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Hautmann X, Rohde V, von der Brelie C. Clinical Course after End-of-Life Decisions on a Neurosurgical Ward: Much to Learn and Improve. J Neurol Surg A Cent Eur Neurosurg 2024. [PMID: 38959942 DOI: 10.1055/s-0043-1771278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
BACKGROUND End-of-life (EoL) decisions are routine in neurosurgical care due to frequent devastating and life-threatening diagnoses. Advance directives, discussions with patients' relatives, and evaluation of the alleged will of the patient play an increasing important role in clinical decision-making. Institutional standards, ethical values, different ethnical backgrounds, and individual physician's experiences influence clinical judgments and decisions. We hypothesize that the implementation of palliative care in neurosurgical wards needs optimization. The aim of this study is to identify possible sources of error and to share our experiences. METHODS This is a retrospective observational analysis. One hundred and sixty-eight patients who died on a regular neurosurgical ward between 2014 and 2019 were included. Medical reports were analyzed in detail. A differentiation between consistent and nonconsistent palliation was made, with consistent palliative care consisting of discontinuation of medication that was no longer indicated, administration of medication for symptom control, and consequent discontinuation of nutrition and fluid substitution that went beyond satisfying hunger or thirst. RESULTS EoL decisions were made in 127 (84.1%) of all 168 cases; 100 patients were included in our analysis. Of these patients, only 24 had an advance directive, and the relatives were included in the communication about the therapy goals in 71 cases. Discontinuation of medication that is not for symptom control was performed in 63 patients, food withdrawal in 66 patients, and fluid substitution that went beyond the quenching of thirst was withdrawn in 27 patients. Thus, consistent palliative care was realized in 25% of all patients. The mean duration from the EoL decision until death was 2.1 days (range: 0-20 days). If a consistent palliative care was carried out, patients survived significantly shorter (nonconsistent palliative care: 2.4 days; range: 0-10 days vs. consistent palliative care: 1.2 days; range: 0-4 days; p = 0.008). CONCLUSIONS The therapy goal should be thoroughly considered and determined at an early stage. If an EoL decision is reached, consistent palliative care should be carried out in order to limit suffering of moribund patients.
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Affiliation(s)
- Xenia Hautmann
- Department of Neurosurgery, Georg August University Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg August University Göttingen, Göttingen, Germany
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2
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Pérez-Blanco A, Manara A. Intensive care admission aiming at organ donation. Pro. Intensive Care Med 2024; 50:437-439. [PMID: 38436724 DOI: 10.1007/s00134-024-07334-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/24/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Alicia Pérez-Blanco
- Organización Nacional de Trasplantes, C/Sinesio Delgado, 6-8 Pabellón 3, 28029, Madrid, Spain.
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3
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Bokek-Cohen Y, Marey-Sarwan I, Tarabeih M. Deontological Guilt and Moral Distress as Diametrically Opposite Phenomena: A Case Study of Three Clinicians. JOURNAL OF BIOETHICAL INQUIRY 2023:10.1007/s11673-023-10300-4. [PMID: 37930560 DOI: 10.1007/s11673-023-10300-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 05/31/2023] [Indexed: 11/07/2023]
Abstract
Feelings of guilt are human emotions that may arise if a person committed an action that contradicts basic moral mores or failed to commit an action that is considered moral according to their ethical standards and values. Psychological scholarship distinguishes between altruistic guilt (AG) and deontological guilt (DG). AG results from having caused harm to an innocent victim, either by acting or failing to act, whereas DG is caused by violating a moral principle. Although physicians may be expected to experience frequent feelings of guilt in their demanding and intensive work, it is surprising to find that this issue has not been explored in the professional literature on medical ethics. To that end, we conducted a qualitative study that included personal in-depth interviews with Sunni Muslim gynaecologists. These doctors provide underground infertility care and perform religiously forbidden treatments involving sex selection and gamete donation. They opened their hearts and spoke about the emotionally taxing pangs of conscience they suffer. Analysing their narratives led us to characterize their feelings of guilt as DG. We discuss the causes for their plight and the way they cope with it, compare DG to the concept of moral distress, and call for future research on clinicians' feelings of guilt and pangs of conscience.
