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Affiliation(s)
- David L S Ryon
- Department of Medicine, Deaconess Health System, Evansville, IN
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Ding CQ, Zhang YP, Wang YW, Yang MF, Wang S, Cui NQ, Jin JF. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland. World J Emerg Med 2020; 11:231-237. [PMID: 33014219 DOI: 10.5847/wjem.j.1920-8642.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Zhang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Wei Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min-Fei Yang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sa Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Nian-Qi Cui
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing-Fen Jin
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review. J Crit Care 2020; 58:10-19. [PMID: 32278227 DOI: 10.1016/j.jcrc.2020.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/24/2020] [Accepted: 03/29/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE Intensive care unit health care professionals must be skilled in providing end-of-life care. Crucial in this kind of care is end-of-life decision-making, which is a complex process involving a variety of stakeholders and requiring adequate justification. The aim of this systematic review is to analyse papers tackling ethical issues in relation to end-of-life decision-making in intensive care units. It explores the ethical positions, arguments and principles. METHODS A literature search was conducted in bibliographic databases and grey literature sources for the time period from 1990 to 2019. The constant comparative method was used for qualitative analysis of included papers in order to identify ethical content including ethical positions, ethical arguments, and ethical principles used in decision-making process. RESULTS In the 15 included papers we have identified a total of 43 ethical positions. Ten positions were identified as substantive, 33 as procedural. Twelve different ethical principles emerged from the ethical arguments. The most frequently used principles are the principles of beneficence, autonomy and nonmaleficence. CONCLUSIONS We have demonstrated that recommendations and guidelines designed specifically by intensive or critical care experts for intensive care units promote similar ethical positions, with minimal dissenting positions.
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Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth 2020; 31:29-46. [PMID: 32284707 PMCID: PMC7144300 DOI: 10.1080/11287462.2020.1736243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/15/2020] [Indexed: 11/12/2022] Open
Abstract
When it is ethically justifiable to stop medical treatment? For many Muslim patients, families, and clinicians this ethical question remains a challenging one as Islamic ethico-legal guidance on such matters remains scattered and difficult to interpret. In light of this gap, we conducted a systematic literature review to aggregate rulings from Islamic jurists and juridical councils on whether, and when, it is permitted to withdraw and/or withhold life-sustaining care. A total of 16 fatwās were found, 8 of which were single-author rulings, and 8 represented the collective view of a juridical council. The fatwās are similar in that nearly all judge that Islamic law, provided certain conditions are met, permits abstaining from life-sustaining treatment. Notably, the justifying conditions appear to rely on physician assessment of the clinical prognosis. The fatwās differ when it comes to what conditions justify withdrawing or withholding life- sustaining care. Our analyses suggest that while notions of futility greatly impact the bioethical discourse regarding with holding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. Therefore, clinicians, Islamic jurists, and bioethicists need to come together in order to unify a conception of medical futility and relate it to the ethics of withholding and/or withdrawal of treatment.
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Affiliation(s)
- Afshan Mohiuddin
- Initiative on Islam and Medicine, Program on Medicine and Religion, The University of Chicago, Chicago, IL, USA
- Department of Internal Medicine, University Hospitals Regional Medical Center, Macomb Township, MI, USA
| | | | - Shoaib Rasheed
- Department of Internal Medicine, Henry Ford Macomb Hospital, Chicago, IL, USA
| | - Aasim I. Padela
- Initiative on Islam and Medicine, Program on Medicine and Religion, The University of Chicago, Chicago, IL, USA
- Section of Emergency Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
- MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA
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Trowbridge A, Bamat T, Griffis H, McConathey E, Feudtner C, Walter JK. Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital. Acad Pediatr 2020; 20:81-88. [PMID: 31376579 PMCID: PMC6944767 DOI: 10.1016/j.acap.2019.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 06/11/2019] [Accepted: 07/16/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Pediatric residents are expected to be competent in end-of-life (EOL) care. We aimed to quantify pediatric resident exposure to patient deaths, and the context of these exposures. METHODS Retrospective chart review of all deceased patients at one children's hospital over 3 years collected patient demographics, time, and location of death. Mode of death was determined after chart review. Each death was cross-referenced with pediatric resident call schedules to determine residents involved within 48 hours of death. Descriptive statistics are presented. RESULTS Of 579 patients who died during the study period, 46% had resident involvement. Most deaths occurred in the NICU (30% of all deaths); however, resident exposure to EOL care most commonly occurred in the PICU (52% of resident exposures) and were after withdrawals of life-sustaining therapy (41%), followed by nonescalation (31%) and failed resuscitation (15%). During their postgraduate year (PGY)-1, <1% of residents encountered a patient death. During PGY-2 and PGY-3, 96% and 78%, respectively, of residents encountered at least 1 death. During PGY-2, residents encountered a mean of 3.5 patient deaths (range 0-12); during PGY-3, residents encountered a mean of 1.4 deaths (range 0-5). Residents observed for their full 3-year residency encountered a mean of 5.6 deaths (range 2-10). CONCLUSIONS Pediatric residents have limited but variable exposure to EOL care, with most exposures in the ICU after withdrawal of life-sustaining technology. Educators should consider how to optimize EOL education with limited clinical exposure, and design resident support and education with these variable exposures in mind.
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Affiliation(s)
- Amy Trowbridge
- Division of Bioethics and Palliative Care, Seattle Children's Hospital and University of Washington (A Trowbridge), Seattle, Wash.
| | - Tara Bamat
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia (T Bamat, E McConathey, C Feudtner, and JK Walter), Philadelphia, Pa
| | - Heather Griffis
- PolicyLab, The Children's Hospital of Philadelphia (H Griffis), Philadelphia, Pa
| | - Eric McConathey
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia (T Bamat, E McConathey, C Feudtner, and JK Walter), Philadelphia, Pa
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia (T Bamat, E McConathey, C Feudtner, and JK Walter), Philadelphia, Pa; Department of Medical Ethics, The Children's Hospital of Philadelphia (C Feudtner and JK Walter), Philadelphia, Pa
| | - Jennifer K Walter
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia (T Bamat, E McConathey, C Feudtner, and JK Walter), Philadelphia, Pa; Department of Medical Ethics, The Children's Hospital of Philadelphia (C Feudtner and JK Walter), Philadelphia, Pa
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Rocker G, Dunbar S. Withholding or Withdrawal of Life Support: The Canadian Critical Care Society Position Paper. J Palliat Care 2019. [DOI: 10.1177/082585970001601s10] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Graeme Rocker
- Canadian Critical Care Society Provincial Representative for Nova Scotia
| | - Scott Dunbar
- Postgraduate Diploma in Medical Law and Medical Ethics, (KCL), and Fellow in Bioethics, Cleveland Clinic Foundation, Ohio, and Medical Ethicist, Halifax, Nova Scotia, Canada
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Masri C, Farrell CA, Lacroix J, Rocker G, Shemie SD. Decision Making and End-of-Life Care in Critically Ill Children. J Palliat Care 2019. [DOI: 10.1177/082585970001601s09] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives 1) To comment on the medical literature on decision making regarding end-of-life therapy, 2) to analyze the data on disagreement about such therapy, including palliative care, and withholding and withdrawal practices for critically ill children in the pediatric intensive care unit (PICU), and 3) to make some general recommendations. Data Sources and Study Selection All papers published in peer-reviewed journals, and all chapters on end-of-life therapy, or on conflict between parents and caregivers about end-of-life decisions in the PICU were retrieved. Results We found three case series, three systematic descriptive studies, two qualitative studies, four surveys, and many legal opinions, editorials, reviews, guidelines, and book chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life. Risk factors in persistent conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event. Conclusion Making decisions about end-of-life care is a frequent event in the PICU. Children may need both intensive care and palliative care concurrently at different stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.
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Affiliation(s)
- Christian Masri
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Catherine Ann Farrell
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Jacques Lacroix
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Graeme Rocker
- Department of Medicine, The Queen Elizabeth II Health Center, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Sam D. Shemie
- Pediatric Intensive Care Unit, The Hospital For Sick Children, and Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Keenan SP, Mawdsley C, Plotkin D, Webster GK, Priestap F. Withdrawal of Life Support: How the Family Feels, and Why. J Palliat Care 2019. [DOI: 10.1177/082585970001601s08] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objectives of this study were to develop an instrument to assess the satisfaction of family members with withdrawal of life support (WLS), and to determine which factors are associated with greater levels of satisfaction. To do this, we developed a self-administered questionnaire that was sent to the next-of-kin of intensive care unit (ICU) patients dying following WLS. Over a six-month period, 69 patients died following WLS in the ICU. Three letters were returned “address unknown”, 33 did not respond, and 33 responded, of whom 29 agreed to participate (29/66 = 44% of those contacted). Of these, 24 (83%) strongly agreed with the patient's death being compassionate and dignified, one moderately agreed, one mildly agreed, one was neutral and two strongly disagreed. Items associated with greater satisfaction included: the process of WLS being well explained, WLS proceeding as expected, patient appearing comfortable, family/friends prepared for the decision, appropriate person initiating discussion, adequate privacy during WLS, chance to voice concerns. The study suggests factors that are important to consider in ensuring family comfort with the process of withdrawing life support.
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Affiliation(s)
- Sean P. Keenan
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Division of Critical Care Medicine, Department of Medicine, London Health Sciences Centre, University of Western Ontario, and Critical Care Research Network (CCR-Net), London Health Sciences Centre, London, Ontario
| | - Cathy Mawdsley
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, and Critical Care Program, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - Donna Plotkin
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, Department of Social Work, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - Gregory K. Webster
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, London, Ontario
| | - Fran Priestap
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, London, Ontario, Canada
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Pérez Pérez FM. [The suitability of therapeutic effort: An end-of-life strategy]. Semergen 2016; 42:566-574. [PMID: 26811015 DOI: 10.1016/j.semerg.2015.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 11/17/2015] [Accepted: 11/22/2015] [Indexed: 01/31/2023]
Abstract
End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged position to approach the life and values of our patients and their families, and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills.
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Affiliation(s)
- F M Pérez Pérez
- Servicio Provincial de Cádiz de Emergencias Sanitarias 061 Andalucía, Hospital Clínico de Puerto Real, Puerto Real, Cádiz, España.
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Irwin RS, Goorsky P. Giants in Chest Medicine. Chest 2015; 148:578-579. [DOI: 10.1378/chest.15-1474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Sprung CL, Paruk F, Kissoon N, Hartog CS, Lipman J, Du B, Argent A, Hodgson RE, Guidet B, Groeneveld ABJ, Feldman C. The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments. J Crit Care 2014; 29:890-5. [PMID: 25151218 DOI: 10.1016/j.jcrc.2014.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/23/2014] [Accepted: 06/21/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. METHODS Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. RESULTS Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. CONCLUSIONS Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Fathima Paruk
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, Children's Hospital and Sunny Hill Health Centre for Children, University British Columbia, Vancouver, British Columbia, Canada
| | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care, Jena, Germany
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Womens Hospital and The University of Queensland, Herston, Queensland, Australia
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Andrew Argent
- School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - R Eric Hodgson
- Department of Anaesthesia and Critical Care, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal eThekwini-Durban, KwaZulu-Natal, South Africa
| | - Bertrand Guidet
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Zhao Q, Zhang X, Fang Y, Gong J, Gu B, Ma G. Current situation and associated factors of withdrawing or withholding life support to patients in an intensive care unit of cancer center in China. PLoS One 2014; 9:e98545. [PMID: 24870360 PMCID: PMC4037202 DOI: 10.1371/journal.pone.0098545] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 05/04/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center. METHODS Three hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis. RESULTS Eighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support. CONCLUSIONS Withdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.
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Affiliation(s)
- Qingyu Zhao
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
- * E-mail:
| | - Xiaodan Zhang
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yi Fang
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jian Gong
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Baochun Gu
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Gang Ma
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China
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Herreros B, Ramnath VR, Bishop L, Pintor E, Martín MD, Sánchez-González MA. Clinical ethics protocols in the clinical ethics committees of Madrid. JOURNAL OF MEDICAL ETHICS 2014; 40:205-208. [PMID: 23579231 DOI: 10.1136/medethics-2012-100791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Currently, The nature and scope of Clinical Ethics Protocols (CEPs) in Madrid (Spain) are not well understood. OBJECTIVES The main objective is to describe the features of 'guideline/recommendation' type CEPs that have been or are being developed by existing Clinical Ethics Committees (CECs) in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development. METHODS We collected CEPs produced and in process by CECs accredited in the public hospitals in Madrid, Spain, from 1996 to 2008. RESULTS CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment (seven CEPs developed; two in process). If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate 'ethical problems at the end of life' category, this CEP subject emerges as the most common (eight developed; four in process). There is a relationship between the age of the CEC and the development of CEPs (the oldest CECs have developed more CEPs). CECs now seem to be more likely to engage in CEP development. CONCLUSIONS The CECs in Madrid, Spain, have developed a significant number of CEPs (30 in total and 10 in process) and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient.
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Affiliation(s)
- Benjamin Herreros
- Department of Biomedical Sciences, European University of Madrid, , Villaviciosa de Odon, Madrid, Spain
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Masood UR, Said A, Faris C, Al Mussady M, Al Jundi A. Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates. Int J Crit Illn Inj Sci 2014; 3:200-5. [PMID: 24404458 PMCID: PMC3883199 DOI: 10.4103/2229-5151.119201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients. Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Results: The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006). Conclusion: Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.
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Affiliation(s)
- Ur Rahman Masood
- Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Abuhasna Said
- Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Chedid Faris
- Department of Neonatal Intensive Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Mousab Al Mussady
- Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Amer Al Jundi
- Department of Pharmacy, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
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Huddle TS, Amos Bailey F. Pacemaker deactivation: withdrawal of support or active ending of life? THEORETICAL MEDICINE AND BIOETHICS 2012; 33:421-433. [PMID: 22351107 DOI: 10.1007/s11017-012-9213-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In spite of ethical analyses assimilating the palliative deactivation of pacemakers to commonly accepted withdrawings of life-sustaining therapy, many clinicians remain ethically uncomfortable with pacemaker deactivation at the end of life. Various reasons have been posited for this discomfort. Some cardiologists have suggested that reluctance to deactivate pacemakers may stem from a sense that the pacemaker has become part of the patient's "self." The authors suggest that Daniel Sulmasy is correct to contend that any such identification of the pacemaker is misguided. The authors argue that clinicians uncomfortable with pacemaker deactivation are nevertheless correct to see it as incompatible with the traditional medical ethics of withdrawal of support. Traditional medical ethics is presently taken by many to sanction pacemaker deactivation when such deactivation honors the patient's right to refuse treatment. The authors suggest that the right to refuse treatment applies to treatments involving ongoing physician agency. This right cannot underwrite patient demands that physicians reverse the effects of treatments previously administered, in which ongoing physician agency is no longer implicated. The permanently indwelling pacemaker is best seen as such a treatment. As such, its deactivation in the pacemaker-dependent patient is best seen not as withdrawal of support but as active ending of life. That being the case, clinicians adhering to the usual ethical analysis of withdrawal of support are correct to be uncomfortable with pacemaker deactivation at the end of life.
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Affiliation(s)
- Thomas S Huddle
- FOT 744, Division of General Internal Medicine, University of Alabama at Birmingham (UAB) School of Medicine, Birmingham VA Medical Center, Birmingham, AL 35294, USA.
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Datta R, Chaturvedi R, Rudra A, Jaideep CN. End of life issues in the intensive care units. Med J Armed Forces India 2012; 69:48-53. [PMID: 24532934 DOI: 10.1016/j.mjafi.2012.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Accepted: 03/23/2012] [Indexed: 11/16/2022] Open
Abstract
A structured discussion of End-of-Life (EOL) issues is a relatively new phenomenon in India. Personal beliefs, cultural and religious influences, peer, family and societal pressures affect EOL decisions. Indian law does not provide sanction to contentious issues such as do-not-resuscitate (DNR) orders, living wills, and euthanasia. Finally, published data on EOL decisions in Indian ICUs is lacking. What is needed is a prospective determination of which patients will benefit from aggressive management and life-support. A consensus regarding the concept of Medical Futility is necessary to give impetus to further discussion on more advanced policies including ideas such as Managed Care to restrict unnecessary health care costs, euthanasia, the principle of withhold and/or withdraw, ethical and moral guidelines that would govern decisions regarding futile treatment, informed consent to EOL decisions and do-not-resuscitate orders. This review examines the above concepts as practiced worldwide and looks at some landmark judgments that have shaped current Indian policy, as well as raising talking points for possible legislative intervention in the field.
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Affiliation(s)
- Rashmi Datta
- Senior Advisor, Anaesthesiology, Army Hospital (R&R), New Delhi, India
| | - R Chaturvedi
- Dean & Deputy Commandant, CH (AF), Bangalore 560 007, India
| | - A Rudra
- Commanding Officer, 408 Field Hospital, C/o 56 APO, India
| | - C N Jaideep
- Associate Professor, Anaesthesiology, AFMC, Pune 40, India
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Critical care physicians' approaches to negotiating with surrogate decision makers: a qualitative study. Crit Care Med 2012; 40:1080-7. [PMID: 22080645 DOI: 10.1097/ccm.0b013e31823c8d21] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe how critical care physicians manage conflicts with surrogates about withdrawing or withholding patients' life support. DESIGN Qualitative analysis of key informant interviews with critical care physicians during 2010. We transcribed interviews verbatim and used grounded theory to code and revise a taxonomy of themes and to identify illustrative quotes. SETTING Three academic medical centers, one academic-affiliated medical center, and four private practice groups or private hospitals in a large Midwestern city SUBJECTS Fourteen critical care physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physicians reported tailoring their approach to address specific reasons for disagreement with surrogates. Five common approaches were identified: 1) building trust; 2) educating and informing; 3) providing surrogates more time; 4) adjusting surrogate and physician roles; and 5) highlighting specific values. When mistrust was an issue, physicians endeavored to build a more trusting relationship with the surrogate before readdressing decision making. Physicians also reported correcting misunderstandings by providing targeted education, and some reported highlighting specific patient, surrogate, or physician values that they hoped would guide surrogates to agree with them. When surrogates struggled with decisionmaking roles, physicians attempted to reinforce the concept of substituted judgment. Physicians noted that some surrogates needed time to "come to terms" with the patent's illness before agreeing with physicians. Many physicians had witnessed colleagues negotiate in ways they found objectionable such as providing misleading information, injecting their own values into the negotiation or behaving unprofessionally toward surrogates. Although some physicians viewed their efforts to encourage surrogates' agreement as persuasive, others strongly denied persuading surrogates and described their actions as "guiding" or "negotiating." CONCLUSIONS Physicians reported using a tailored approach to resolve decisional conflicts about life support and attempted to change surrogates' decisions in accordance with what the physician thought was in the patients' best interests. Although physicians acknowledged their efforts to change surrogates' decisions, many physicians did not perceive these efforts as persuasive.
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Damghi N, Belayachi J, Aggoug B, Dendane T, Abidi K, Madani N, Zekraoui A, Belabes AB, Zeggwagh AA, Abouqal R. Withholding and withdrawing life-sustaining therapy in a Moroccan Emergency Department: an observational study. BMC Emerg Med 2011; 11:12. [PMID: 21838861 PMCID: PMC3199862 DOI: 10.1186/1471-227x-11-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 08/12/2011] [Indexed: 11/18/2022] Open
Abstract
Background Withdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions. Method A survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record. Results 177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases. Conclusion Life-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.
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Affiliation(s)
- Nada Damghi
- Medical Emergency Department, Ibn Sina University Hospital, 10000, Rabat, Morocco
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21
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Abstract
BACKGROUND Intracerebral hemorrhage (ICH) care can vary among centers and previous studies have demonstrated differences in ICH outcome based on variations in patient care in various settings. The purpose of this paper is to present the design of an evidence-based dataset of elements of a new ICH specific intensity of care quality metrics. METHODS The articles were identified based on personal knowledge of the subject supplemented by data derived from multi-center randomized trials, and selected non-randomized or observational clinical studies. The information was identified with multiple searches on MEDLINE from 1986 through 2009. The current guidelines from American Heart Association (AHA)/American Stroke Association (ASA) Stroke Council and The European Stroke Initiative (EUSI) Writing Committee for management of ICH were reviewed extensively for identifying quality indicators and available scientific evidence. For certain elements where stroke-specific data was not available, data derived from other disease process with direct relevance was used. RESULTS A total of 26 quality indicators related to 18 facets of care with thresholds for quality response were identified. A pilot study was performed to asses and score 1300 (26 indicator per patientX25 patientsX2 raters) quality indicators. The minimum proportion of patients meeting quality parameter ranged from 44% to 100% depending upon the variable. The lowest performance scores were observed in the early intubation and mechanical ventilation, treatment of significant intracranial mass effect or transtentorial herniation, and timely acquisition of neuroimaging. The highest performance scores were seen in treatment of any seizure within 2 weeks of admission, status epilepticus, and prevention of gastric ulcer. CONCLUSIONS The next step in development of a new ICH specific intensity of care quality metrics is validation and refinement of the quality indicators and thresholds presented in the current report. Future activities may include selection and validation based on consensus of experts and application of the system to a large series of patients with ICH and assessment of relationship of components in isolation and as a group to outcome after severity adjustment.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, 12-100 PWB, 516 Delaware St. SE, Minneapolis, MN 55455, USA.
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Abstract
The limited capacity and resources of a Field Hospital Intensive Care Unit may necessitate the triage or prioritisation of critically ill patients requiring admission. The use of critical care resources by members of the local population in certain Areas of Operation, who can not be discharged or transferred to equivalent care in their local health service, impacts significantly on bed occupancy. Therefore available resources must be distributed efficiently and equitably with decisions guided by the principles of advocacy for the patient. Patients must be admitted only on the concept of potential benefit and reasonable chance of recovery, which would not be available elsewhere. Discriminating between seriously ill patients before admission and decision making regarding withdrawal of care is very difficult. Senior clinicians working regularly in a critical care setting demonstrate a better level of discrimination in assessing outcome of seriously ill patients and are best placed to make decisions regarding admission, continuation and withdrawal of treatment.
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Affiliation(s)
- K Birch
- Department of Anaesthetics, North Bristol NHS Trust, Southmead Hospital, Bristol.
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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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Affiliation(s)
- J J Paris
- Department of Theology, Boston College, Chestnut Hill, MA 02467, USA.
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Hill QA. Intensify, resuscitate or palliate: Decision making in the critically ill patient with haematological malignancy. Blood Rev 2010; 24:17-25. [DOI: 10.1016/j.blre.2009.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bitsori M, Georgopoulos D, Galanakis E. The question of futility and Roger C. Bone. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2009; 12:477-481. [PMID: 19259787 DOI: 10.1007/s11019-009-9196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Accepted: 02/13/2009] [Indexed: 05/27/2023]
Abstract
Medical futility, one of the most debated end-of-life issues in medical ethics, has been discussed among physicians and scholars for years but remained an unresolved question. Roger C. Bone (1941-1997), an outstanding pulmonologist and critical care specialist, devoted his last years to ethical issues of terminal care, while facing himself metastatic renal cancer. Criticising the abuse of technology in terminal care and the administrative and financial interference on medical decisions, he bequeathed important points on futility, bringing also patients' views into attention. He stressed the importance of physician-patient relationship and prompted physicians to remain honest with their patients and stand with them till their very last moments. Roger Bone's insight of futility, terminal care and physician-patient relationship remains an important legacy for health care professionals and for families and patients facing end-of-life issues.
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Affiliation(s)
- Maria Bitsori
- Department of Paediatrics, University of Crete, P.O. Box 1352, 71500, Heraklion, Greece.
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Varelas PN, Hacein-Bey L, Schultz L, Conti M, Spanaki MV, Gennarelli TA. Withdrawal of life support in critically ill neurosurgical patients and in-hospital death after discharge from the neurosurgical intensive care unit. Clinical article. J Neurosurg 2009; 111:396-404. [PMID: 19374492 DOI: 10.3171/2009.3.jns08493] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI). METHODS Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI. RESULTS One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03-1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04-1.07), transfer from another hospital (OR 3.7, 95% CI 1.6-8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4-12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2-17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4-20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9-16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92-0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1-1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83-47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate. CONCLUSIONS The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI-including patient age and the severity and type of neurological injury-play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.
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Affiliation(s)
- Panayiotis N Varelas
- Department of Neurology, Henry Ford Hospital, K-11, 2799 West Grand Boulevard, Detroit, Michigan 48202, USA.
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Abstract
In the face of acute life-threatening illness, especially when superimposed upon chronic illness, patients and their families often face great difficulty in establishing treatment preferences and goals of care. This is especially true early in treatment when prognostication is difficult. The "defined trial period" is discussed and emphasized as a useful strategy in resolving some of these dilemmas. This strategy depends on acceptance of the moral and legal equivalency of withholding and withdrawing treatment. An unusual case is presented in which the use of a defined trial period enabled the entire care team to form a consensus on a treatment plan. Society faces a great challenge in how it balances competing interests in the allocation of scarce resources.
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Affiliation(s)
- Gary A Johanson
- Palliative Care Consultation Service, St Joseph Health System, Santa Rosa, CA 95405, USA.
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Lee SY, Hung CL, Lee JH, Shih SC, Weng YL, Chang WH, Ho YH, Huang WC, Lai YL. Attaining Good End-of-Life Care in Intensive Care Units in Taiwan—The Dilemma And the Strategy. INT J GERONTOL 2009. [DOI: 10.1016/s1873-9598(09)70017-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Because they provide potential benefit at great personal and public cost, the intensive care unit (ICU) and the interventions rendered therein have become symbols of both the promise and the limitations of medical technology. At the same time, the ICU has served as an arena in which many of the ethical and legal dilemmas created by that technology have been defined and debated. This article outlines major events in the history of ethics and law in the ICU, covering the evolution of ICUs, ethical principles, informed consent and the law, medical decision-making, cardiopulmonary resuscitation, withholding and withdrawing life-sustaining therapy, legal cases involving life support, advance directives, prognostication, and futility and the allocation of medical resources. Advancement of the ethical principle of respect for patient autonomy in ICUs increasingly is in conflict with physicians' concern about their own prerogatives and with the just distribution of medical resources.
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Affiliation(s)
- John M Luce
- Department of Medicine, University of California, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
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Managing Conflict at the End-of-Life. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Persistent coma after cardiac arrest is a source of great emotional and financial cost to grieving family members in particular and the healthcare system in general. Neurologic prognostication helps guide appropriate discussions between family members and healthcare providers. Recent advances in therapeutic care increase the challenges, both medical and financial, on local practitioners. RECENT FINDINGS Evidence-based reviews by prestigious associations add additional support and guidance to the practitioner who must guide family members in this very difficult decision process. Therapeutic hypothermia may alter findings, thus skewing the prognostic abilities of many accepted methodologies. This study reviews the usefulness of clinical examination, electrophysiologic studies, biochemical markers, and imaging modalities in predicting poor neurologic recovery in comatose survivors after cardiac arrest resuscitation. Some data from studies of therapeutic hypothermia are presented. SUMMARY Evidence-based tests of prognostication for neurologic outcome after cardiac arrest are presented. A review of the practice of withdrawal of life-sustaining therapies and the diagnosis of brain death is also provided. The reader is cautioned that most prognostic studies do not include possible amelioration with the use of therapeutic hypothermia.
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Lee K, Jang HJ, Hong SB, Lim CM, Koh Y. Do-not-resuscitate Order in Patients, Who Were Deceased in a Medical Intensive Care Unit of an University Hospital in Korea. ACTA ACUST UNITED AC 2008. [DOI: 10.4266/kjccm.2008.23.2.84] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Kwangha Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hang Jea Jang
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Neurologic Criteria for Death in Adults. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50065-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Withdrawing life-sustaining technologies requires all of the resources and concepts that the field of palliative care has to offer. By learning some fundamental principles of medical management at the time of withdrawal and by mastering a few communication techniques, pediatricians, neonatologists, and pediatric intensivists can dramatically improve the care provided to their patients at the end of life. Although we may argue in pediatrics if there is ever such a thing as a good death, we should all strive to ensure one that is free of suffering, and one that supports the family in moving down a path of healthy grief and recovery.
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Affiliation(s)
- David Munson
- Division of Neonatology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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MacKay K, Moss AH. Acute Dialysis of Patients with Multiple Organ Dysfunction Syndrome: Should it be Done? Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1996.tb00878.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tan GH, Totapally BR, Torbati D, Wolfsdorf J. End-of-life decisions and palliative care in a children's hospital. J Palliat Med 2006; 9:332-42. [PMID: 16629563 DOI: 10.1089/jpm.2006.9.332] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate clinical and demographic factors affecting the nature of end-of-life decisions and pediatric palliative care. DESIGN Charts of 236 expired children were retrospectively reviewed for presence of endof- life care (EOLC) discussions and spiritual support, the nature of EOLC decisions, and the degree of opioid analgesics (OA) and sedatives (SDT) administration. RESULTS Approximately 60% of patients had EOLC discussion, of whom 87.4% obtained an EOLC decision, mostly opting for withholding therapy (68.8%). Presence of EOLC discussion was associated with a longer hospital stay (univariate analyses: odds ratio [OR] = 1.9; p < 0.029), higher number of failed organs (OR = 2.5; p < 0.003), chronic illnesses (OR = 2.4; p < 0.002), spiritual support (OR = 1.8; p < 0.028) and respiratory diseases (OR = 3.1; p < 0.0006). Younger patients and those with higher number of failed organs were more likely to have withdrawal of therapy (OR = 10.9 and 6.0; p < 0.0001 and <0.002, respectively), whereas patients with chronic illness opted for withholding of therapy (OR = 3.1; p < 0.006). Spiritual support was associated with higher use of both OA and SDT (OR = 1.9 and 2.3; p < 0.014 and p < 0.005, respectively). Younger patients received less OA and SDT (OR = 0.2 and 0.4, respectively; p < 0.0001). Multivariate analyses showed that EOLC discussion is associated with higher use of OA and SDT (OR = 4.4 and 4.2; p < 0.00001 and p < 0.0001, respectively), whereas younger age is associated with withdrawal of therapy (OR = 8.3; p < 0.0005) and lower use of SDT (OR = 0.23; p < 0.0001). CONCLUSIONS Patterns of care at the end of life vary in children with differing clinical and demographic characteristics. Because EOLC discussions are associated with greater focus on palliative care, strategies to enhance EOLC communications for pediatric patients should be further evaluated.
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Affiliation(s)
- Gim H Tan
- Division of Critical Care Medicine, Miami Children's Hospital, FL 33155, USA
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Hernández González A, Hermana Tezanos MT, Hernández Rastrollo R, Cambra Lasaosa FJ, Rodríguez Núñez A, Failde I. [Ethical attitudes in Spanish pediatric critical care units]. An Pediatr (Barc) 2006; 64:542-9. [PMID: 16792962 DOI: 10.1157/13089919] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To assess physicians' awareness and experience of ethical problems that arise when dealing with critically ill children in pediatric intensive care units (PICUs). MATERIAL AND METHODS Questionnaires containing 20 questions about ethical dilemmas and attitudes related to the care of children admitted to PICUs were mailed to 43 PICUs in Spain. RESULTS Ninety-five responses corresponding to 24 residents and 71 attending physicians were received from 21 PICUs. The occurrence of ethical dilemmas in the PICU was recognized by 96.8 % of the respondents. The most frequent method of solving these problems was through medical consensus (80 %), while family participation in the decision making process was highly variable. A total of 95.8 % of respondents stated that decisions to limit therapy were made in their PICU, although only one third of these decisions were written in the medical record. The most frequent form of therapeutic limitation was the do not resuscitate order. One third (32.6 %) of participants considered there were ethical differences between withdrawal and withholding of treatment. Attending physicians had greater experience of therapeutic limitation than did residents, but their opinions on the subject were similar. CONCLUSIONS Ethical dilemmas are common in the PICU. In this setting, decisions about limitation of therapy are frequent, although many physicians admit to not being clear on this issue or on other aspects of clinical ethics. Family members' participation in the decision making process is insufficient in Spanish PICUs.
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Affiliation(s)
- A Hernández González
- Unidad de Cuidados Intensivos Pediátricos, Hospital Universitario Puerta del Mar de Cadiz, Avda. Ana de Viya 21, 11009 Cádiz, Spain.
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Giacomini M, Cook D, DeJean D, Shaw R, Gedge E. Decision tools for life support: a review and policy analysis. Crit Care Med 2006; 34:864-70. [PMID: 16521283 DOI: 10.1097/01.ccm.0000201904.92483.c6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care. DESIGN Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search. MEASUREMENTS AND MAIN RESULTS Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied. CONCLUSIONS Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.
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Affiliation(s)
- M Giacomini
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
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41
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Abstract
Are deaths that occur in critical care expected or unexpected? The objective was to illustrate the incidence of deaths in adult critical care units. We also wanted to discover if our patient population fit the norm of those who die in these units in the United States. Are the patients with many comorbid conditions? Could they benefit from advance care planning? A prospective chart review was completed on all deaths that occurred in our 5 critical care units. Most deaths (76.6%) were expected. Patients had an average of 3.3 comorbidities. Greater public knowledge about advance care planning is needed and must include education about the full range of options in end-of-life care.
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Affiliation(s)
- Vicki A Lindgren
- Inova Fair Oaks Hospital, Fairfax; the Inova Research Center, Falls Church; and the Inova Fairfax Hospital, Falls Church, VA 22032, USA.
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Casarett D, Kapo J, Caplan A. Appropriate use of artificial nutrition and hydration--fundamental principles and recommendations. N Engl J Med 2005; 353:2607-12. [PMID: 16354899 DOI: 10.1056/nejmsb052907] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David Casarett
- Center for Health Equity Research and Promotion, Veterans Affairs Medical Center, Philadelphia, USA
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Curtis JR. Interventions to Improve Care during Withdrawal of Life-Sustaining Treatments. J Palliat Med 2005; 8 Suppl 1:S116-31. [PMID: 16499459 DOI: 10.1089/jpm.2005.8.s-116] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Withdrawal of life-sustaining therapies is a common occurrence in the intensive care unit (ICU) setting and also occurs in other hospital settings, long-term care facilities, and even at home. Many studies have documented dramatic geographic variations in the prevalence of withdrawal of life-sustaining therapies, and some evidence suggests this variation may be driven more by physician attitudes and biases than by factors such as patient preferences or cultural differences. A number of studies of interventions in the ICU setting have provided some evidence that withdrawal of life-sustaining therapies is a process of care that can be improved. The interventions have included routine ethics or palliative care consultations, routine family conferences, and standardized order protocol for withdrawal of life support. For some of the interventions, for example, ethics consultations or palliative care consultations, the precise mechanisms by which the process of care is improved are not clear. Furthermore, many of these studies have used surrogate outcomes for quality, such as ICU length of stay. Emerging research suggests more direct outcome measures may be useful, including family satisfaction with care and assessments of the quality of dying. Despite these relative limitations, these studies provide convincing evidence that withdrawal of life-sustaining therapy is a process of care that presents opportunities for quality improvement and that interventions are successful at improving this care. Further research is needed to identify and test the most appropriate and responsive outcome measures and to identify the most effective and cost-effective interventions.
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Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, Washington 98104-2499, USA.
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44
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Abstract
All surgeons must take risks when providing medical care. No guarantees of protection from a lawsuit exist in any guise. Concerning postoperative futile care, the stakes are high when withdrawal of support seems to be indicated but the surrogate believes in sanctity-of-life and demands continued aggressive care. Open-ended questions posed to the family may initiate a dialog that help the surgeon understand their values and negotiate a resolution. Other preventive measures can also reduce the chance of conflict and potential liability. "Do what's right" is a proverbial motto in surgical training and clinical practice. To some surgeons, it may be to honor the wishes of the family surrogate. To others, the right thing may be to withdraw care in the best interest of the patient. If so, "do what's right" is not just to "stop the train." It also consists of a range of clinical activities, including effective communication, emotional care, and pursuing a fair and open negotiation process established by the institution. Properly conducted, "stopping the train" should incur no greater risk for professional liability than any other challenging procedure that surgeons perform. Withdrawal of futile care should be considered as a procedure, and as such, the skills to deliver it should be mastered like any other.
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Affiliation(s)
- K Francis Lee
- Department of Surgery, Baystate Medical Center Tufts University School of Medicine, Springfield, MA 01199, USA.
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45
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Selecky PA, Eliasson CAH, Hall RI, Schneider RF, Varkey B, McCaffree DR. Palliative and End-of-Life Care for Patients With Cardiopulmonary Diseases. Chest 2005; 128:3599-610. [PMID: 16304319 DOI: 10.1378/chest.128.5.3599] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Acute and chronic pulmonary and cardiac diseases often have a high mortality rate, and can be a source of significant suffering. Palliative care, as described by the Institute of Medicine, "seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure... Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs." The American College of Chest Physicians strongly supports the position that such palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine. This care is best provided through an interdisciplinary effort by competent and experienced professionals under the leadership of a knowledgeable and compassionate physician. To that end, it is hoped that this statement will serve as a framework within which physicians may develop their own approach to the management of patients requiring palliative care.
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Affiliation(s)
- Paul A Selecky
- Hoag Memorial Hospital, Newport Beach, CA 92658-6100, USA.
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46
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Fauriel I, Moutel G, Duchange N, Montuclard L, Moutard ML, Cochat P, Hervé C. Decision making concerning life-sustaining treatment in paediatric nephrology: professionals' experiences and values. Nephrol Dial Transplant 2005; 20:2746-50. [PMID: 16204280 PMCID: PMC1910593 DOI: 10.1093/ndt/gfi160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In a previous article, we studied decisions to withhold or withdraw life-sustaining treatment (LST) taken between 1995 and 2001 in 31 French-speaking paediatric nephrology centres. Files were available for 18 of the 31 centres. A grid was used to analyse the criteria on which decisions were based, and the results were enriched by an analysis of interviews with the doctors at these centres (31 interviews with doctors from the 18 centres). The goal was to describe in detail and to specify the criteria on which decisions to withhold or withdraw LST were based, in cases extracted from the files. The second paper deals exclusively with the interviews with doctors and analyses their lifetime's experience and perception. METHODS We carried out semi-directed interviews with nephrologists from all the paediatric nephrology centres in France and the French-speaking regions of Switzerland and Belgium. RESULTS We interviewed 46 paediatric nephrologists. Most were aware that decisions relating to LST are necessary and based on the assessment of the child's quality of life. According to them, decisions are not based on scientific criteria, but on the capacity to accept handicap, the family's past experiences and the doctor's own projections. They report that their task is particularly difficult when their action may contribute to death (withdrawal of treatment or acceleration of the process). They feel that their duty is to help the families in the acceptance of the doctors' decision rather than to encourage their participation in the decision-making process (DMP). CONCLUSIONS This article shows that paediatric nephrologists differ in their opinions, mostly due to their own ethical convictions. This observation highlights the need to establish common rules taking into account the views held by doctors. This is the only way to establish an ethical code shared by professionals.
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Affiliation(s)
- Isabelle Fauriel
- Laboratoire d'Ethique médicale et de Médecine Légale, Faculté de médecine de Paris 5, 45 rue des Saints Pères, 75006 Paris, France.
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47
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Curtis JR, Rubenfeld GD. Improving Palliative Care For Patients In The Intensive Care Unit. J Palliat Med 2005; 8:840-54. [PMID: 16128659 DOI: 10.1089/jpm.2005.8.840] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Harborview Medical Center, Box 359761, 325 Ninth Avenue, Seattle, WA 98104-2499, USA.
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48
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Mast KR, Salama M, Silverman GK, Arnold RM. End-of-life content in treatment guidelines for life-limiting diseases. J Palliat Med 2005; 7:754-73. [PMID: 15684843 DOI: 10.1089/jpm.2004.7.754] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical guidelines are systematically developed statements that influence medical practice, education, and funding. Guidelines represent the consensus of leaders, often based on systematic reviews of the literature, regarding the "state of the art." OBJECTIVE To assess the degree to which end-of-life care is integrated into nationally developed guidelines for chronic, noncurable, life-limiting diseases. DESIGN Four compendia were reviewed: The Healthcare Standards Directory ECRI, 2001; the Clinical Practice Guidelines Directory, 2000 edition; the National Guidelines Clearinghouse, (guideline.gov); and the National Library of Medicine's MEDLINE database on the OVID platform for guidelines on nine chronic diseases (chronic obstructive pulmonary disease, end-stage liver disease, amyotrophic lateral sclerosis, congestive heart failure, dementia, cerebrovascular accident, end-stage renal disease, cancer [breast, colon, prostate, lung], and human immunodeficiency virus). They were assessed by two reviewers for end-of-life content in 15 domains (e.g., epidemiology of death, symptom management, spiritual, family roles, and settings of care), the presence of eight specific terms dealing with palliative care, integration of palliative care information into the guideline, and descriptive variables. SETTING/SUBJECTS Not available. MEASUREMENTS Each guideline was examined and rated on a 0-2 scale (0, absent content; 1, minimal content; 2, helpful content) using 15 end-of-life content domains. Scores from domains were summed and classified into 3 categories: 4 or less, minimal; 5-12, moderate; and more than 12, significant content. RESULTS Ten percent of guidelines had significant palliative care content, 64% had minimal content, and 26% had moderate content. The least addressed domains dealt with spirituality, ethics, advocacy and family roles. When guidelines that dealt solely with prevention, acute exacerbations or complications of an illness, or specific treatment modalities were excluded 28% and 16% of these general guidelines (n = 58) had moderate and significant palliative care content, respectively, compared to 24% and 0% of all nongeneral guidelines. Similar results were found when analyzing the data by disease course or treatment focus. Only 14% of guidelines advised physicians to consider palliative care at a specific point in the disease course. Ninety-one percent of the guidelines mentioned death, dying, end of life, mortality, or terminal illness but only 36% mentioned palliation or hospice. CONCLUSION Current national guidelines on nine chronic, life-limiting illnesses offer little guidance in end-of-life care issues despite a recent increase in attention to this aspect of medical care.
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Affiliation(s)
- Kimberly R Mast
- McAuley Medical Associates, Mercy Hospital, Pittsburgh, Pennsylvania, USA
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49
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Yazigi A, Riachi M, Dabbar G. Withholding and withdrawal of life-sustaining treatment in a Lebanese intensive care unit: a prospective observational study. Intensive Care Med 2005; 31:562-7. [PMID: 15750799 DOI: 10.1007/s00134-005-2578-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Accepted: 01/26/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the implementation and process of withholding and withdrawing life-sustaining treatment in an intensive care unit. DESIGN AND SETTING Prospective observational study in the medical intensive care unit of a university hospital in Lebanon. PATIENTS Forty-five consecutive adult patients admitted to the ICU for a 1-year period and for whom a decision to withholding and withdrawal of life-sustaining treatment was made. MEASUREMENTS AND RESULTS Patients were followed up until their death. Data regarding all aspects of the implementation and the process of withholding and withdrawal of life-sustaining treatment were recorded by a senior staff nurse. Withholding and withdrawing life-sustaining treatment was applied to 9.6% of all admitted patients to ICU. Therapies were withheld in 38% and were withdrawn in 7% of patients who died. Futility of care and poor quality of life were the two most important factors supporting these decisions. The nursing staff was not involved in 26% of the decisions to limit care. Families were not implicated in 21% of the cases. Decisions were not notified in the patients' medical record in 23% of the cases. Sixty-three percent of patients did not have a sedative or an analgesic to treat discomfort during end-of-life care. CONCLUSIONS Life-sustaining treatment were frequently withheld or withdrawn from adult patients in the Lebanese ICU. Cultural differences and the lack of guidelines and official statements could explain the ethical limitations of the decision-making process recorded in this study.
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Affiliation(s)
- Alexandre Yazigi
- Department of Anesthesiology and Surgical Intensive Care, Hotel-Dieu de France Hospital, Saint Joseph University, Adib Ishac Street, Beirut, Lebanon.
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50
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Sibbald RW, Lazar NM. Bench-to-bedside review: Ethical challenges for those in directing roles in critical care units. Crit Care 2005; 9:76-80. [PMID: 15693987 PMCID: PMC1065098 DOI: 10.1186/cc2979] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Though much attention in the medical literature has focused on the ethics of critical care, it seems to be disproportionately weighted toward clinical issues. On the presumption that the operational management of an intensive care unit (ICU) also requires ethical considerations, it would be useful to know what these are. This review undertook to identify what literature exists with regard to the non-clinical issues of ethical importance in the ICU as encountered by clinician-managers. We found that in addition to issues of resource allocation, there exist many areas of ethical importance to clinician-managers in the ICU that have been described only superficially. We argue that a renewed focus on ICU ethics is merited to shed light on these other, non-clinical, issues.
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Affiliation(s)
- Robert W Sibbald
- Research Associate, Department of Medicine and Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
| | - Neil M Lazar
- Associate Professor of Medicine, Department of Medicine and Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
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