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Ko YK, Cho C, Sun S, Ngan OM, Chan HY. Moral sensitivity and academic ethical awareness of nursing and medical students: A cross-sectional survey. Nurs Ethics 2024:9697330241226604. [PMID: 38315791 DOI: 10.1177/09697330241226604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND Moral sensitivity and academic integrity discernment hold paramount importance for healthcare professionals. Owing to distinct undergraduate educational backgrounds, nurses and physicians may exhibit divergent moral perspectives, academic integrity cognisance, and moral sensitivity within clinical environments. A limited number of studies have investigated the disparities and congruencies pertaining to moral sensitivity and academic ethical awareness among nursing and medical students. OBJECTIVE The study compares moral sensitivity and academic ethical awareness of undergraduate nursing and medical students with and without clinical exposure. RESEARCH DESIGN A self-administered cross-sectional survey conducted from January to February 2022 was used to collect data from a medical school in Hong Kong. PARTICIPANTS AND RESEARCH CONTEXT A total of 545 respondents, including 137 nursing students and 408 medical students, completed the questionnaire. ETHICAL CONSIDERATION Ethics approval of the study was obtained. Written consent was waived to maintain anonymity because completing the questionnaire was considered implied consent. FINDINGS Both groups of undergraduates demonstrated a high level of bioethics knowledge. In terms of academic integrity, medical students were found to have a less concerned attitude towards punctuality, attendance, and skipping classes. Regarding moral sensitivity, senior medical students with clinical experience put less emphasis on decision-making involving patient participation, while senior nursing students were more hesitant in withholding treatment for incompetent patients who refused treatment. Both nursing and medical students showed decreased moral sensitivity in the 'conflicts' domain with increased clinical exposure. CONCLUSION Study findings contribute to the discussion comparing the ethical attitudes of nursing and medical students. More effort should be made in nursing and medical education to promote practices in line with high academic integrity and to develop the ability to be morally sensitive in professional settings.
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Affiliation(s)
- Yuet Kiu Ko
- Faculty of Medicine, The Chinese University of Hong Kong
| | - Cordelia Cho
- Faculty of Medicine, The Chinese University of Hong Kong
| | - Sihan Sun
- CUHK Centre of Bioethics, Faculty of Medicine, The Chinese University of Hong Kong
| | - Olivia My Ngan
- Medical Ethics and Humanities Unit and Centre for Centre for Medical Ethics and Law, The University of Hong Kong
| | - Helen Yl Chan
- School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong
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Brenner AB, Skolarus LE, Perumalswami CR, Burke JF. Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans. J Pain Symptom Manage 2020; 60:595-601.e3. [PMID: 32376264 PMCID: PMC7483277 DOI: 10.1016/j.jpainsymman.2020.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL). METHODS This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models. RESULTS Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability. CONCLUSIONS Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.
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Affiliation(s)
- Allison B Brenner
- Survey Research Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Lesli E Skolarus
- Population Health Research Director, Cascadia Behavioral Healthcare, Portland, Oregon, USA; Department of Neurology, Stroke Program, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chithra R Perumalswami
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Burke
- Department of Neurology, Stroke Program, Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan, USA.
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Svantesson M, Sjökvist P, Thorsén H, Ahlström G. Nurses’ and Physicians’ Opinions on Aggressiveness of Treatment for General Ward Patients. Nurs Ethics 2016; 13:147-62. [PMID: 16526149 DOI: 10.1191/0969733006ne861oa] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.
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Affiliation(s)
- Mia Svantesson
- Centre for Nursing Science, Orebro University Hospital, Sweden.
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Benhamou-Jantelet G. Nurses’ Ethical Perceptions of Health Care and of Medical Clinical Research: an audit in a French university teaching hospital. Nurs Ethics 2016; 8:114-22. [PMID: 16010886 DOI: 10.1177/096973300100800204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Very few data exist in France on: (1) nurses’ knowledge and behaviour concerning ethical decisions in clinical practice; and (2) their knowledge of ethical rules in clinical research. This questionnaire-based audit tried mainly to assess these questions in a large French university teaching hospital. Of the 257 questionnaires distributed to nurses in 23 clinical units of the hospital, 206 were returned (80% response rate). When responding to the vignette describing a clinical situation requiring an ethical decision to be made, most nurses acted as the patient’s advocate although they have had no formal training in ethics. Indeed, 66% of nurses responding considered that the patients themselves should be the primary decision makers in situations that relate to their health and medical care. For children or comatose patients, the decision should be left to the relatives according to 72% of the responses. The results indicated that the role of health care professionals in ethical decisions made for a given patient should be marginal. Nurses’ knowledge concerning research protocols, particularly their ethical requirements and consequences, is poor at present and information from and communication with doctors should be improved.