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Affiliation(s)
- Y Bokek-Cohen
- School of Psychology, Tel Aviv University, 30 Haim Levanon Street, Postal code 699780, Tel Aviv, Israel.
| | - I Marey-Sarwan
- School of Education, Sakhnin College Academic for Teacher Education, Sakhnin, Israel
| | - M Tarabeih
- School of Nursing, Tel Aviv Jaffa Academic College, 2 Rabenu Yerucham St., Postal code 6161001, Tel Aviv, Israel
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4
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George LS, Epstein RM, Akincigil A, Saraiya B, Trevino KM, Kuziemski A, Pushparaj L, Policano E, Prigerson HG, Godwin K, Duberstein P. Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis. J Gen Intern Med 2023; 38:1516-1525. [PMID: 36732436 PMCID: PMC10160244 DOI: 10.1007/s11606-022-08011-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized. OBJECTIVE Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others. METHODS Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings. RESULTS The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism. CONCLUSIONS Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kendra Godwin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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5
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Wikstøl D, Horn MA, Pedersen R, Magelssen M. Citizen attitudes to non-treatment decision making: a Norwegian survey. BMC Med Ethics 2023; 24:20. [PMID: 36890542 PMCID: PMC9993678 DOI: 10.1186/s12910-023-00900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/03/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Decisions about appropriate treatment at the end of life are common in modern healthcare. Non-treatment decisions (NTDs), comprising both withdrawal and withholding of (potentially) life-prolonging treatment are in principle accepted in Norway. However, in practice they may give rise to significant moral problems for health professionals, patients and next of kin. Here, patient values must be considered. It is relevant to study the moral views and intuitions of the general population on NTDs and special areas of contention such as the role of next of kin in decision-making. METHODS Electronic survey to members of a nationally representative panel of Norwegian adults. Respondents were presented with vignettes describing patients with disorders of consciousness, dementia, and cancer where patient preferences varied. Respondents answered ten questions about the acceptability of non-treatment decision making and the role of next of kin. RESULTS We received 1035 complete responses (response rate 40.7%). A large majority, 88%, supported the right of competent patients to refuse treatment in general. When an NTD was in line with the patient's previously expressed preferences, more respondents tended to find NTDs acceptable. More respondents would accept NTDs for themselves than for the vignette patients. In a scenario with an incompetent patient, clear majorities wanted the views of next of kin to be given some but not decisive weight, and more weight if concordant with the patient's wishes. There were, however, large variations in the respondents' views. CONCLUSION This survey of a representative sample of the Norwegian adult population indicates that attitudes to NTDs are often in line with national laws and guidelines. However, the high variance among the respondents and relatively large weight given to next of kin's views, indicate a need for appropriate dialogue among all stakeholders to prevent conflicts and extra burdens. Furthermore, the emphasis given to previously expressed opinions indicates that advance care planning may increase the legitimacy of NTDs and prevent challenging decision-making processes.
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Affiliation(s)
- David Wikstøl
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | | | - Reidar Pedersen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway
| | - Morten Magelssen
- Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Pb. 1130, 0318, Blindern, Oslo, Norway. .,MF Norwegian School of Theology, Religion and Society, Oslo, Norway.
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6
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Ketharanathan N, Hunfeld MAW, de Jong MC, van der Zanden LJ, Spoor JKH, Wildschut ED, de Hoog M, Tibboel D, Buysse CMP. Withdrawal of Life-Sustaining Therapies in Children with Severe Traumatic Brain Injury. J Neurotrauma 2023. [PMID: 36475884 DOI: 10.1089/neu.2022.0321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Neuroprognostication in severe traumatic brain injury (sTBI) is challenging and occurs in critical care settings to determine withdrawal of life-sustaining therapies (WLST). However, formal pediatric sTBI neuroprognostication guidelines are lacking, brain death criteria vary, and dilemmas regarding WLST persist, which lead to institutional differences. We studied WLST practice and outcome in pediatric sTBI to provide insight into WLST-associated factors and survivor recovery trajectory ≥1 year post-sTBI. This retrospective, single center observational study included patients <18 years admitted to the pediatric intensive care unit (PICU) of Erasmus MC-Sophia (a tertiary university hospital) between 2012 and 2020 with sTBI defined as a Glasgow Coma Scale (GCS) ≤8 and requiring intracranial pressure (ICP) monitoring. Clinical, neuroimaging, and electroencephalogram data were reviewed. Multi-disciplinary follow-up included the Pediatric Cerebral Performance Category (PCPC) score, educational level, and commonly cited complaints. Seventy-eight children with sTBI were included (median age 10.5 years; interquartile range [IQR] 5.0-14.1; 56% male; 67% traffic-related accidents). Median ICP monitoring was 5 days (IQR 3-8), 19 (24%) underwent decompressive craniectomy. PICU mortality was 21% (16/78): clinical brain death (5/16), WLST due to poor neurological prognosis (WLST_neuro, 11/16). Significant differences (p < 0.001) between survivors and non-survivors: first GCS score, first pupillary reaction and first lactate, Injury Severity Score, pre-hospital cardiopulmonary resuscitation, and Rotterdam CT (computed tomography) score. WLST_neuro decision timing ranged from 0 to 31 days (median 2 days, IQR 0-5). WLST_neuro decision (n = 11) was based on neurologic examination (100%), brain imaging (100%) and refractory intracranial hypertension (5/11; 45%). WLST discussions were multi-disciplinary with 100% agreement. Immediate agreement between medical team and caregivers was 81%. The majority (42/62, 68%) of survivors were poor outcome (PCPC score 3 to 5) at PICU discharge, of which 12 (19%) in a vegetative state. One year post-injury, no patients were in a vegetative state and the median PCPC score had improved to 2 (IQR 2-3). No patients died after PICU discharge. Twenty percent of survivors could not attend school 2 years post-injury. Survivors requiring an adjusted educational level increased to 45% within this timeframe. Chronic complaints were headache, behavioral problems, and sleeping problems. In conclusion, two-thirds of sTBI PICU mortality was secondary to WLST_neuro and occurred early post-injury. Median survivor PCPC score improved from 4 to 2 with no vegetative patients 1 year post-sTBI. Our findings show the WLST decision process was multi-disciplinary and guided by specific clinical features at presentation, clinical course, and (serial) neurological diagnostic modalities, of which the testing combination was determined by case-to-case variation. This stresses the need for international guidelines to provide accurate neuroprognostication within an appropriate timeframe whereby overall survivor outcome data provides valuable context and guidance in the acute phase decision process.
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Affiliation(s)
- Naomi Ketharanathan
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maayke A W Hunfeld
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marcus C de Jong
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Lineke J van der Zanden
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Jochem K H Spoor
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Enno D Wildschut
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Matthijs de Hoog
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Corinne M P Buysse
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, the Netherlands
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Bouchereau E, Marchi A, Hermann B, Pruvost-Robieux E, Guinard E, Legouy C, Schimpf C, Mazeraud A, Baron JC, Ramdani C, Gavaret M, Sharshar T, Turc G. Quantitative analysis of early-stage EEG reactivity predicts awakening and recovery of consciousness in patients with severe brain injury. Br J Anaesth 2023; 130:e225-e232. [PMID: 36243578 DOI: 10.1016/j.bja.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Decisions of withdrawal of life-sustaining therapy for patients with severe brain injury are often based on prognostic evaluations such as analysis of electroencephalography (EEG) reactivity (EEG-R). However, EEG-R usually relies on visual assessment, which requires neurophysiological expertise and is prone to inter-rater variability. We hypothesised that quantitative analysis of EEG-R obtained 3 days after patient admission can identify new markers of subsequent awakening and consciousness recovery. METHODS In this prospective observational study of patients with severe brain injury requiring mechanical ventilation, quantitative EEG-R was assessed using standard 11-lead EEG with frequency-based (power spectral density) and functional connectivity-based (phase-lag index) analyses. Associations between awakening in the intensive care unit (ICU) and reactivity to auditory and nociceptive stimulations were assessed with logistic regression. Secondary outcomes included in-ICU mortality and 3-month Coma Recovery Scale-Revised (CRS-R) score. RESULTS Of 116 patients, 86 (74%) awoke in the ICU. Among quantitative EEG-R markers, variation in phase-lag index connectivity in the delta frequency band after noise stimulation was associated with awakening (adjusted odds ratio=0.89, 95% confidence interval: 0.81-0.97, P=0.02 corrected for multiple tests), independently of age, baseline severity, and sedation. This new marker was independently associated with improved 3-month CRS-R (adjusted β=-0.16, standard error 0.075, P=0.048), but not with mortality (adjusted odds ratio=1.08, 95% CI: 0.99-1.18, P=0.10). CONCLUSIONS An early-stage quantitative EEG-R marker was independently associated with awakening and 3-month level of consciousness in patients with severe brain injury. This promising marker based on functional connectivity will need external validation before potential integration into a multimodal prognostic model.
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Affiliation(s)
- Eléonore Bouchereau
- Anaesthesiology and ICU Department, Sainte Anne Hospital, Paris, France; Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France.
| | - Angela Marchi
- Epileptology and Cerebral Rhythmology Department, APHM, Timone Hospital, Marseille, France
| | - Bertrand Hermann
- ICU Department, Hôpital Européen Georges Pompidou, Paris, France; Institut du Cerveau et de la Moelle épinière - ICM, Paris, France; Université Paris Cité, Paris, France
| | - Estelle Pruvost-Robieux
- Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France; Université Paris Cité, Paris, France; Neurophysiology Department, Sainte Anne Hospital, Paris, France
| | - Eléonore Guinard
- Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France; Université Paris Cité, Paris, France; Neurophysiology Department, Sainte Anne Hospital, Paris, France
| | - Camille Legouy
- Anaesthesiology and ICU Department, Sainte Anne Hospital, Paris, France
| | - Caroline Schimpf
- Anaesthesiology and ICU Department, Sainte Anne Hospital, Paris, France
| | - Aurélien Mazeraud
- Anaesthesiology and ICU Department, Sainte Anne Hospital, Paris, France; Université Paris Cité, Paris, France
| | - Jean-Claude Baron
- Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France; Université Paris Cité, Paris, France; Neurology Department, GHU Paris Psychiatry and Neurosciences, Sainte Anne Hospital, Paris, France; FHU NeuroVasc, Paris, France
| | - Céline Ramdani
- Institut de Recherche Biomédicale des Armées (IRBA), Brétigny-sur-Orge, France
| | - Martine Gavaret
- Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France; Université Paris Cité, Paris, France; Neurophysiology Department, Sainte Anne Hospital, Paris, France; FHU NeuroVasc, Paris, France
| | - Tarek Sharshar
- Anaesthesiology and ICU Department, Sainte Anne Hospital, Paris, France; Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France; Université Paris Cité, Paris, France; FHU NeuroVasc, Paris, France
| | - Guillaume Turc
- Institute of Psychiatry and Neurosciences of Paris (IPNP), INSERM U1266, Paris, France; Université Paris Cité, Paris, France; Neurology Department, GHU Paris Psychiatry and Neurosciences, Sainte Anne Hospital, Paris, France; FHU NeuroVasc, Paris, France
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8
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Shaw D, Manara A, Dalle Ave AL. The ethics of semantics in medicine. JOURNAL OF MEDICAL ETHICS 2022; 48:1026-1031. [PMID: 34446529 DOI: 10.1136/medethics-2020-107192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 08/01/2021] [Indexed: 06/13/2023]
Abstract
In this paper, we discuss the largely neglected topic of semantics in medicine and the associated ethical issues. We analyse several key medical terms from the informed perspective of the healthcare professional, the lay perspective of the patient and the patient's family, and the descriptive perspective of what the term actually signifies objectively. The choice of a particular medical term may deliver different meanings when viewed from these differing perspectives. Consequently, several ethical issues may arise. Technical terms that are not commonly understood by lay people may be used by physicians, consciously or not, and may obscure the understanding of the situation by lay people. The choice of particular medical terms may be accidental use of jargon, an attempt to ease the communication of psychologically difficult information, or an attempt to justify a preferred course of action and/or to manipulate the decision-making process.
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Affiliation(s)
- David Shaw
- Department of Health, Ethics and Society, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Alex Manara
- Intensive Care Unit, North Bristol NHS Trust, Westbury on Trym, UK
| | - Anne Laure Dalle Ave
- Ethics Unit, Institute of Humanities in Medicine, University Hospital of Lausanne, Lausanne, Switzerland
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9
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Itagaki Y, Hayakawa M, Maekawa K, Kodate A, Moriki K, Takahashi Y, Sageshima H. Early prediction model of brain death in out-of-hospital cardiac arrest patients: a single-center retrospective and internal validation analysis. BMC Emerg Med 2022; 22:177. [PMID: 36333656 PMCID: PMC9636638 DOI: 10.1186/s12873-022-00734-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
Abstract
Background A shortage of donor organs amid high demand for transplantable organs is a worldwide problem, and an increase in organ donation would be welcomed by the global healthcare system. Patients with brain death (BD) are potential organ donors, and early prediction of patients with BD may facilitate the process of organ procurement. Therefore, we developed a model for the early prediction of BD in patients who survived the initial phase of out-of-hospital cardiac arrest (OHCA). Methods We retrospectively analyzed data of patients aged < 80 years who experienced OHCA with a return of spontaneous circulation (ROSC) and were admitted to our hospital between 2006 and 2018. We categorized patients into either a non-BD or BD group. Demographic and laboratory data on ED admission were used for stepwise logistic regression analysis. Prediction scores of BD after OHCA were based on β-coefficients of prognostic factors identified in the multivariable logistic model. Results Overall, 419 OHCA patients with ROSC were admitted to our hospital during the study period. Seventy-seven patients showed BD (18.3%). Age and etiology of OHCA were significantly different between the groups. Logistic regression analysis confirmed that age, low-flow time, pH, and etiology were independent predictors of BD. The area under the receiver operating characteristic curve for this model was 0.831 (95% confidence interval, 0.786–0.876). Conclusions We developed and internally validated a new prediction model for BD after OHCA, which could aid in the early identification of potential organ donors for early donor organ procurement.
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Chan NPX, Chia JL, Ho CY, Ngiam LXL, Kuek JTY, Ahmad Kamal NHB, Hanifah Marican Abdurrahman AB, Ong YT, Chiam M, Lee ASI, Chin AMC, Mason S, Radha Krishna LK. Extending the Ring Theory of Personhood to the Care of Dying Patients in Intensive Care Units. Asian Bioeth Rev 2022; 14:71-86. [PMID: 34691261 PMCID: PMC8526529 DOI: 10.1007/s41649-021-00192-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/17/2021] [Accepted: 09/23/2021] [Indexed: 11/29/2022] Open
Abstract
It is evident, in the face of the COVID-19 pandemic that has physicians confronting death and dying at unprecedented levels along with growing data suggesting that physicians who care for dying patients face complex emotional, psychological and behavioural effects, that there is a need for their better understanding and the implementation of supportive measures. Taking into account data positing that effects of caring for dying patients may impact a physician's concept of personhood, or "what makes you, 'you'", we adopt Radha Krishna's Ring Theory of Personhood (RToP) to scrutinise the experiences of physicians working in intensive care units (ICU) using a fictional scenario that was inspired by real events. The impact of death and dying, its catalysts, internal constituents, external factors, dyssynchrony, and buffers, specific to ICU physicians, were identified and explored. Such a framework allows for ramifications to be considered holistically and facilitates the curation of strategies for conflict resolution. This evaluation of the RToP acknowledges the experience and wide-ranging effects it has on ICU physicians. As such, our findings provide insight into their specific needs and highlight the importance of support on a personal and organisational level. Although further research needs to be conducted, the RToP could serve as the basis for a longitudinal assessment tool supported by the use of portfolios or mentorship due to their provision of personalised, appropriate, specific, timely, accessible and long-term support.
