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Schembs L, Racine E, Shevell M, Jox RJ. Physicians' attitudes towards ethical issues and end-of-life decision-making for pediatric patients with unresponsive wakefulness syndrome: An international survey. Dev Med Child Neurol 2023; 65:1646-1655. [PMID: 36758014 DOI: 10.1111/dmcn.15540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
AIM We examined physicians' perspectives on the mental capabilities of pediatric patients with unresponsive wakefulness syndrome (UWS) and their attitudes towards limiting life-sustaining treatment (LST) in an international context. METHOD A questionnaire survey was conducted among 267 neuropediatricians, practicing in 65 countries. Comparisons were made according to the Human Development Index (HDI) of the countries. The Idler Index of Religiosity was applied to determine religiosity. RESULTS Participants from countries with a very high HDI were generally more favorable to limiting LST (p < 0.001), specifically cardiopulmonary resuscitation (p = 0.021), intubation/ventilation (p = 0.014), hemodialysis/hemofiltration (p < 0.001), and antibiotic therapy (p < 0.001). Treatment costs that were too high had a weaker influence on their decisions (p < 0.001). Participants who found it never ethically justifiable to limit LST had a higher mean Idler Index of private (p = 0.001) and general (p = 0.020) religiosity and were less satisfied with treatment decisions (p < 0.001) and the communication during the process (p = 0.016). INTERPRETATION The perspectives towards limiting LST for pediatric patients with UWS are markedly different between physicians from countries with very high and lower HDIs.
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Affiliation(s)
- Leah Schembs
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Robertson-Preidler J, Kaplan H. "But my mom still blinks when I talk to her." Understanding the concept of social death to avoid bias and improve goals-of-care discussions at the end of life. J Eval Clin Pract 2023; 29:1083-1089. [PMID: 37525563 DOI: 10.1111/jep.13907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
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Carlson JM, Lin DJ. Prognostication in Prolonged and Chronic Disorders of Consciousness. Semin Neurol 2023; 43:744-757. [PMID: 37758177 DOI: 10.1055/s-0043-1775792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with prolonged disorders of consciousness (DOCs) longer than 28 days may continue to make significant gains and achieve functional recovery. Occasionally, this recovery trajectory may extend past 3 (for nontraumatic etiologies) and 12 months (for traumatic etiologies) into the chronic period. Prognosis is influenced by several factors including state of DOC, etiology, and demographics. There are several testing modalities that may aid prognostication under active investigation including electroencephalography, functional and anatomic magnetic resonance imaging, and event-related potentials. At this time, only one treatment (amantadine) has been routinely recommended to improve functional recovery in prolonged DOC. Given that some patients with prolonged or chronic DOC have the potential to recover both consciousness and functional status, it is important for neurologists experienced in prognostication to remain involved in their care.
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Affiliation(s)
- Julia M Carlson
- Division of Neurocritical Care, Department of Neurology, University of North Carolina Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Division of Neurocritical Care and Stroke Service, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Neurorestoration and Neurotechnology, Rehabilitation Research and Development Service, Department of Veterans Affairs, Providence, Rhode Island
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Ferrand A, Poleksic J, Racine E. Factors Influencing Physician Prognosis: A Scoping Review. MDM Policy Pract 2022; 7:23814683221145158. [PMID: 36582416 PMCID: PMC9793048 DOI: 10.1177/23814683221145158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction. Prognosis is an essential component of informed consent for medical decision making. Research shows that physicians display discrepancies in their prognostication, leading to variable, inaccurate, optimistic, or pessimistic prognosis. Factors driving these discrepancies and the supporting evidence have not been reviewed systematically. Methods. We undertook a scoping review to explore the literature on the factors leading to discrepancies in medical prognosis. We searched Medline (Ovid) and Embase (Ovid) databases for peer-reviewed articles from 1970 to 2017. We included articles that discussed prognosis variation or discrepancy and where factors influencing prognosis were evaluated. We extracted data outlining the participants, methodology, and prognosis discrepancy information and measured factors influencing prognosis. Results. Of 4,723 articles, 73 were included in the final analysis. There was significant variability in research methodologies. Most articles showed that physicians were pessimistic regarding patient outcomes, particularly in early trainees and acute care specialties. Accuracy rates were similar across all time periods. Factors influencing prognosis were clustered in 4 categories: patient-related factors (such as age, gender, race, diagnosis), physician-related factors (such as age, race, gender, specialty, training and experience, attitudes and values), clinical situation-related factors (such as physician-patient relationship, patient location, and clinical context), and environmental-related factors (such as country or hospital size). Discussion. Obtaining accurate prognostic information is one of the highest priorities for seriously ill patients. The literature shows trends toward pessimism, especially in early trainees and acute care specialties. While some factors may prove difficult to change, the physician's personality and psychology influence prognosis accuracy and could be tackled using debiasing strategies. Exposure to long-term patient outcomes and a multidisciplinary practice setting are environmental debiasing strategies that may warrant further research. Highlights Literature on discrepancies in physician's prognostication is heterogeneous and sparse.Literature shows that physicians are mostly pessimistic regarding patient outcomes.Literature shows that a physician's personality and psychology influence prognostic accuracy and could be improved with evidence-based debiasing strategies.Medical specialty strongly influences prognosis, with specialties exposed to acutely ill patients being more pessimistic, whereas specialties following patients longitudinally being more optimistic.Physicians early in their training were more pessimist than more experienced physicians.
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Affiliation(s)
- Amaryllis Ferrand
- Amaryllis Ferrand, Pragmatic Health Ethics
Research Unit, Montreal Clinical Research Institute, 10 Pine Ave West, Montreal,
QC H2W 1R7, Canada; ()
| | - Jelena Poleksic
- Pragmatic Health Ethics Research Unit, Montreal
Clinical Research Institute, Montreal, QC, Canada,Faculty of Medicine, University of Western
Ontario, London, ON, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal
Clinical Research Institute, Montreal, QC, Canada,Departments of Medicine and Social and
Preventive Medicine, University of Montreal, Montreal, Canada,Biomedical Ethics Unit, McGill University,
Montreal, QC, Canada
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5
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Abstract
Disorders of consciousness (DOC) continue to profoundly challenge both families and medical professionals. Once a brain-injured patient has been stabilized, questions turn to the prospect of recovery. However, what “recovery” means in the context of patients with prolonged DOC is not always clear. Failure to recognize potential differences of interpretation—and the assumptions about the relationship between health and well-being that underlie these differences—can inhibit communication between surrogate decisionmakers and a patient’s clinical team, and make it difficult to establish the goals of care. The authors examine the relationship between health and well-being as it pertains to patients with prolonged DOC. They argue that changes in awareness or other function should not be equated to changes in well-being, in the absence of a clear understanding of the constituents of well-being for that particular patient. The authors further maintain that a comprehensive conception of recovery for patients with prolonged DOC should incorporate aspects of both experienced well-being and evaluative well-being.
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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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Quiñones-Ossa GA, Durango-Espinosa YA, Janjua T, Moscote-Salazar LR, Agrawal A. Persistent vegetative state: an overview. EGYPTIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1186/s41984-021-00111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Disorder of consciousness diagnosis, especially when is classified as persistent vegetative state (without misestimating the other diagnosis classifications), in the intensive care is an important diagnosis to evaluate and treat. Persistent vegetative state diagnosis is a challenge in the daily clinical practice because the diagnosis is made mainly based upon the clinical history and the patient behavior observation. There are some specific criteria for this diagnosis, and this could be very tricky when the physician is not well trained.
Main body
We made a literature review regarding the persistent vegetative state diagnosis, clinical features, management, prognosis, and daily medical practice challenges while considering the bioethical issues and the family perspective about the patient status. The objective of this overview is to provide updated information regarding this clinical state’s features while considering the current medical literature available.
Conclusions
Regardless of the currently available guidelines and literature, there is still a lot of what we do not know about the persistent vegetative state. There is a lack of evidence regarding the optimal diagnosis and even more, about how to expect a natural history of this disorder of consciousness. It is important to recall that the patients (despite of their altered mental state diagnosis) should always be treated to avoid some of the intensive care unit long-stance complications.
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Gray A, Pickering M, Sturman S. Absence of monitoring in withdrawal of clinically-assisted nutrition and hydration (CANH) and other treatments: a cause for concern? Clin Med (Lond) 2021; 21:235-237. [PMID: 34001577 PMCID: PMC8140723 DOI: 10.7861/clinmed.2020-0673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Since 2018, there has been no requirement to bring decisions about the withdrawal of clinically-assisted nutrition and hydration (CANH) in patients with persistent disorders of consciousness before the courts, providing that the requirements of the Mental Capacity Act 2005 (MCA) are fulfilled. Subsequent British Medical Association and Royal College of Physicians guidance on CANH withdrawal recommended standards of record keeping and internal and external audit to ensure local decision making was compliant with the MCA to safeguard patients. The scope of the guidance also included patients with stroke and neurodegenerative disorders.Freedom of Information requests made 2 years after the introduction of this guidance have shown that none of the NHS trusts or clinical commissioning groups who responded were undertaking any systematic monitoring of these decisions. Neither is the Care Quality Commission reviewing these decisions, as there is 'no statutory requirement' to do so. It appears there is a lack of organised scrutiny of these highly complex life-ending treatment decisions. This omission must surely be a cause for concern.
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Affiliation(s)
- Alice Gray
- Christian Medical Fellowship, London, UK and specialist registrar in palliative medicine, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Mark Pickering
- Christian Medical Fellowship, London, UK and prison general practitioner, London, UK
| | - Stephen Sturman
- Christian Medical Fellowship, London, UK and consultant neurologist (neurorehabilitation), University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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How Does Functional Neurodiagnostics Inform Surrogate Decision-Making for Patients with Disorders of Consciousness? A Qualitative Interview Study with Patients’ Next of Kin. NEUROETHICS-NETH 2020. [DOI: 10.1007/s12152-019-09425-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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10
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Blain-Moraes S, Racine E, Mashour GA. Consciousness and Personhood in Medical Care. Front Hum Neurosci 2018; 12:306. [PMID: 30116185 PMCID: PMC6082939 DOI: 10.3389/fnhum.2018.00306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/16/2018] [Indexed: 11/25/2022] Open
Abstract
Current paradigms in Western medicine often fail to differentiate clearly between consciousness, responsiveness and personhood. The growing number of individuals who exist with sustainable cardiopulmonary systems but who are behaviorally unresponsive has prompted a cultural reconsideration of the relationship between the presence of consciousness and what it means to be a person. This article presents relevant clinical situations that exemplify the different modes in which personhood and consciousness can be associated and dissociated: disorders of consciousness, emergence from anesthesia, and neocortical death. We draw from these examples to call for a reflection on and possible revision of the dominant approach towards unresponsive persons to one in which care providers may work from the default assumption of the existence of an individual’s personhood as part of their therapeutic intervention. Behavior consistent with this assumption aligns with the principle of respect for persons in the face of the uncertainty created by the high rate of misdiagnosis of unconsciousness in unresponsive patients and is most consistent with a therapeutic approach to care considering evidence suggesting that attributing personhood may in fact evoke consciousness in these patients.
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Affiliation(s)
- Stefanie Blain-Moraes
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Eric Racine
- Institut de Recherches Cliniques de Montréal, Montreal, QC, Canada
| | - George A Mashour
- Department of Anesthesiology, Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI, United States
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Alshamsi FE, Chaaban A, Alrukhaimi M, Bernieh B, Bakoush O. Provision of renal care for patients with end stage kidney disease in persistent vegetative state, in United Arab Emirates: a national survey of renal physicians. Libyan J Med 2018; 13:1490610. [PMID: 29979643 PMCID: PMC6041784 DOI: 10.1080/19932820.2018.1490610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Patients with end stage kidney disease (ESKD) with severely impaired cognitive function have no survival benefit from dialysis. We therefore undertook a survey to explore the renal physicians' practices of withholding and withdrawal of dialysis treatment in vegetative state patients in the United Arab Emirates (UAE). A cross sectional survey of 29 nephrology practices in UAE exploring physicians' practices in making decisions of withholding and withdrawal of dialysis treatment during provision end-of-life care for patients in persistent vegetative state (PVS).The majority of participants practice in governmental non-for-profit dialysis units (79%), and think they are well prepared to make decision with patients and family on issues of dialysis withdrawal and withholding (69%). If a chronic dialysis patient became permanently unconscious only few respondents (17%) indicated probability of stopping dialysis. On the other hand, more respondents (48%) reported that dialysis is likely to be withheld in PVS patients who develop kidney failure. In high risk or poor prognosis ESKD patients and given how likely they would consider each option independently, respondents reported they are likely to consider time-limited dialysis in 78% of the time followed by stopping (46%) or forgoing (27%) dialysis. Majority of the participants perceived that their decisions in providing renal care for PVS patients in UAE were influenced by the family sociocultural beliefs (76% of participants), the current hospital policies (72% of participants), and by Islamic beliefs (66% of participants). Only few perceived access to palliative care (30%) and treatment cost (17%) to have an impact on their decision making.Decisions of initiation and continuation of dialysis treatment to ESKD patients in PVS are prevalent among nephrology practices in UAE. Development of local guidelines based on the societal values along with early integration of palliative kidney failure management care would be required to improve the quality of provision of end-of-life renal care in UAE. ABBREVIATIONS ESKD: stage kidney disease; UAE: United Arab Emirates; PVS: persistent vegetative state; RPA: Renal Physicians Association; ASN: American Society of Nephrology; EMAN: Emirates Medical Association Nephrology Society; CPR: cardiopulmonary resuscitation.
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Affiliation(s)
| | - Ahmed Chaaban
- b Nephrology Department , Tawam Hopsital , United Arab Emirates
| | - Mona Alrukhaimi
- c Department of Internal Medicine , Dubai Medical College , Dubai , United Arab Emirates
| | - Bassam Bernieh
- b Nephrology Department , Tawam Hopsital , United Arab Emirates
| | - Omran Bakoush
- a College of Medicine , United Arab Emirates University , United Arab Emirates
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12
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Span-Sluyter CAMFH, Lavrijsen JCM, van Leeuwen E, Koopmans RTCM. Moral dilemmas and conflicts concerning patients in a vegetative state/unresponsive wakefulness syndrome: shared or non-shared decision making? A qualitative study of the professional perspective in two moral case deliberations. BMC Med Ethics 2018; 19:10. [PMID: 29471814 PMCID: PMC5824545 DOI: 10.1186/s12910-018-0247-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Patients in a vegetative state/ unresponsive wakefulness syndrome (VS/UWS) pose ethical dilemmas to those involved. Many conflicts occur between professionals and families of these patients. In the Netherlands physicians are supposed to withdraw life sustaining treatment once recovery is not to be expected. Yet these patients have shown to survive sometimes for decades. The role of the families is thought to be important. The aim of this study was to make an inventory of the professional perspective on conflicts in long-term care of patients in VS/UWS. Methods A qualitative study of transcripts on 2 Moral Deliberations (MD’s) in 2 cases of patients in VS/UWS in long-term care facilities. Results Six themes emerged: 1) Vision on VS/UWS; 2) Treatment and care plan; 3) Impact on relationships; 4) Feelings/attitude; 5) Communication; 6) Organizational aspects. These themes are related to professionals and to what families had expressed to the professionals. We found conflicts as well as contradictory feelings and thoughts to be a general feature in 4 of these themes, both in professionals and families. Conflicts were found in several actors: within families concerning all 6 themes, in nurse teams concerning the theme treatment and care plan, and between physicians concerning all 6 themes. Conclusions Different visions, different expectations and hope on recovery, deviating goals and contradictory feelings/thoughts in families and professionals can lead to conflicts over a patient with VS/UWS. Key factors to prevent or solve such conflicts are a carefully established diagnosis, clarity upon visions, uniformity in treatment goals and plans, an open and empathic communication, expertise and understanding the importance of contradictory feelings/thoughts. Management should bridge conflicts and support their staff, by developing expertise, by creating stability and by facilitating medical ethical discourses. Shared compassion for the patient might be a key to gain trust and bridge the differences from non-shared to shared decision making.
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Affiliation(s)
- Conny A M F H Span-Sluyter
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands. .,Novicare, Professionals in Elderly Care, Best, the Netherlands.
| | - Jan C M Lavrijsen
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands
| | | | - Raymond T C M Koopmans
- Radboud University Medical Centre, department of primary care, Nijmegen, The Netherlands.,Joachim en Anna, Centre for Specialized Geriatric Care, Nijmegen, The Netherlands
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13
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Steppacher I, Kissler J. The living dead? Perception of persons in the unresponsive wakefulness syndrome in Germany compared to the USA. BMC Psychol 2018; 6:5. [PMID: 29467036 PMCID: PMC5822482 DOI: 10.1186/s40359-018-0217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/15/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The extent to which people ascribe mind to others has been shown to predict the extent to which human rights are conferred. Therefore, in the context of disorders of consciousness (DOC), mind ascription can influence end of life decisions. A previous US-American study indicated that participants ascribed even less mind to patients with unresponsive-wakefulness-syndrome (UWS) than to the dead. Results were explained in terms of implicit dualism and religious beliefs, as highly religious people ascribed least mind to UWS. Here, we addresses mind ascription to UWS patients in Germany. METHODS We investigate the perception of UWS patients in a large German sample (N = 910) and compare the results to the previous US data, addressing possible cultural differences. We further assess effects of medical expertise, age, gender, socio-economic status and subjective knowledge about UWS in the German sample. RESULTS Unlike the US sample, German participants did not perceive UWS patients as "more dead than dead", ascribing either equal (on 3 of 5 items) or more (on 2 items) mental abilities to UWS patients than to the dead. Likewise, an effect of implicit dualism was not replicated and German medically trained participants ascribed more capabilities to UWS patients than did a non-medical sample. Within the German sample, age, gender, religiosity and socio-economic status explained about 15% of the variability of mind ascription. Age and religiosity were individually significant predictors, younger and more religious people ascribing more mind. Gender had no effect. CONCLUSION Results are consistent with cross-cultural differences in the perception of UWS between Germany and the USA, Germans ascribing more mind to UWS patients. The German sample ascribed as much or more but not less mind to a UWS patient than to a deceased, although within group variance was large, calling for further research. Mind ascription is vital, because, in times of declining resources for healthcare systems, and an increasing legalization of euthanasia, public opinion will influence UWS patients' rights and whether 'the right to die' will be the only right conceded to them.
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Affiliation(s)
- Inga Steppacher
- Department of Psychology, University of Bielefeld, Universitätsstr. 25, 33615 Bielefeld, Germany
| | - Johanna Kissler
- Department of Psychology, University of Bielefeld, Universitätsstr. 25, 33615 Bielefeld, Germany
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14
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Wu K, Chen Y, Yan C, Huang Z, Wang D, Gui P, Bao J. Effects of percutaneous endoscopic gastrostomy on survival of patients in a persistent vegetative state after stroke. J Clin Nurs 2016; 26:3232-3238. [PMID: 27878869 DOI: 10.1111/jocn.13672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To assess the effect of percutaneous endoscopic gastrostomy on short- and long-term survival of patients in a persistent vegetative state after stroke and determine the relevant prognostic factors. BACKGROUND Stroke may lead to a persistent vegetative state, and the effect of percutaneous endoscopic gastrostomy on survival of stroke patients in a persistent vegetative state remains unclear. DESIGN Prospective study. METHODS A total of 97 stroke patients in a persistent vegetative state hospitalised from January 2009 to December 2011 at the Second Hospital, University of South China, were assessed in this study. Percutaneous endoscopic gastrostomy was performed in 55 patients, and mean follow-up time was 18 months. Survival rate and risk factors were analysed. RESULTS Median survival in the 55 percutaneous endoscopic gastrostomy-treated patients was 17·6 months, higher compared with 8·2 months obtained for the remaining 42 patients without percutaneous endoscopic gastrostomy treatment. Univariate analyses revealed that age, hospitalisation time, percutaneous endoscopic gastrostomy treatment status, family financial situation, family care, pulmonary infection and nutrition were significantly associated with survival. Multivariate analysis indicated that older age, no gastrostomy, poor family care, pulmonary infection and poor nutritional status were independent risk factors affecting survival. Indeed, percutaneous endoscopic gastrostomy significantly improved the nutritional status and decreased pulmonary infection rate in patients with persistent vegetative state after stroke. Interestingly, median survival time was 20·3 months in patients with no or one independent risk factors of poor prognosis (n = 38), longer compared with 8·7 months found for patients with two or more independent risk factors (n = 59). CONCLUSION Percutaneous endoscopic gastrostomy significantly improves long-term survival of stroke patients in a persistent vegetative state and is associated with improved nutritional status and decreased pulmonary infection. RELEVANCE TO CLINICAL PRACTICE Percutaneous endoscopic gastrostomy is a promising option for the management of stroke patients in a persistent vegetative state.