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Affiliation(s)
- G Benhamou-Jantelet
- Direction du Service des Soins Infirmiers - Hôpital Henri-Mondor, 51 avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
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Abdallah FS, Radaeda MS, Gaghama MK, Salameh B. Intensive Care Unit Physician's Attitudes on Do Not Resuscitate Order in Palestine. Indian J Palliat Care 2016; 22:38-41. [PMID: 26962279 PMCID: PMC4768448 DOI: 10.4103/0973-1075.173947] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: There is some ambiguity concerning the do-not-resuscitate (DNR) orders in the Arabic world. DNR is an order written by a doctor, approved by the patient or patient surrogate, which instructs health care providers to not do CPR when cardiac or respiratory arrest occurs. Therefore, this research study investigated the attitudes of Intensive Care Unit physicians and nurses on DNR order in Palestine. Materials and Methods: A total of 123 males and females from four different hospitals voluntarily participated in this study by signing a consent form; which was approved by the Ethical Committee at Birzeit University and the Ministry of Health. A non-experimental, quantitative, descriptive, and co-relational method was used, the data collection was done by a three page form consisting of the consent form, demographical data, and 24 item-based questionnaire based on a 5-point-Likert scale from strongly agree (score 1) to strongly disagree (score 5). Results: The Statistical Package for Social Sciences (SPSS) software program version 17.0 was used to analyze the data. Finding showed no significant relationship between culture and opinion regarding the DNR order, but religion did. There was statistical significance difference between the physicians’ and nurses’ religious beliefs, but there was no correlation. Moreover, a total of 79 (64.3%) physicians and nurses agreed with legalizing the DNR order in Palestine. Conclusion: There was a positive attitude towards the legalization of the DNR order in Palestine, and culture and religion did not have any affect towards their attitudes regarding the legalization in Palestine.
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Affiliation(s)
| | | | | | - Basma Salameh
- Department of Nursing, Birzeit University, Palestine
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Darlington ASE, Long-Sutehall T, Richardson A, Coombs MA. A national survey exploring views and experience of health professionals about transferring patients from critical care home to die. Palliat Med 2015; 29:363-70. [PMID: 25656087 DOI: 10.1177/0269216315570407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transferring critically ill patients home to die is poorly explored in the literature to date. This practice is rare, and there is a need to understand health care professionals' (HCP) experience and views. OBJECTIVES To examine (1) HCPs' experience of transferring patients home to die from critical care, (2) HCPs' views about transfer and (3) characteristics of patients, HCPs would hypothetically consider transferring home to die. DESIGN A national study developing a web-based survey, which was sent to the lead doctors and nurses in critical care units. SETTING/PARTICIPANTS Lead doctors and senior nurses (756 individuals) working in 409 critical care units across the United Kingdom were invited to participate in the survey. RESULTS In total, 180 (23.8%) completed surveys were received. A total of 65 (36.1%) respondents had been actively involved in transferring patients home to die and 28 (15.5%) had been involved in discussions that did not lead to transfer. Respondents were supportive of the idea of transfer home to die (88.8%). Patients identified by respondents as unsuitable for transfer included unstable patients (61.8%), intubated and ventilated patients (68.5%) and patients receiving inotropes (65.7%). There were statistically significant differences in views between those with and without experience and between doctors and nurses. Nurses and those with experience tended to have more positive views. CONCLUSION While transferring patients home to die is supported in critical care, its frequency in practice remains low. Patient stability and level of intervention are important factors in decision-making in this area. Views held about this practice are influenced by previous experience and the professional role held.
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Affiliation(s)
| | | | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Maureen A Coombs
- Faculty of Health Sciences, University of Southampton, Southampton, UK Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
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Patient and healthcare professional factors influencing end-of-life decision-making during critical illness: A systematic review*. Crit Care Med 2011; 39:1174-89. [DOI: 10.1097/ccm.0b013e31820eacf2] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Fumis RRL, Deheinzelin D. Respiratory support withdrawal in intensive care units: families, physicians and nurses views on two hypothetical clinical scenarios. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R235. [PMID: 21190560 PMCID: PMC3220008 DOI: 10.1186/cc9390] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2010] [Revised: 11/27/2010] [Accepted: 12/29/2010] [Indexed: 12/05/2022]
Abstract
Introduction Evidence suggests that dying patients' physical and emotional suffering is inadequately treated in intensive care units. Although there are recommendations regarding decisions to forgo life-sustaining therapy, deciding on withdrawal of life support is difficult, and it is also difficult to decide who should participate in this decision. Methods We distributed a self-administered questionnaire in 13 adult intensive care units (ICUs) assessing the attitudes of physicians and nurses regarding end-of-life decisions. Family members from a medical-surgical ICU in a tertiary cancer hospital were also invited to participate. Questions were related to two hypothetical clinical scenarios, one with a competent patient and the other with an incompetent patient, asking whether the ventilator treatment should be withdrawn and about who should make this decision. Results Physicians (155) and nurses (204) of 12 ICUs agreed to take part in this study, along with 300 family members. The vast majority of families (78.6%), physicians (74.8%) and nurses (75%) want to discuss end-of-life decisions with competent patients. Most of the physicians and nurses desire family involvement in end-of-life decisions. Physicians are more likely to propose withdrawal of the ventilator with competent patients than with incompetent patients (74.8% × 60.7%, P = 0.028). When the patient was incompetent, physicians (34.8%) were significantly less prone than nurses (23.0%) and families (14.7%) to propose decisions regarding withdrawal of the ventilator support (P < 0.001). Conclusions Physicians, nurses and families recommended limiting life-support therapy with terminally ill patients and favored family participation. In decisions concerning an incompetent patient, physicians were more likely to maintain the therapy.
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Affiliation(s)
- Renata R L Fumis
- Unidade de Terapia Intensiva, Centro de Tratamento e Pesquisa Hospital AC Camargo, Rua Prof, Antônio Prudente, 211 - São Paulo, SP, Brazil CEP 01509-900.
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10
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Prognostication in acutely admitted older patients by nurses and physicians. J Gen Intern Med 2008; 23:1883-9. [PMID: 18769983 PMCID: PMC2585689 DOI: 10.1007/s11606-008-0741-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Revised: 04/16/2008] [Accepted: 07/03/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND The process of prognostication has not been described for acutely hospitalized older patients. OBJECTIVE To investigate (1) which factors are associated with 90-day mortality risk in a group of acutely hospitalized older medical patients, and (2) whether adding a clinical impression score of nurses or physicians improves the discriminatory ability of mortality prediction. DESIGN Prospective cohort study. PARTICIPANTS Four hundred and sixty-three medical patients 65 years or older acutely admitted from November 1, 2002, through July 1, 2005, to a 1024-bed tertiary university teaching hospital. MEASUREMENTS At admission, the attending nurse and physician were asked to give a clinical impression score for the illness the patient was admitted for. This score ranged from 1 (high possibility of a good outcome) until 10 (high possibility of a bad outcome, including mortality). Of all patients baseline characteristics and clinical parameters were collected. Mortality was registered up to 90 days after admission. MAIN RESULTS In total, 23.8% (n = 110) of patients died within 90 days of admission. Four parameters were significantly associated with mortality risk: functional impairment, diagnosis malignancy, co-morbidities and high urea nitrogen serum levels. The AUC for the baseline model which included these risk factors (model 1) was 0.76 (95% CI 0.71 to 0.82). The AUC for the model using the risk factors and the clinical impression score of the physician (model 2) was 0.77 (0.71 to 0.82). The AUC for the model using the risk factors and the clinical impression score of the nurse (model 3) was 0.76 (0.71 to 0.82) and the AUC for the model, including the baseline covariates and the clinical impression score of both nurses and physicians was 0.77 (0.72 to 0.82). Adding clinical impression scores to model 1 did not significantly improve its accuracy. CONCLUSION A set of four clinical variables predicted mortality risk in acutely hospitalized older patients quite well. Adding clinical impression scores of nurses, physicians or both did not improve the discriminating ability of the model.
