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DeMartino ES, Ennis JS, Wolf SM, Sulmasy DP. Learning from COVID-19 triage schemes to face the next public health emergency. J Am Geriatr Soc 2024; 72:1298-1301. [PMID: 38284315 DOI: 10.1111/jgs.18765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/15/2023] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Affiliation(s)
- Erin S DeMartino
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jackson S Ennis
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Susan M Wolf
- Law School and Medical School, University of Minnesota, Minneapolis, Minnesota, USA
- Consortium on Law and Values in Health, Environment & the Life Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel P Sulmasy
- Departments of Medicine and Philosophy, Georgetown University, Washington, DC, USA
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
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2
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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Addressing Challenges With Sedation in End-of-Life Care. J Pain Symptom Manage 2024; 67:346-349. [PMID: 38158164 PMCID: PMC10939822 DOI: 10.1016/j.jpainsymman.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/04/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024]
Abstract
In 2009, Quill and colleagues stipulated that there are three types of sedation practices at the end of life: ordinary sedation, proportionate palliative sedation (PPS), and palliative sedation to unconsciousness (PSU). Of the three, PPS and PSU are described as "last-resort options" to relieve refractory symptoms, and PSU as the most ethically controversial type that "should be quite rare." Unfortunately, little is known about actual sedation practices at the end of life in the United States. This may be due in part to a lack of conceptual clarity about sedation in end-of-life care. We argue that, until more is known about what sedation practices occur at the end of life, and how practices can be improved by research and more specific guidelines, "palliative sedation" will remain more misunderstood and controversial than it might otherwise be. In our view, overcoming the challenges posed by sedation in end-of-life care requires: 1) greater specificity regarding clinical situations and approaches to sedation, 2) research tailored to focused clinical questions, and 3) improved training and safeguards in sedation practices. Terms like PPS and PSU are relatively simple to understand in the abstract, but their application comprises various clinical situations and approaches to sedation. An obvious barrier to empirical research on sedation practices in end-of-life care is the challenge of determining these elements, especially if not clearly communicated. Additionally, we argue that training for palliative care specialists and others should include monitoring and rescue techniques as required competencies.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA.
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College (Y.A.), New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences (Y.A., W.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine (E.B.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee (L.B.), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics (C.T., D.P.S.), Georgetown University, Washington, District of Columbia, USA; Departments of Medicine and Philosophy (D.P.S.), Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, District of Columbia, USA
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3
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Sulmasy DP, DeCock CA, Tornatore CS, Roberts AH, Giordano J, Donovan GK. A Biophilosophical Approach to the Determination of Brain Death. Chest 2024; 165:959-966. [PMID: 38599752 DOI: 10.1016/j.chest.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 04/12/2024] Open
Abstract
Technical and clinical developments have raised challenging questions about the concept and practice of brain death, culminating in recent calls for revision of the Uniform Determination of Death Act (UDDA), which established a whole brain standard for neurologic death. Proposed changes range from abandoning the concept of brain death altogether to suggesting that current clinical practice simply should be codified as the legal standard for determining death by neurologic criteria (even while acknowledging that significant functions of the whole brain might persist). We propose a middle ground, clarifying why whole brain death is a conceptually sound standard for declaring death, and offering procedural suggestions for increasing certainty that this standard has been met. Our approach recognizes that whole brain death is a functional, not merely anatomic, determination, and incorporates an understanding of the difficulties inherent in making empirical judgments in medicine. We conclude that whole brain death is the most defensible standard for determining neurologic death-philosophically, biologically, and socially-and ought to be maintained.
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Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC; Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC.
| | - Christopher A DeCock
- Essentia Health, