Biomedical ethics and the withdrawal of advanced life support

Perceptions of Medical Providers on Morality and Decision-Making Capacity in Withholding and Withdrawing Life-Sustaining Treatment and Suicide

BACKGROUND

This study attempts to understand if medical providers beliefs about the moral permissibility of honoring patient-directed refusals of life-sustaining treatment (LST) are tied to their beliefs about the patient's decision-making capacity. The study aims to answer: 1) does concern about a patient's treatment decision-making capacity relate to beliefs about whether it is morally acceptable to honor a refusal of LST, 2) are there differences between provider types in assessments of decision-making capacity and the moral permissibility to refuse LST, and 3) do provider demographics impact beliefs about decision-making capacity and the moral permissibility to refuse LST. Methods: A mixed-methods survey using Likert assessment and vignette-based questions was administered to medical providers within a single health system in the upper Midwest (N = 714) to assess their perspectives on the moral acceptance and decision-making capacity in cases of withholding and withdrawing treatment and suicide. Results: Behavioral health providers report accepting of the moral permissibility of suicide (91.2%) more than either medical providers (77.2%) or surgeons (74.4%) (n = 283). Decision-making capacity was questioned more in the vignettes of the patients refusing life-saving surgery (36%) and voluntarily starvation (40.8%) than in the vignette of the patient requesting to deactivate a pacemaker (13%) (n = 283). Behavioral health providers were more concerned about the capacity to refuse life-saving surgery (55.9%) than medical providers (33.8%) or surgeons (23.1%) (n = 283). Conclusions: Respondents endorse the moral permissibility of persons to withhold or withdraw from treatment regardless of motive. Clinical concerns about a patient's treatment decision-making capacity do not strongly correlate to views about the moral permissibility of honoring refusals of LST. Different provider types appear to have different thresholds for when to question treatment decision-making capacity. Behavioral health providers tend to question treatment decision-making capacity to refuse LST more than non-behavioral health providers.

Economic implications of end-of-life care in the ICU

PURPOSE OF REVIEW

Advance care planning and palliative care interventions can improve the quality of end-of-life care by reducing unwanted high intensity care at the end of life. This may have important economic implications and may reduce the financial burden of patients' families. We review the literature to examine the impact advance care planning and palliative care has on ICU utilization, specifically ICU admissions and ICU length of stay (LOS), and to provide insight into ways to reduce costs and financial burden of care while simultaneously improving quality of care.

RECENT FINDINGS

We identified three studies assessing the impact of palliative care consultation on ICU admissions for patients with life-limiting illness; all three demonstrate reduced ICU admissions for patients receiving palliative care consultation. Among 16 studies evaluating ICU LOS as an outcome, five report no change and 11 report decrease in LOS for patients receiving advance care planning or palliative care. These studies are heterogeneous in design and target population; however, a trend toward reduced ICU utilization exists.

SUMMARY

Advance care planning and palliative care can reduce ICU utilization at the end of life. The degree to which reducing ICU utilization decreases emotional and financial burden of end-of-life care for patients and families is unknown.

Discretionary death: conditions, dilemmas, and normative regulation

The author examines a major shift in the conceptualization and practices relating to death and dying in Western and other societies with advanced medicine. This shift is the result of socio-technical and cultural developments characterized by but not limited to the routine widespread application of life support technologies in the hospital together with notions of increased patient rights. It has resulted in a class of end-of-life situations, which the author defines as "discretionary death." The concept of discretionary death underscores the role of contextual and discretionary factors in end-of-life decision-making. The author identifies and discusses the necessary and complex process of norm formation that informs and regulates end-of-life medical practice and establishes societal consensus across society with respect to legitimizing "discretionary death."

Ethical issues and the role of anesthesiologists in non-heart-beating organ donation

PURPOSE OF REVIEW

Demand for vital organs for transplantation continues to increase, and the supply of organs has not kept up with demand. The use of organs harvested immediately after death from patients who have requested withdrawal of life support may be one way to increase supply. Anesthesiologists frequently become involved with such 'non-heart-beating' organ donations when they are asked to withdraw life support from patients in the operating room and monitor them, providing terminal care, until death ensues.

RECENT FINDINGS

Despite thorough debate in the literature and reviews by the Institute of Medicine, ethical controversies remain concerning the use of non-heart-beating donors. Further, non-heart-beating organ donation has failed to produce the windfall of vital organs for transplant predicted by optimistic early estimates. There is agreement in the medical specialties of palliative care, intensive care medicine, internal medicine, and family practice that competency in end-of-life care requires specialty training. Most anesthesiologists are poorly qualified to carry out the tasks involved in non-heart-beating donation, and may even potentially compromise care.

SUMMARY

Ethical controversies in the use of non-heart-beating donors remain despite thorough review. No physician should be involved in withdrawal of life support in non-heart-beating donors, unless specialty trained in end-of-life care. Most anesthesiologists should not be involved in non-heart-beating organ donations; potential exceptions include those with specialty training or experienced in palliative care or intensive care medicine.

Psychiatric issues in pulmonary disease

This article has attempted to provide an overview of the clinical literature regarding the psychological issues facing patients with pulmonary disease, depending on when the illness begins in the life span, because different developmental tasks are disrupted. Patients must contend with side effects of medication that may mimic or exacerbate psychiatric disorders. The main drug interactions for psychiatrists to be aware of in this patient population occur between rifampin, or theophylline and psychotropic medications. In lung transplant recipients on cyclosporine therapy, the antidepressant drug nefazadone may cause increased cyclosporine levels. Psychiatrists must be aware of the risks, benefits, and survival statistics; educate patients; and ascertain whether the patient is competent to make medical decisions regarding treatment procedures.