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Salahuddin N, Shafqat S, Mapara S, Khan S, Siddiqui S, Manasia R, Ahmad A. End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan. Intern Med J 2008; 38:307-13. [PMID: 18402559 DOI: 10.1111/j.1445-5994.2007.01595.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit. METHODS This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way ANOVA were used to compare differences in response between the groups. RESULTS One hundred and thirty-seven physicians and critical care nurses completed the survey. 'Brain death' was defined as an 'irreversible cessation of brainstem function' by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P-value < 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors (P-value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to 'sustain life at all costs' and only 8% gave religious beliefs as a reason. CONCLUSIONS There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians' and nurses' perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula.
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Affiliation(s)
- N Salahuddin
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
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Patient-related factors and circumstances surrounding decisions to forego life-sustaining treatment, including intensive care unit admission refusal*. Crit Care Med 2008; 36:2076-83. [DOI: 10.1097/ccm.0b013e31817c0ea7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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De Gendt C, Bilsen J, Vander Stichele R, Van Den Noortgate N, Lambert M, Deliens L. Nurses' involvement in 'do not resuscitate' decisions on acute elder care wards. J Adv Nurs 2007; 57:404-9. [PMID: 17291204 DOI: 10.1111/j.1365-2648.2007.04090.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM This paper reports the involvement of nurses in 'do not resuscitate' decision-making on acute elder care wards and their adherence to such decisions in the case of an actual cardiopulmonary arrest. BACKGROUND Previous literature showed that nurses are involved in half or less than half of 'do not resuscitate' decisions in hospitals, but their involvement in this decision-making on acute elder care wards in particular has not been investigated. METHOD A questionnaire was sent in 2002 to the head nurses of all acute elder care wards in Flanders, Belgium (n = 94). They were asked whether nurses had been involved in the last 'do not resuscitate' decision-making process on their ward and whether nurses 'never', 'rarely', 'sometimes', 'often' or 'always' started resuscitation in case of cardiopulmonary arrest of patients with 'do not resuscitate' status and of those without. RESULTS The response rate was 86.2% (n = 81). In 74.7% of the last 'do not resuscitate' decisions on acute elder care wards in Flanders, a nurse was involved in the decision-making process. For patients with 'do not resuscitate' status, 54.3% of respondents reported that cardiopulmonary resuscitation was 'never' started on their ward, 'rarely' on 39.5% and 'sometimes' on 6.2%. For patients without 'do not resuscitate' status, nurses started cardiopulmonary resuscitation 'rarely' or 'sometimes' on 22.2% of all wards, and 'often' or 'always' on 77.8%. CONCLUSION To make appropriate 'do not resuscitate' decisions and to avoid rash decision-making in cases of actual cardiopulmonary arrest, nurses should be involved early in 'do not resuscitate' decision-making. If institutional 'do not resuscitate' guidelines were to stress more clearly the important role of nurses in all kinds of end-of-life decisions, this might improve the 'do not resuscitate' decision-making process.
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Affiliation(s)
- Cindy De Gendt
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.
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Moselli NM, Debernardi F, Piovano F. Forgoing life sustaining treatments: differences and similarities between North America and Europe. Acta Anaesthesiol Scand 2006; 50:1177-86. [PMID: 17067320 DOI: 10.1111/j.1399-6576.2006.01150.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities. METHODS A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed. RESULTS There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present. CONCLUSION Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.
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Affiliation(s)
- N M Moselli
- Unit of Anaesthesiology, Intensive Care and Pain Therapy, Institute for Cancer Research and Treatment (IRCC), Candiolo (Torino), Italy.
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Puntillo KA, McAdam JL. Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Crit Care Med 2006; 34:S332-40. [PMID: 17057595 DOI: 10.1097/01.ccm.0000237047.31376.28] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.
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Affiliation(s)
- Kathleen A Puntillo
- Department of Physiological Nursing, University of California, San Francisco, California, USA
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Carter G, Morris GM, VandeKieft GK, Owens D. Ethics roundtable. Am J Hosp Palliat Care 2006; 23:59-64. [PMID: 16450664 DOI: 10.1177/104990910602300110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Greg Carter
- Rehabilitation Services, Providence Healthcare System, Centralia, Washington, USA
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Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004; 30:770-84. [PMID: 15098087 DOI: 10.1007/s00134-004-2241-5] [Citation(s) in RCA: 311] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2003] [Accepted: 02/19/2004] [Indexed: 10/26/2022]
Abstract
The jurors identified numerous problems with end of life in the ICU including variability in practice, inadequate predictive models for death, elusive knowledge of patient preferences, poor communication between staff and surrogates, insufficient or absent training of health-care providers, the use of imprecise and insensitive terminology, and incomplete documentation in the medical records. The jury strongly recommends that research be conducted to improve end-of-life care. The jury advocates a "shared" approach to end-of-life decision-making involving the caregiver team and patient surrogates. Respect for patient autonomy and the intention to honour decisions to decline unwanted treatments should be conveyed to the family. The process is one of negotiation, and the outcome will be determined by the personalities and beliefs of the participants. Ultimately, it is the attending physician's responsibility, as leader of the health-care team, to decide on the reasonableness of the planned action. In the event of conflict, the ICU team may agree to continue support for a predetermined time. Most conflicts can be resolved. If the conflict persists, however, an ethics consultation may be helpful. Nurses must be involved in the process. The patient must be assured of a pain-free death. The jury of the Consensus Conference subscribes to the moral and legal principles that prohibit administering treatments specifically designed to hasten death. The patient must be given sufficient analgesia to alleviate pain and distress; if such analgesia hastens death, this "double effect" should not detract from the primary aim to ensure comfort.
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Affiliation(s)
- Jean Carlet
- Réanimation Polyvalente, Fondation Hopital St Joseph, 185 rue Raymond Losserand, 75674 Paris CEDEX 14, France.
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Myrianthefs P, Kalafati M, Lemonidou C, Minasidou E, Evagelopoulou P, Karatzas S, Baltopoulos G. Efficacy of CPR in a general, adult ICU. Resuscitation 2003; 57:43-8. [PMID: 12668298 DOI: 10.1016/s0300-9572(02)00432-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AIM To investigate the initial cardiopulmonary resuscitation (CPR) success rate and long term survival in an Intensive care unit (ICU) population. PATIENTS All patients with cardiac arrest over a 2-year-period (1999-2000) in a general, adult ICU of a general hospital of Athens. METHODS Retrospective collection of clinical data concerning patients, CPR characteristics and survival rates. RESULTS We examined 111 ICU patients, aged 56.4+/-1.9 years (72 males). SAPS II score was 43.9+/-3.8. CPR was performed in 98.2% of the patients within 30 s. Initial restoration of cardiac function (RCF) and successful CPR rate was 100% while 24 h survival was 9.2%. Survivors at 24 h were younger, mainly males, with lower SAPS II score, mainly with pulmonary disease, ventricular fibrillation or ventricular tachycardia (8/10) and initial pupil reactivity (5/10). Four patients required more than one cycle of CPR. Survival to discharge was zero. CONCLUSION Although the initial successful CPR rate in ICU patients may be high, long term survival and hospital discharge is disappointing. Although ICU patients are better monitored and treated in a timely fashion, they are disadvantaged by chronic underlying diseases, severe current medical illnesses and multi organ dysfunction syndrome (MODS) leads to worst outcome after CPR compared with in-ward patients.
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Affiliation(s)
- Pavlos Myrianthefs
- Athens University School of Nursing ICU at 'KAT' General Hospital, Nikis 2, Kifissia, 14561, Athens, Greece.
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Frick S, Uehlinger DE, Zuercher Zenklusen RM. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors--a prospective comparative study. Crit Care Med 2003; 31:456-61. [PMID: 12576951 DOI: 10.1097/01.ccm.0000049945.69373.7c] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE First, to assess the pattern of the prediction of intensive care unit patients' outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictions with the quality of life reported by the surviving patients. DESIGN Prospective opinion survey of critical care providers; comparison with follow-up for survival, functional status, and quality of life. SETTING Six-bed medical intensive care unit subunit of a 1,000-bed tertiary care, university hospital. PATIENTS All patients older than 18 yrs, admitted to the medical intensive care unit for >24 hrs over a 1-yr period (December 1997 to November 1998). INTERVENTIONS Daily judgment of eventual futility of medical interventions by nurses and doctors with respect to survival and future quality of life. Telephone interviews with discharged patients for quality of life and functional status 6 months after intensive care unit admission. MEASUREMENTS AND MAIN RESULTS Data regarding 521 patients including 1,932 daily judgments by nurses and doctors were analyzed. Disagreement on at least one of the daily judgments by nurses and doctors was found in 21% of all patients and in 63% of the dying patients. The disagreements more frequently concerned quality of life than survival. The higher the Simplified Acute Physiology Score and the longer the intensive care unit stay, the more divergent judgments were observed (p <.001). In surviving and dying patients, nurses gave more pessimistic judgment and considered withdrawal more often than did doctors (p <.001). Patients only rarely indicated bad quality of life (6%) and severe physical disability (2%) 6 months after intensive care unit admission. Compared with patients' own assessment, neither nurses nor doctors correctly predicted quality of life; false pessimistic and false optimistic appreciation was given. CONCLUSIONS Disagreement between nurses and doctors was frequent with respect to their judgment of futility of medical interventions. Disagreements most often concerned the most severely ill patients. Nurses, being more pessimistic in general, were more often correct than doctors in the judgment of dying patients but proposed treatment withdrawal in some very sick patients who survived. Future quality of life cannot reliably be predicted either by doctors or by nurses.
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Affiliation(s)
- Sonia Frick
- Medical ICU, University Hospital, Geneva, Switzerland
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20
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21
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Campbell ML, Guzman JA. Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest 2003; 123:266-71. [PMID: 12527629 DOI: 10.1378/chest.123.1.266] [Citation(s) in RCA: 249] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
STUDY OBJECTIVES To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia (GCI) after cardiopulmonary resuscitation and multiple organ system failure (MOSF) in comparison to historical control subjects. DESIGN Comparative study of retrospective and prospective cohorts. SETTING Medical ICU of a university hospital. INTERVENTIONS Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review were compared to proactive case finding facilitated by the inpatient palliative care service. Interventions included identification of patient's advance directives or preferences about end-of life care, if any; assistance with discussion of the prognosis and treatment options with patients or their surrogates; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures. RESULTS Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation, a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals (4.7 +/- 2.4 days and 3.5 +/- 0.5 days for patients with MOSF and GCI, respectively [mean +/- SE]). The proactive case finding approach decreased hospital length of stay (mean, 20.6 +/- 4.1 days vs 15.1 +/- 2.5 days and 8.6 +/- 1.6 days vs 4.7 +/- 0.6 days for MOSF and GCI patients, respectively; p = 0.063 and < 0.001, respectively). More importantly, a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals (7.3 +/- 2.9 days vs 2.2 +/- 0.8 days and 6.3 +/- 1.2 days vs 3.5 +/- 0.4 days for MOSF and GCI patients, respectively; p < 0.05 for both), decreased the time dying patients with MOSF remained in the ICU, and reduced the use of nonbeneficial resources, thus reducing the cost of care. CONCLUSIONS Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.
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Affiliation(s)
- Margaret L Campbell
- Palliative Care Service, Detroit Receiving Hospital, and the Division of Pulmonary and Critical Care Medicine, Wayne State University, Detroit, MI, USA
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22
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Buchman TG, Cassell J, Ray SE, Wax ML. Who should manage the dying patient?: Rescue, shame, and the surgical ICU dilemma. J Am Coll Surg 2002; 194:665-73. [PMID: 12022609 DOI: 10.1016/s1072-7515(02)01157-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Ryan CJ, Santucci MA, Gattuso MC, Czurylo K, O'Brien J, Stark B. Perceptions about advance directives by nurses in a community hospital. CLIN NURSE SPEC 2001; 15:246-52. [PMID: 11855479 DOI: 10.1097/00002800-200111000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite the legal mandate for hospitals to comply with the Patient Self-Determination Act and recommendations by the American Nurses' Association for nurses to advocate for the participation of patients in end-of-life decisions, nurses' compliance has been less than enthusiastic. This study used an exploratory descriptive design and a 10-item self-reported questionnaire, which included both multiple-choice and open-ended questions. This study examined nurses' knowledge and comfort with the implementation of the Patient Self-Determination Act. An analysis of this research shows that two major themes emerged: a need for more education involving advance directives and a desire to have other healthcare workers involved in informing patients about advance directives.
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Affiliation(s)
- C J Ryan
- Alexian Brothers Medical Center, Elk Grove Village, Ill 60007, USA.
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24
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Burns JP, Mitchell C, Griffith JL, Truog RD. End-of-life care in the pediatric intensive care unit: Attitudes and practices of pediatric critical care physicians and nurses. Crit Care Med 2001; 29:658-64. [PMID: 11373439 DOI: 10.1097/00003246-200103000-00036] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the attitudes and practices of pediatric critical care attending physicians and pediatric critical care nurses on end-of-life care. DESIGN Cross-sectional survey. SETTING A random sample of clinicians at 31 pediatric hospitals in the United States. MEASUREMENTS AND MAIN RESULTS The survey was completed by 110/130 (85%) physicians and 92/130 (71%) nurses. The statement that withholding and withdrawing life support is unethical was not endorsed by any of the physicians or nurses. More physicians (78%) than nurses (57%) agreed or strongly agreed that withholding and withdrawing are ethically the same (p < .001). Physicians were more likely than nurses to report that families are well informed about the advantages and limitations of further therapy (99% vs. 89%; p < .003); that ethical issues are discussed well within the team (92% vs. 59%; p < .0003), and that ethical issues are discussed well with the family (91% vs. 79%; p < .0002). On multivariable analyses, fewer years of practice in pediatric critical care was the only clinician characteristic associated with attitudes on end-of-life care dissimilar to the consensus positions reached by national medical and nursing organizations on these issues. There was no association between clinician characteristics such as their political or religious affiliation, practice-related variables such as the size of their intensive care unit or the presence of residents and fellows, and particular attitudes about end-of-life care. CONCLUSIONS Nearly two-thirds of pediatric critical care physicians and nurses express views on end-of-life care in strong agreement with consensus positions on these issues adopted by national professional organizations. Clinicians with fewer years of pediatric critical care practice are less likely to agree with this consensus. Compared with physicians, nurses are significantly less likely to agree that families are well informed and ethical issues are well discussed when assessing actual practice in their intensive care unit. More collaborative education and regular case review on bioethical issues are needed as part of standard practice in the intensive care unit.
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MESH Headings
- Adult
- Analysis of Variance
- Attitude of Health Personnel
- Attitude to Death
- Child
- Child Advocacy
- Critical Care/organization & administration
- Critical Care/psychology
- Cross-Sectional Studies
- Decision Making
- Ethics, Medical
- Ethics, Nursing
- Health Knowledge, Attitudes, Practice
- Hospitals, Pediatric
- Humans
- Intensive Care Units, Pediatric
- Medical Staff, Hospital/education
- Medical Staff, Hospital/psychology
- Middle Aged
- Multivariate Analysis
- Nursing Staff, Hospital/education
- Nursing Staff, Hospital/psychology
- Pediatrics/methods
- Practice Patterns, Physicians'/organization & administration
- Surveys and Questionnaires
- Terminal Care/organization & administration
- Terminal Care/psychology
- United States
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Affiliation(s)
- J P Burns
- Department of Anesthesia, Harvard Medical School, Children's Hospital, USA
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25
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Baggs JG, Schmitt MH. End-of-life decisions in adult intensive care: current research base 158 and directions for the future. Nurs Outlook 2000; 48:158-64. [PMID: 10953074 DOI: 10.1067/mno.2000.100364] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- J G Baggs
- University of Rochester, School of Nursing, Rochester, New York
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26
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Richter J, Eisemann MR. The compliance of doctors and nurses with do-not-resuscitate orders in Germany and Sweden. Resuscitation 1999; 42:203-9. [PMID: 10625161 DOI: 10.1016/s0300-9572(99)00092-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A questionnaire based on a case-scenario offering three levels of available information about the patients' wishes was circulated with the objective to evaluate compliance with do-not-resuscitate orders (DNR) and advance directives (AD) from a cross-cultural perspective. Replies from 191 doctors and 182 nurses from Germany and 104 doctors and 122 nurses from Sweden were studied. The frequency of cardiopulmonary resuscitation (CPR) performed against the patients wishes varied between 32.5% (German doctors for DNR-scenario) and 8.3% (Swedish nurses for AD-scenario). The variance regarding the CPR decision could be explained by the help obtained by increasing information regarding the patients wishes and preferred treatment options. Since compliance is related to detailed information given by the patient the use of DNRs and ADs should be encouraged to a larger extent.
