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Bitar HN. Greek Orthodox. Cancer Treat Res 2023; 187:219-229. [PMID: 37851229 DOI: 10.1007/978-3-031-29923-0_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
There are approximately 300 million members of the Greek Orthodox Church worldwide. It is the second-largest Christian church. Followers of this religion believe in eternal life. Thus, the church strongly emphasizes a positive outcome in death- "the deceased is alive with God." God is believed to be the healer of our souls and bodies, which is facilitated through prayer and participation in the life of the Church. Traditional medical interventions are generally accepted. Artificial life support is justifiable only when it offers a hope for meaningful recovery. Just as death should not be hastened, the natural dying process should not be prolonged. Timely advance care planning and early treatment goals discussions to help understand how the patient would define quality of life is paramount to setting limitations on what could be considered as nonbeneficial care. The medical team should not assume that all patients of the Greek Orthodox faith will feel the same around end-of-life beliefs and practices. This chapter aims to identify common themes and the historical contextual framework that may influence the way in which medical decision making is made by those who specifically subscribe to the Greek Orthodox faith.
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Affiliation(s)
- Heather N Bitar
- Palliative Medicine Supportive Care Medicine City of Hope, 1500 E. Duarte Rd, Duarte, CA, 91010, USA.
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2
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Reader TW, Dayal R, Brett SJ. At the end: A vignette-based investigation of strategies for managing end-of-life decisions in the intensive care unit. J Intensive Care Soc 2021; 22:305-311. [PMID: 35154368 PMCID: PMC8829767 DOI: 10.1177/1751143720954723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Decision-making on end-of-life is an inevitable, yet highly complex, aspect of intensive care decision-making. End-of-life decisions can be challenging both in terms of clinical judgement and social interaction with families, and these two processes often become intertwined. This is especially apparent at times when clinicians are required to seek the views of surrogate decision makers (i.e., family members) when considering palliative care. METHODS Using a vignette-based interview methodology, we explored how interactions with family members influence end-of-life decisions by intensive care unit clinicians (n = 24), and identified strategies for reaching consensus with families during this highly emotional phase of care. RESULTS We found that the enactment of end-of-life decisions were reported as being affected by a form of loss aversion, whereby concerns over the consequences of not reaching a consensus with families weighed heavily in the minds of clinicians. Fear of conflict with families tended to arise from anticipated unrealistic family expectations of care, family normalization of patient incapacity, and belief systems that prohibit end-of-life decision-making. CONCLUSIONS To support decision makers in reaching consensus, various strategies for effective, coherent, and targeted communication (e.g., on patient deterioration and limits of clinical treatment) were suggested as ways to effectively consult with families on end-of-life decision-making.
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Affiliation(s)
- Tom W Reader
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Ria Dayal
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Stephen J Brett
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
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3
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Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Crit Care Nurse 2021; 40:14-22. [PMID: 32476029 DOI: 10.4037/ccn2020834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices. CLINICAL RELEVANCE Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members. PURPOSE OF PAPER To provide recommendations for high-quality end-of-life care for patients and family members. CONTENT COVERED This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.
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Affiliation(s)
- Hanne Irene Jensen
- Hanne Irene Jensen is an associate professor at the Department of Anaesthesiology and Intensive Care, Vejle and Middelfart Hospitals, Vejle, Denmark, and the University of Southern Denmark, Odense, Denmark
| | - Kristin Halvorsen
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Heidi Jerpseth
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Isabell Fridh
- Isabell Fridh is an associate professor at the Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
| | - Ranveig Lind
- Ranveig Lind is an associate professor at UiT, the Arctic University of Norway, and a research nurse in the intensive care unit at University Hospital of North Norway, Tromsø, Norway
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4
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Limiting ICU admission from emergency services and wards. Med Clin (Barc) 2021; 157:524-529. [PMID: 33423823 DOI: 10.1016/j.medcli.2020.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/15/2020] [Accepted: 08/20/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Decisions not to admit a patient to intensive care units (ICU) as a way of limiting life support treatment (LLST) is a practice that can affect the operation of the emergency services and the way in which patients die. METHODS Post hoc analysis of the ADENI-UCI study. The main variable analysed was the reason for refusal of admission to the ICU as a measure of LLST. For the present post hoc analysis, the registered patients were divided into 2 groups: the patients assessed in the intensive medicine services from the emergency department and the patients assessed from the conventional hospitalization areas. Student t was used in the comparative statistics when the mean values of the patient sub-cohorts were compared. Categorical variables were compared with the χ2 tests. RESULTS The ADENI-ICU study included 2,284 decisions not to admit to the ICU as a measure of LLST. Estimated poor quality of life (p=.0158), the presence of severe chronic disease (P=.0169) and futility of treatment (P=.0006) were percentage decisions with greater weight within the population of hospitalized patients. The percentage of disagreement between the consulting physician and the intensivist was significantly lower in patients assessed from the emergency services (P=.0021). CONCLUSIONS There are appreciable differences in the reasons for consultation, as well as in those for refusal of admission to an ICU between the consultations made from an emergency department and a conventional hospitalization facility.
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5
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Lee JD, Jennerich AL, Engelberg RA, Downey L, Curtis JR, Khandelwal N. Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness. J Palliat Med 2020; 24:857-864. [PMID: 33156728 DOI: 10.1089/jpm.2020.0412] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.
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Affiliation(s)
- Joshua D Lee
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Lois Downey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington, USA
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6
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Abstract
Critical care clinicians strive to reverse the disease process and are frequently faced with difficult end-of-life (EoL) situations, which include transitions from curative to palliative care, avoidance of disproportionate care, withholding or withdrawing therapy, responding to advance treatment directives, as well as requests for assistance in dying. This article presents a summary of the most common issues encountered by intensivists caring for patients around the end of their life. Topics explored are the practices around limitations of life-sustaining treatment, with specific mention to the thorny subject of assisted dying and euthanasia, as well as the difficulties encountered regarding the adoption of advance care directives in clinical practice and the importance of integrating palliative care in the everyday practice of critical-care physicians. The aim of this article is to enhance understanding around the complexity of EoL decisions, highlight the intricate cultural, religious, and social dimensions around death and dying, and identify areas of potential improvement for individual practice.
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Affiliation(s)
- Victoria Metaxa
- Critical Care Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
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7
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Chartrand L. Dying on television versus dying in intensive care units following withdrawal of life support: how normative frames may traumatise the bereaved. SOCIOLOGY OF HEALTH & ILLNESS 2020; 42:1155-1170. [PMID: 32304256 DOI: 10.1111/1467-9566.13089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
While treatment is often withdrawn from patients in intensive care units (ICUs), few people outside the healthcare profession have witnessed a death under such circumstances. Family members who have made the decision to withdraw treatment may have expectations about the dying process, what constitutes a good death and how they should behave in an ICU based on popular prime-time television series. An inductive comparative thematic coding strategy is therefore used to examine how death following treatment withdrawal as depicted in a US medical drama (Grey's Anatomy) differs from realities observed for 6 months fieldwork at an ICU in Canada. Three common frames (privacy, emotional control and memorialising) help patients' intimates normalise the unfamiliar experience and guide their behaviour during the event. However, discrepancies between media representations and experiences in the ICU, especially around the frames of timing of death and the physicality of the unbounded body (incontinence and agonal breathing), can traumatise them. The bereaved may be left viewing ventilator withdrawal and dying as chaotic processes and believing their loved one suffered through a bad death. Understanding these normative and discrepant frames should help healthcare professionals better prepare the public to witness death.
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Perceptions of Ethical Decision-Making Climate Among Clinicians Working in European and U.S. ICUs: Differences Between Nurses and Physicians. Crit Care Med 2020; 47:1716-1723. [PMID: 31625980 DOI: 10.1097/ccm.0000000000004017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses. DESIGN Prospective observational study. SETTING A total of 68 adult ICUs in 13 European countries and the United States. SUBJECTS ICU physicians and nurses. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions. CONCLUSIONS Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.
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9
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Nordenskjöld Syrous A, Ågård A, Kock Redfors M, Naredi S, Block L. Swedish intensivists' experiences and attitudes regarding end-of-life decisions. Acta Anaesthesiol Scand 2020; 64:656-662. [PMID: 31954072 DOI: 10.1111/aas.13549] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 12/17/2019] [Accepted: 01/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND To make end-of-life (EOL) decisions is a complex and challenging task for intensive care physicians and a substantial variability in this process has been previously reported. However, a deeper understanding of intensivists' experiences and attitudes regarding the decision-making process is still, to a large extent, lacking. The primary aim of this study was to address Swedish intensivists' experiences, beliefs and attitudes regarding decision-making pertaining to EOL decisions. Second, we aimed to identify underlying factors that may contribute to variability in the decision-making process. METHOD This is a descriptive, qualitative study. Semi-structured interviews with nineteen intensivists from five different Swedish hospitals, with different ICU levels, were performed from 1 February 2017 to 31 May 2017. RESULTS Intensivists strive to make end-of-life decisions that are well-grounded, based on sufficient information. Consensus with the patient, family and other physicians is important. Concurrently, decisions that are made with scarce information or uncertain medical prognosis, decisions made during on-call hours and without support from senior consultants cause concern for many intensivists. Underlying factors that contribute to the variability in decision-making are lack of continuity among senior intensivists, lack of needed support during on-call hours and disagreements with physicians from other specialties. There is also an individual variability primarily depending on the intensivist's personality. CONCLUSION Swedish intensivists' wish to make end-of-life decisions based on sufficient information, medically certain prognosis and consensus with the patient, family, staff and other physicians. Swedish intensivists' experience a variability in end-of-life decisions, which is generally accepted and not questioned.
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Affiliation(s)
- Alma Nordenskjöld Syrous
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology Angereds Hospital Region Västra Götaland Gothenburg Sweden
| | - Anders Ågård
- Department of Cardiology Institute of MedicineSahlgrenska AcademyUniversity of Gothenburg Gothenburg Sweden
| | - Maria Kock Redfors
- Department of Anaesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Silvana Naredi
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care Institute of Clinical Sciences Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Anaesthesiology and Intensive Care Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
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10
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Wilson ME, Mittal A, Karki B, Dobler CC, Wahab A, Curtis JR, Erwin PJ, Majzoub AM, Montori VM, Gajic O, Murad MH. Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis. Intensive Care Med 2019; 46:36-45. [PMID: 31659387 PMCID: PMC7223954 DOI: 10.1007/s00134-019-05828-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/07/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure. METHODS We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019. RESULTS Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate. CONCLUSIONS One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.
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Affiliation(s)
- Michael E Wilson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. .,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA. .,Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | - Aniket Mittal
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Bibek Karki
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Claudia C Dobler
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Institute for Evidence-Based Healthcare, Bond University and Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Abdul Wahab
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | | | - Abdul M Majzoub
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.,Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Mayo Clinic, Rochester, MN, USA
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11
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Cain CL, Surbone A, Elk R, Kagawa-Singer M. Culture and Palliative Care: Preferences, Communication, Meaning, and Mutual Decision Making. J Pain Symptom Manage 2018; 55:1408-1419. [PMID: 29366913 DOI: 10.1016/j.jpainsymman.2018.01.007] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 01/11/2023]
Abstract
Palliative care is gaining acceptance across the world. However, even when palliative care resources exist, both the delivery and distribution of services too often are neither equitably nor acceptably provided to diverse population groups. The goal of this study was to illustrate tensions in the delivery of palliative care for diverse patient populations to help clinicians to improve care for all. We begin by defining and differentiating culture, race, and ethnicity, so that these terms-often used interchangeably-are not conflated and are more effectively used in caring for diverse populations. We then present examples from an integrative literature review of recent research on culture and palliative care to illustrate both how and why varied responses to pain and suffering occur in different patterns, focusing on four areas of palliative care: the formation of care preferences, communication patterns, different meanings of suffering, and decision-making processes about care. For each area, we provide international and multiethnic examples of variations that emphasize the need for personalization of care and the avoidance of stereotyping beliefs and practices without considering individual circumstances and life histories. We conclude with recommendations for improving palliative care research and practice with cultural perspectives, emphasizing the need to work in partnerships with patients, their family members, and communities to identify and negotiate culturally meaningful care, promote quality of life, and ensure the highest quality palliative care for all, both domestically and internationally.
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Affiliation(s)
- Cindy L Cain
- Department of Health Policy and Management, University of California-Los Angeles, Los Angeles, California.
| | - Antonella Surbone
- Department of Medicine, Division of Haematology and Medical Oncology, New York University Medical School, New York, New York
| | - Ronit Elk
- College of Nursing, University of South Carolina, Columbia, South Carolina
| | - Marjorie Kagawa-Singer
- Department of Community Health Sciences and Asian American Studies Center, University of California-Los Angeles, Los Angeles, California
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12
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Koksvik GH. Medically Timed Death as an Enactment of Good Death: An Ethnographic Study of Three European Intensive Care Units. OMEGA-JOURNAL OF DEATH AND DYING 2018; 81:66-79. [PMID: 29402160 DOI: 10.1177/0030222818756555] [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: 11/17/2022]
Abstract
The article is based on ethnographic observation and semistructured interviews with personnel in three European adult intensive care units. Intensive care is a domain of contemporary biomedicine centered on invasive and intense efforts to save lives in acute, critical conditions. It echoes our culture's values of longevity. Nevertheless, mortality rates are elevated. Many deaths follow from nontreatment decisions. Medicalized dying in technological medical settings are often presented as unnatural, impersonal, and undesirable ways of dying. How does this affect the way in which death is experienced by intensive care professionals? What might the enactment of dying in intensive care reveal about our cultural values of good and bad dying?
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Affiliation(s)
- Gitte H Koksvik
- Department of Interdisciplinary Studies of Culture, Norwegian University of Science and Technology, Trondheim, Norway
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13
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Kolman JM, Miller SM. Six Values Never to Silence: Jewish Perspectives on Nazi Medical Professionalism. Rambam Maimonides Med J 2018; 9:RMMJ.10327. [PMID: 29406846 PMCID: PMC5796738 DOI: 10.5041/rmmj.10327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
An ideological case study based on medical profession norms during the Third Reich will be used to exemplify the importance of diversity in the manifestations of professional ethics. The German professional medical community banned their Jewish colleagues from treating German citizens. This included legally mandated employment discrimination and outright censure which led to a professional ethic devoid of diverse voices. While the escalation to the T-4 program and medicalized genocide was influenced by many causes, the intentional, ethnocentric-based exclusion of voices was an important contributing element to the chronicled degradation of societal mores. For illustration, six core Jewish values-life, peace, justice, mercy, scholarship, and sincerity of intention-will be detailed for their potential to inspire health-care professionals to defend and protect minorities and for readers to think critically about the role of medical professionalism in Third Reich society. The Jewish teachings highlight the inherent professional obligations physicians have toward their patients in contrast to the Third Reich's corruption of patient-centered professionalism. More fundamentally, juxtaposing Jewish and Nazi teachings exposes the loss of perspective when a profession's identity spurns diversity. To ensure respect for persons in all vulnerable minorities, the first step is addressing professional inclusion of minority voices.
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Affiliation(s)
- Jacob M. Kolman
- Houston Methodist Hospital, Center for Outcomes Research, Houston, Texas, USA
- Houston Methodist Research Institute, Houston, Texas, USA
- To whom correspondence should be addressed. E-mail:
| | - Susan M. Miller
- Houston Methodist Hospital, Center for Outcomes Research, Houston, Texas, USA
- Houston Methodist Research Institute, Houston, Texas, USA
- Weill Cornell College, New York, New York, USA
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14
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Bandini JI, Courtwright A, Zollfrank AA, Robinson EM, Cadge W. The role of religious beliefs in ethics committee consultations for conflict over life-sustaining treatment. JOURNAL OF MEDICAL ETHICS 2017; 43:353-358. [PMID: 28137999 DOI: 10.1136/medethics-2016-103930] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 12/23/2016] [Accepted: 01/10/2017] [Indexed: 06/06/2023]
Abstract
Previous research has suggested that individuals who identify as being more religious request more aggressive medical treatment at end of life. These requests may generate disagreement over life-sustaining treatment (LST). Outside of anecdotal observation, however, the actual role of religion in conflict over LST has been underexplored. Because ethics committees are often consulted to help mediate these conflicts, the ethics consultation experience provides a unique context in which to investigate this question. The purpose of this paper was to examine the ways religion was present in cases involving conflict around LST. Using medical records from ethics consultation cases for conflict over LST in one large academic medical centre, we found that religion can be central to conflict over LST but was also present in two additional ways through (1) religious coping, including a belief in miracles and support from a higher power, and (2) chaplaincy visits. In-hospital mortality was not different between patients with religiously versus non-religiously centred conflict. In our retrospective cohort study, religion played a variety of roles and did not lead to increased treatment intensity or prolong time to death. Ethics consultants and healthcare professionals involved in these cases should be cognisant of the complex ways that religion can manifest in conflict over LST.
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Affiliation(s)
- Julia I Bandini
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
| | - Andrew Courtwright
- Institute for Patient Care, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angelika A Zollfrank
- Department of Spiritual Care, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Ellen M Robinson
- Institute for Patient Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wendy Cadge
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
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15
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Bein T. [Intercultural competence. Management of foreignness in intensive care medicine]. Anaesthesist 2016; 64:562-8. [PMID: 26231291 DOI: 10.1007/s00101-015-0069-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Living in a multicultural society is characterized by different attitudes caused by a variety of religions and cultures. In intensive care medicine such a variety of cultural aspects with respect to pain, shame, bodiliness, dying and death is of importance in this scenario. AIM To assess the importance of cultural and religious attitudes in the face of foreignness in intensive care medicine and nursing. Notification of misunderstandings and misinterpretations in communication and actions. MATERIAL AND METHODS An analysis of the scientific literature was carried out and typical intercultural conflict burden situations regarding the management of brain death, organ donation and end of life decisions are depicted. RESULTS Specific attitudes are found in various religions or cultures regarding the change of a therapeutic target, the value of the patient's living will and the organization of rituals for dying. Intercultural conflicts are mostly due to misunderstandings, assessment differences, discrimination and differences in values. CONCLUSION Intercultural competence is crucial in intensive care medicine and includes knowledge of social and cultural influences of different attitudes on health and illness, the abstraction from own attitudes and the acceptance of other or foreign attitudes.
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Affiliation(s)
- T Bein
- Klinik für Anästhesiologie, Universitätsklinikum, 93042, Regensburg, Deutschland,
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16
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Zubek L. [Options for the improvement of communication and self-determination in end-of-life decisions in intensive care units]. Orv Hetil 2016; 157:669-74. [PMID: 27084441 DOI: 10.1556/650.2016.30459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The end-of-life decision making process normally based on patient autonomy or substituted judgement. If the patient can express his/her wishes, one must take note of his autonomy. If he/she is unable to self-determination, the importance of advanced directives or substituted judgement increases in the field of end-of-life care. The most important target of the efforts is to improve end-of-life care at intensive care units. Based on bioethical studies of the author and international literature this paper analizes the practice of end-of-life care and presents recommendations for lawmakers. The author proposes to divide patients with organ failure into three parts (end-of-life triage). The first part includes definitely salvageable, the second part definitely unsalvageable, and the third part possibly salvageable groups. This classification depends on the development of medical science and the local options of medical treatment. The quality of the decision-making process can be improved, but all participants must participate and medio-legal regulation must be improved.
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Affiliation(s)
- László Zubek
- Aneszteziológiai és Intenzív Terápiás Klinika, Semmelweis Egyetem, Általános Orvostudományi Kar Budapest, Kútvölgyi út 4., 1125
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17
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Grosek S, Orazem M, Kanic M, Vidmar G, Groselj U. Attitudes of Slovene paediatricians to end-of-life care. J Paediatr Child Health 2016; 52:278-83. [PMID: 26515146 DOI: 10.1111/jpc.13006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2015] [Indexed: 11/27/2022]
Abstract
AIMS The aims of this study were to assess the attitudes of Slovene paediatricians to aspects of end-of-life (EOL) care and compare these attitudes between paediatric intensivists, paediatric specialists and paediatric residents. METHODS We performed a cross-sectional survey, using a specifically designed 43-item anonymous questionnaire. RESULTS We included 323 out of 586 Slovene paediatricians and residents, while 46.7% (151 of 323) of them responded to our questionnaire. More than half of intensivists (54.2%) had sought counsel from the Committee for Medical Ethics in the past as compared with 12.0% and 12.1% of specialists and residents, respectively (P < 0.001). The decision to limit life-sustaining treatment (LST) was found to be ethically acceptable in all groups of respondents. The highest level of agreement was found in residents (90.2%), followed by 83.3% among intensivists and 73.8% among specialists (P = not statistically significant (NS)). Disagreement with termination of hydration was highest among residents (85%) and intensivists (79.2%) while it was lower among specialists (66.7%) (P = NS). Patient's best interest, good clinical practice and patient's autonomous decision were graded as the top three aspects of the EOL care, while cost effectiveness and availability of patient's bed in intensive care were the least important. CONCLUSIONS The decision to limit LST measures was found to be ethically acceptable for Slovene paediatricians. No major differences were found among paediatric intensivists, specialist paediatricians and paediatric residents in the attitudes towards the EOL care.
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Affiliation(s)
- Stefan Grosek
- Department of Pediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Pediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Orazem
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Kanic
- Department for Rhythmology, Heartcenter Leipzig, Leipzig, Germany
| | - Gaj Vidmar
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Medical Department, University Rehabilitation Institute of the Republic of Slovenia, Ljubljana, Slovenia
| | - Urh Groselj
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
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18
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Kumar A, Psirides A, Maheshwari N, Chawla V, Mandal AK. Framework for decision-making and management of end-of-life decisions in Intensive Care Units: A modified protocol. Indian J Crit Care Med 2016; 19:655-60. [PMID: 26730116 PMCID: PMC4687174 DOI: 10.4103/0972-5229.169339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
End-of-life decisions are being made daily in Intensive Care Units worldwide. The spectrum of options varies from full-continued care, withholding treatment, withdrawing treatment, and active life-ending procedures depending on the institutional practices and legal framework. Considering the complexity of the situation and the legalities involved, it is important to have a structured approach toward these sensitive decisions. It does make sense to have a protocol that ensures proper documentation and helps ease the physicians involved in such decisions. Clear documentation in the format of a checklist would ensure consistency and help the entire medical team to be uniformly informed about the end-of-life plan.
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Affiliation(s)
- Arun Kumar
- Department of Critical Care, Pulmonology and Sleep Medicine, Medical Intensive Care Unit, Fortis Hospital, Mohali, Punjab, India
| | - Alex Psirides
- Department of Intensive Care Medicine, Wellington Regional Hospital, Wellington, New Zealand
| | - Namrata Maheshwari
- Department of Critical Care, Pulmonology and Sleep Medicine, Medical Intensive Care Unit, Fortis Hospital, Mohali, Punjab, India
| | - Vipal Chawla
- Department of Critical Care, Pulmonology and Sleep Medicine, Medical Intensive Care Unit, Fortis Hospital, Mohali, Punjab, India
| | - Amit K Mandal
- Department of Critical Care, Pulmonology and Sleep Medicine, Medical Intensive Care Unit, Fortis Hospital, Mohali, Punjab, India
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19
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Hart JL, Harhay MO, Gabler NB, Ratcliffe SJ, Quill CM, Halpern SD. Variability Among US Intensive Care Units in Managing the Care of Patients Admitted With Preexisting Limits on Life-Sustaining Therapies. JAMA Intern Med 2015; 175:1019-26. [PMID: 25822402 PMCID: PMC4451380 DOI: 10.1001/jamainternmed.2015.0372] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although the end-of-life care patients receive is known to vary across nations, regions, and centers, these differences are best explored within a group of patients with presumably similar care preferences. OBJECTIVE To examine the proportions of patients admitted to the intensive care unit (ICU) with limitations on life-sustaining treatments and the proportions of such patients who receive aggressive care across individual ICUs. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective cohort study using the Project IMPACT database (from April 1, 2001, to December 31, 2008) including 141 ICUs in 105 hospitals in the United States and 277,693 ICU patient visits. We used logistic regression analysis models adjusted for available patient characteristics and clustered visits by individual ICU. The full analysis was last performed in October 2014. MAIN OUTCOMES AND MEASURES Outcomes included the provision of (1) cardiopulmonary resuscitation, (2) new forms of life support, and the (3) addition or (4) reversal of treatment limitations. RESULTS Of the ICU admissions evaluated, 4.8% (95% CI, 4.7%-4.9%) had previously established treatment limitations. Patients admitted with treatment limitations were more likely to be older with more functional limitations and comorbidities. Among patients who survived to hospital discharge, more experienced reversals of existing treatment limitations during the ICU stay (17.8% [95% CI, 17.0%-18.7%]) than additions of new limits (11.7% [95% CI, 11.1%-12.4%]) (P < .01). Among patients who died, 15.7% (95% CI, 14.7-16.8%) had received cardiopulmonary resuscitation. After risk adjustment, ICUs varied widely in the proportions of patients admitted with treatment limitations (median, 4.0%; range, <1.0%-20.9%), the proportions of those who received cardiopulmonary resuscitation (37.7% [95% CI, 3.8%-92.4%]), the proportions of new forms of life support (30.0% [95% CI, 6.0%-84.2%]), and, among survivors, the proportion who had new treatment limitations established (11.2% [95% CI, 1.9%-57.3%]) and reversal of treatment limitations during or following ICU admission (20.2% [95% CI, 1.8%-76.2%]). The observed variability could not be consistently explained using measurable center-level characteristics. CONCLUSIONS AND RELEVANCE Intensive care units vary dramatically in how they manage care for patients admitted with treatment limitations. Among patients who survive, escalations in the aggressiveness of care are more common during the ICU stay than are de-escalations in aggressiveness. This study cannot directly measure whether care received was consistent with patients' preferences but suggests that ICU culture and physicians' practice styles contribute to the aggressiveness of care.
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Affiliation(s)
- Joanna L Hart
- Division of Pulmonary, Allergy & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia3Fostering Imp
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole B Gabler
- Fostering Improvement in End-of-Life Decision Science Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia4Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah J Ratcliffe
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Caroline M Quill
- Department of Medicine, Pulmonary Diseases and Critical Care, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Scott D Halpern
- Division of Pulmonary, Allergy & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia2Leonard Davis Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia3Fostering Imp
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20
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Thompson DR. "No escalation of treatment" as a routine strategy for decision-making in the ICU: pro. Intensive Care Med 2014; 40:1372-3. [PMID: 25091793 DOI: 10.1007/s00134-014-3422-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/23/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Dan R Thompson
- Alden March Bioethics Institute, Albany Medical College, 47 New Scotland Avenue, MC162, Albany, NY, 12208, USA,
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