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White BP, Willmott L, Close E. Better Regulation of End-Of-Life Care: A Call For A Holistic Approach. JOURNAL OF BIOETHICAL INQUIRY 2022; 19:683-693. [PMID: 36251135 PMCID: PMC9908626 DOI: 10.1007/s11673-022-10213-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/10/2022] [Indexed: 06/16/2023]
Abstract
Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying "regulatory space" theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers.
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Affiliation(s)
- Ben P. White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, Queensland 4001 Australia
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Ahmed N, Davids R. COVID 19: are South African junior doctors prepared for critical care management outside the intensive care unit? Pan Afr Med J 2021; 40:41. [PMID: 34795822 PMCID: PMC8571942 DOI: 10.11604/pamj.2021.40.41.30134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION the coronavirus disease 2019 (COVID-19) pandemic has negatively impacted countries across the globe. Infected individuals will seek aid at various health care facilities. Many patients will recover without requiring specialised treatment. A significant percentage of infected individuals will need critical care management, which will begin in the emergency department, generally staffed by junior doctors. Junior doctors will need to stabilize, triage and manage these patients prior to referral to specialized units. Above and beyond the usual occupational demands that accompany junior doctors in state facilities, this pandemic will thrust further responsibility on them. The objectives were to describe crisis preparedness of junior doctors in the areas of triage decision-making and critical care management, outside the intensive care unit. METHODS this is a descriptive, cross-sectional study, utilizing a web-based survey. Junior doctors in South Africa, being doctors in year one or year two of internship and community service, were invited to participate anonymously via various social media platforms. Results: a total of 210 junior doctors across South Africa answered the survey. Junior doctors expressed confidence with knowledge of intubation drugs, to perform intubation and cardiopulmonary arrest resuscitation without supervision. Only 13.3% of respondents expressed comfort with setting and adjusting ventilator settings independently. 57% of participants expressed discomfort with making critical care triage decisions. Ninety-three percent (93%) of participants expressed benefit from a telemedicine intervention. CONCLUSION junior doctors in South Africa indicate that they are prepared to initiate management of the critically ill patient outside the intensive care unit but remain uncertain in their ability to provide ongoing critical care management. The COVID-19 pandemic has highlighted the need to prepare junior doctors with the ability to manage critical care triage and management in emergency rooms. Leveraging of the workforce in South Africa may be potentiated by telemedicine interventions.
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Affiliation(s)
- Nadiya Ahmed
- Department of Surgical Sciences, Department Anaesthesiology and Critical Care, Tygerberg Hospital, Stellenbosch University, Western Cape, South Africa
| | - Ryan Davids
- Department of Surgical Sciences, Department Anaesthesiology and Critical Care, Tygerberg Hospital, Stellenbosch University, Western Cape, South Africa
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Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
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Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
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Close E, White BP, Willmott L. Balancing Patient and Societal Interests in Decisions About Potentially Life-Sustaining Treatment : An Australian Policy Analysis. JOURNAL OF BIOETHICAL INQUIRY 2020; 17:407-421. [PMID: 32964352 DOI: 10.1007/s11673-020-09994-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 07/15/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND This paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources. METHODS All publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation. RESULTS Four resource-related themes were identified: (1) doctors' ethical duties to consider resource allocation; (2) balancing ethical obligations to patient and society; (3) fair process and transparent resource allocation; and (4) legal guidance on distributive justice as a rationale to limit life-sustaining treatment. CONCLUSION Of the policies that addressed resource allocation, this review found broad agreement about the existence of doctors' duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia.
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, 2 George St, Brisbane, Queensland, 4000, Australia
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Joynt GM, Gopalan PD, Argent A, Chetty S, Wise R, Lai VKW, Hodgson E, Lee A, Joubert I, Mokgokong S, Tshukutsoane S, Richards GA, Menezes C, Mathivha LR, Espen B, Levy B, Asante K, Paruk F. The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri). SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2019; 35:10.7196/SAJCC.2019.v35.i1b.383. [PMID: 37719327 PMCID: PMC10503494 DOI: 10.7196/sajcc.2019.v35.i1b.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 09/19/2023] Open
Abstract
Background In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector. Purpose The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care. Recommendations In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years. Conclusion In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.
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Affiliation(s)
- G M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - P D Gopalan
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - A Argent
- Department of Paediatrics and Child Health, University of Cape Town, South Africa
| | - S Chetty
- Department of Anaesthesiology and Critical Care, Stellenbosch University, Cape Town, South Africa
| | - R Wise
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Edendale Hospital,
Pietermaritzburg, South Africa
| | - V K W Lai
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - E Hodgson
- Department of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, and Inkosi Albert Luthuli
Central Hospital, Durban, South Africa
| | - A Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - I Joubert
- Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - S Mokgokong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - S Tshukutsoane
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Menezes
- Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - L R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - B Espen
- Centre for Health Professions Education, Stellenbosch University, Cape Town, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - K Asante
- African Organization for Research and Training in Cancer, Cape Town, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
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Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making. Disaster Med Public Health Prep 2010; 3 Suppl 2:S132-40. [PMID: 19755912 DOI: 10.1097/dmp.0b013e3181ac3dd2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states.
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Hahn J, Mandraka F, Fröhlich G. Ethische Aspekte in der Therapie kritisch kranker Tumorpatienten. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s00390-007-0819-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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