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Affiliation(s)
- Natalie Pei Xin Chan
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Jeng Long Chia
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Chong Yao Ho
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Lisa Xin Ling Ngiam
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Joshua Tze Yin Kuek
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Nur Haidah Binte Ahmad Kamal
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Ahmad Bin Hanifah Marican Abdurrahman
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
| | - Min Chiam
- Division of Cancer Education , National Cancer Centre Singapore, Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education , National Cancer Centre Singapore, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Cancer Research Centre, University of Liverpool, Liverpool, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine , National University of Singapore, Singapore
- Division of Supportive and Palliative Care , National Cancer Centre Singapore, Singapore
- Division of Cancer Education , National Cancer Centre Singapore, Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool, Liverpool, UK
- Cancer Research Centre, University of Liverpool, Liverpool, UK
- Palliative Care Centre for Excellence in Research and Education (PalC), Singapore
- Centre for Biomedical Ethics, National University of Singapore , Singapore
- Duke-NUS Graduate Medical School, Singapore
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11
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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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Kuek JTY, Ngiam LXL, Kamal NHA, Chia JL, Chan NPX, Abdurrahman ABHM, Ho CY, Tan LHE, Goh JL, Khoo MSQ, Ong YT, Chiam M, Chin AMC, Mason S, Krishna LKR. The impact of caring for dying patients in intensive care units on a physician's personhood: a systematic scoping review. Philos Ethics Humanit Med 2020; 15:12. [PMID: 33234133 PMCID: PMC7685911 DOI: 10.1186/s13010-020-00096-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/11/2020] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Supporting physicians in Intensive Care Units (ICU)s as they face dying patients at unprecedented levels due to the COVID-19 pandemic is critical. Amidst a dearth of such data and guided by evidence that nurses in ICUs experience personal, professional and existential issues in similar conditions, a systematic scoping review (SSR) is proposed to evaluate prevailing accounts of physicians facing dying patients in ICUs through the lens of Personhood. Such data would enhance understanding and guide the provision of better support for ICU physicians. METHODS An SSR adopts the Systematic Evidenced Based Approach (SEBA) to map prevailing accounts of caring for dying patients in ICUs. To enhance the transparency and reproducibility of this process, concurrent and independent use of tabulated summaries, thematic analysis and directed content analysis (Split Approach) is adopted. RESULTS Eight thousand three hundred fifty-eight abstracts were reviewed from four databases, 474 full-text articles were evaluated, 58 articles were included, and the Split Approach revealed six categories/themes centered around the Innate, Individual, Relational and Societal Rings of Personhood, conflicts in providing end of life care and coping mechanisms employed. CONCLUSION This SSR suggests that caring for dying patients in ICU impacts how physicians view their personhood. To resolve conflicts within individual concepts of personhood, physicians use prioritization, reframing and rely on accessible, personalized support from colleagues to steer coping strategies. An adapted form of the Ring Theory of Personhood is proposed to direct timely personalized, appropriate and holistic support.
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Affiliation(s)
- Joshua Tze Yin Kuek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Lisa Xin Ling Ngiam
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Nur Haidah Ahmad Kamal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Jeng Long Chia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Natalie Pei Xin Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Ahmad Bin Hanifah Marican Abdurrahman
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Chong Yao Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Lorraine Hui En Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Jun Leng Goh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Michelle Shi Qing Khoo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore, Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore.
- Division of Cancer Education, National Cancer Centre Singapore, Singapore, Singapore.
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA, UK.
- Duke-NUS Graduate Medical School, Singapore, Singapore.
- Centre for Biomedical Ethics, National University of Singapore, Singapore, Singapore.
- PalC, The Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore.
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Skaansar O, Tverdal C, Rønning PA, Skogen K, Brommeland T, Røise O, Aarhus M, Andelic N, Helseth E. Traumatic brain injury-the effects of patient age on treatment intensity and mortality. BMC Neurol 2020; 20:376. [PMID: 33069218 PMCID: PMC7568018 DOI: 10.1186/s12883-020-01943-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI. Methods Included in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015–2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression. Results A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15–98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity. Conclusion The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.
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Affiliation(s)
- Ola Skaansar
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Cathrine Tverdal
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Karoline Skogen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Brommeland
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Olav Røise
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Mads Aarhus
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Nada Andelic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Eirik Helseth
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
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