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Affiliation(s)
- J Richter
- Department of Psychiatry and Psychotherapy, Rostock University Hospital, Germany.
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27
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Abstract
Medical futility is a recent, complex bioethical issue. There is disagreement about how futility should be defined and who should be involved in futility decisions when an impasse exists between the patient/family and the physician. Bioethical discussions about Quinlan and Cruzan of the past have been replaced with the Wanglie, Baby K, and Linares cases--all of which involved critical care settings. Nurses often are involved in the debate and encounter ethical conflicts. Cost-containment, managed care, scarce resource allocation, and care due the elderly have fueled the debate. Key issues and their importance for critical care nurses will be reviewed.
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Affiliation(s)
- J F Cogliano
- Department of Nursing, College of Health Professions, Towson University, Maryland, USA
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28
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Miguel N, León MA, Ibáñez J, Díaz RM, Merten A, Gahete F. Sepsis-related organ failure assessment and withholding or withdrawing life support from critically ill patients. Crit Care 1998; 2:61-66. [PMID: 11056711 PMCID: PMC29003 DOI: 10.1186/cc127] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/1998] [Revised: 04/23/1998] [Accepted: 04/23/1998] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND: We studied the incidence of withholding or withdrawing therapeutic measures in intensive care unit (ICU) patients, as well as the possible implications of sepsis-related organ failure assessment (SOFA) in the decision-making process and the ethical conflicts emerging from these measures. METHODS: The patients (n = 372) were placed in different groups: those surviving 1 year after ICU admission (S; n = 301), deaths at home (DH; n = 2), deaths in the hospital after ICU discharge (DIH; n = 13) and deaths in the ICU (DI; n = 56). The last group was divided into the following subgroups: two cardiovascular deaths (CVD), 20 brain deaths (BD), 25 deaths after withholding of life support (DWH) and nine deaths after withdrawal of life support (DWD). RESULTS: APACHE III, daily therapeutic intervention scoring system (TISS) and daily SOFA scores were good mortality predictors. The length of ICU stay in DIH (20 days) and in DWH (14 days) was significantly greater than in BD (5 days) or in S (7 days). The number of days with a maximum SOFA score was greater in DWD (5 days) than in S, BD or DWH (2 days). CONCLUSIONS: Daily SOFA is a useful parameter when the decision to withhold or withdraw treatment has to be considered, especially if the established measures do not improve the clinical condition of the patient. Although making decisions based on the use of severity parameters may cause ethical problems, it may reduce the anxiety level. Additionally, it may help when considering the need for extraordinary measures or new investigative protocols for better management of resources.
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Affiliation(s)
- Nolla Miguel
- Intensive Care Unit, Hospital General de Catalunya, C/ Gomera s/n, 08190, Sant Cugat del Vallès, Barcelona, Spain
| | - Mariá A León
- Intensive Care Unit, Hospital General de Catalunya, C/ Gomera s/n, 08190, Sant Cugat del Vallès, Barcelona, Spain
| | - Jordi Ibáñez
- Intensive Care Unit, Hospital General de Catalunya, C/ Gomera s/n, 08190, Sant Cugat del Vallès, Barcelona, Spain
| | - Rosa M Díaz
- Intensive Care Unit, Hospital General de Catalunya, C/ Gomera s/n, 08190, Sant Cugat del Vallès, Barcelona, Spain
| | - Alfredo Merten
- Intensive Care Unit, Hospital General de Catalunya, C/ Gomera s/n, 08190, Sant Cugat del Vallès, Barcelona, Spain
| | - Francesc Gahete
- Intensive Care Unit, Hospital General de Catalunya, C/ Gomera s/n, 08190, Sant Cugat del Vallès, Barcelona, Spain
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