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Affiliation(s)
- Kunpeng Wu
- Department of Intensive Care Medicine, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
| | - Ying Chen
- Department of Anesthesia, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
| | - Caihong Yan
- Department of Intensive Care Medicine, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
| | - Zhijia Huang
- Department of Intensive Care Medicine, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
| | - Deming Wang
- Department of Anesthesia, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
| | - Peigen Gui
- Department of Intensive Care Medicine, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
| | - Juan Bao
- Department of Intensive Care Medicine, the Second Hospital Affiliated to South China University, Hengyang, Hunan, China
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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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Morrison W, Womer J, Nathanson P, Kersun L, Hester DM, Walsh C, Feudtner C. Pediatricians' Experience with Clinical Ethics Consultation: A National Survey. J Pediatr 2015. [PMID: 26210945 DOI: 10.1016/j.jpeds.2015.06.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To conduct a national survey of pediatricians' access to and experience with clinical ethics consultation. STUDY DESIGN We surveyed a randomly selected sample of 3687 physician members of the American Academy of Pediatrics. We asked about their experiences with ethics consultation, the helpfulness of and barriers to consultation, and ethics education. Using a discrete choice experiment with maximum difference scaling, we evaluated which traits of ethics consultants were most valuable. RESULTS Of the total sample of 3687 physicians, 659 (18%) responded to the survey. One-third of the respondents had no experience with clinical ethics consultation, and 16% reported no access to consultation. General pediatricians were less likely to have access. The vast majority (90%) who had experience with consultation had found it helpful. Those with fewer years in practice were more likely to have training in ethics. The most frequently reported issues leading to consultation concerned end-of-life care and conflicts with patients/families or among the team. Intensive care unit physicians were more likely to have requested consultation. Mediation skills and ethics knowledge were the most highly valued consultant characteristics, and representing the official position of the hospital was the least-valued characteristic. CONCLUSION There is variability in pediatricians' access to ethics consultation. Most respondents reported that consultation had been helpful in the past. Determining ethically appropriate end-of-life care and mediation of disagreements are common reasons that pediatricians request consultation.
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Affiliation(s)
- Wynne Morrison
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - James Womer
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Temple University School of Medicine, Philadelphia, PA
| | - Pamela Nathanson
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Leslie Kersun
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - D Micah Hester
- Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Corbett Walsh
- New York University School of Medicine, New York, NY
| | - Chris Feudtner
- Pediatric Advanced Care Team, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Bender A, Jox RJ, Grill E, Straube A, Lulé D. Persistent vegetative state and minimally conscious state: a systematic review and meta-analysis of diagnostic procedures. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 112:235-42. [PMID: 25891806 PMCID: PMC4413244 DOI: 10.3238/arztebl.2015.0235] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/22/2015] [Accepted: 01/22/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute brain damage can cause major disturbances of consciousness, ranging all the way to the persistent vegetative state (PVS), which is also known as "unresponsive wakefulness syndrome". PVS can be hard to distinguish from a state of minimal preserved consciousness ("minimally conscious state," MCS); the rate of misdiagnosis is high and has been estimated at 37-43%. In contrast, PVS is easily distinguished from brain death. We discuss the various diagnostic techniques that can be used to determine whether a patient is minimally conscious or in a persistent vegetative state. METHODS This article is based on a systematic review of pertinent literature and on a quantitative meta-analysis of the sensitivity and specificity of new diagnostic methods for the minimally conscious state. RESULTS We identified and evaluated 20 clinical studies involving a total of 906 patients with either PVS or MCS. The reported sensitivities and specificities of the various techniques used to diagnose MCS vary widely. The sensitivity and specificity of functional MRI-based techniques are 44% and 67%, respectively (with corresponding 95% confidence intervals of 19%-72% and 55%-77%); those of quantitative EEG are 90% and 80%, respectively (95% CI, 69%-97% and 66%-90%). EEG, event-related potentials, and imaging studies can also aid in prognostication. Contrary to prior assumptions, 10% to 24% of patients in PVS can regain consciousness, sometimes years after the event, but only with marked functional impairment. CONCLUSION The basic diagnostic evaluation for differentiating PVS from MCS consists of a standardized clinical examination. In the future, modern diagnostic techniques may help identify patients who are in a subclinical minimally conscious state.
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Affiliation(s)
- Andreas Bender
- Department of Neurology, Therapiezentrum Burgau
- Neurological Clinic and Policlinic, Großhadern Hospital, Ludwig-Maximilian-Universität
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-Universität München
| | - Eva Grill
- Institute for Medical Data Processing, Biometrics and Epidemiology, Ludwig-Maximilian-Universität München
| | - Andreas Straube
- Neurological Clinic and Policlinic, Großhadern Hospital, Ludwig-Maximilian-Universität
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