for hope and preservation of personhood challenge care in the neuro-ICU as identified by families and clinicians of patients with SABI. Specific practical approaches can address these challenges and improve the palliative care provided to patients and families in the neuro-ICU.
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Affiliation(s)
| | - Heather L Coats
- 2 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 2 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - J Randall Curtis
- 2 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
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Samuel G, Cribb A, Owens J, Williams C. Relative Values: Perspectives on a Neuroimaging Technology From Above and Within the Ethical Landscape. JOURNAL OF BIOETHICAL INQUIRY 2016; 13:407-18. [PMID: 27334528 PMCID: PMC5021745 DOI: 10.1007/s11673-016-9725-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/29/2015] [Indexed: 06/06/2023]
Abstract
In this paper we contribute to "sociology in bioethics" and help clarify the range of ways sociological work can contribute to ethics scholarship. We do this using a case study of an innovative neurotechnology, functional magnetic resonance imaging, and its use to attempt to diagnose and communicate with severely brain-injured patients. We compare empirical data from interviews with relatives of patients who have a severe brain injury with perspectives from mainstream bioethics scholars. We use the notion of an "ethical landscape" as an analogy for the different ethical positions subjects can take-whereby a person's position relative to the landscape makes a difference to the way they experience and interact with it. We show that, in comparison to studying abstract ethics "from above" the ethical landscape, which involves universal generalizations and global judgements, studying ethics empirically "from the ground," within the ethical landscape foregrounds a more plural and differentiated picture. We argue it is important not to treat empirical ethics as secondary to abstract ethics, to treat on-the-ground perspectives as useful only insofar as they can inform ethics from above. Rather, empirical perspectives can illuminate the plural vantage points in ethical judgments, highlight the "lived" nature of ethical reasoning, and point to all ethical vantage points as being significant. This is of epistemic importance to normative ethics, since researchers who pay attention to the various positions in and trajectories through the ethical landscape are unlikely to think about ethics in terms of abstract agency-as can happen with top-down ethics-or to elide agency with the agency of policymakers. Moreover, empirical perspectives may have transformative implications for people on the ground, especially where focus on the potential harms and benefits they face brings their experiences and interests to the forefront of ethical and policy discussion.
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Affiliation(s)
- Gabrielle Samuel
- Brighton and Sussex Medical School, Falmer, East Sussex, UK.
- Department of Educational Research, Lancaster University, Lancaster, UK.
| | - Alan Cribb
- Department of Education and Professional Studies, King's College London, London, UK
| | - John Owens
- Department of Education and Professional Studies, King's College London, London, UK
| | - Clare Williams
- College of Business, Arts and Social Sciences, Brunel University London, Uxbridge, UK
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Colbeck M. 'Is she alive? Is she dead?' Representations of chronic disorders of consciousness in Douglas Coupland's Girlfriend in a Coma. MEDICAL HUMANITIES 2016; 42:160-165. [PMID: 26988694 DOI: 10.1136/medhum-2015-010763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 06/05/2023]
Abstract
Depictions of coma have come to dominate literary and filmic texts over the last half century, a phenomenon coinciding with advancements in medical technology that have led to remarkable increases in the survival rates of patients with chronic disorders of consciousness. Authors of coma fiction are preoccupied with the imagined subjective experience of coma, often creating complex, dream-like worlds from which the protagonist must escape if survival is to be achieved. However, such representations appear to conflict with medical case studies and patient narratives that reveal that most often survivors of coma have no recollection of the coma itself. Providing a close reading of Douglas Coupland's Girlfriend in a Coma (1998) against the context of medical literature and diagnoses, this article examines how the coma patient is represented, often depicting the realities of a prolonged vegetative state, in contrast with other popular representations of coma. It explores how the author develops a work of 'fantastic' fiction (a genre defined by the structuralist critic Tzvetan Todorov), using the condition of coma as a metaphor for a postmodern existential crisis, while simultaneously employing mimetic techniques that raise important medical, ethical and philosophical questions surrounding the ontological status of the comatose patient. It is argued that coma fiction, even in its misrepresentation of the condition, can help us to engage with and interrogate how we think about chronic disorders of consciousness, thereby providing a valuable insight into our attitudes towards illness and mortality.
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Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA, 94143-0131, USA. .,Department of Social and Behavioral Science, Sociology Program, University of California, San Francisco, CA, USA. .,Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
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Birchley G, Jones K, Huxtable R, Dixon J, Kitzinger J, Clare L. Dying well with reduced agency: a scoping review and thematic synthesis of the decision-making process in dementia, traumatic brain injury and frailty. BMC Med Ethics 2016; 17:46. [PMID: 27461340 PMCID: PMC4962460 DOI: 10.1186/s12910-016-0129-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/13/2016] [Indexed: 12/02/2022] Open
Abstract
Background In most Anglophone nations, policy and law increasingly foster an autonomy-based model, raising issues for large numbers of people who fail to fit the paradigm, and indicating problems in translating practical and theoretical understandings of ‘good death’ to policy. Three exemplar populations are frail older people, people with dementia and people with severe traumatic brain injury. We hypothesise that these groups face some over-lapping challenges in securing good end-of-life care linked to their limited agency. To better understand these challenges, we conducted a scoping review and thematic synthesis. Methods To capture a range of literature, we followed established scoping review methods. We then used thematic synthesis to describe the broad themes emerging from this literature. Results Initial searches generated 22,375 references, and screening yielded 49, highly heterogeneous, studies that met inclusion criteria, encompassing 12 countries and a variety of settings. The thematic synthesis identified three themes: the first concerned the processes of end-of-life decision-making, highlighting the ambiguity of the dominant shared decision-making process, wherein decisions are determined by families or doctors, sometimes explicitly marginalising the antecedent decisions of patients. Despite this marginalisation, however, the patient does play a role both as a social presence and as an active agent, by whose actions the decisions of those with authority are influenced. The second theme examined the tension between predominant notions of a good death as ‘natural’ and the drive to medicalise death through the lens of the experiences and actions of those faced with the actuality of death. The final theme considered the concept of antecedent end-of-life decision-making (in all its forms), its influence on policy and decision-making, and some caveats that arise from the studies. Conclusions Together these three themes indicate a number of directions for future research, which are likely to be applicable to other conditions that result in reduced agency. Above all, this review emphasises the need for new concepts and fresh approaches to end of life decision-making that address the needs of the growing population of frail older people, people with dementia and those with severe traumatic brain injury. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0129-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Giles Birchley
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK.
| | - Kerry Jones
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jeremy Dixon
- Department of Social and Policy Sciences, University of Bath, Bath, UK
| | - Jenny Kitzinger
- Coma and Disorders of Consciousness Research Centre, Cardiff University, Cardiff, UK
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, University of Exeter, Exeter, UK
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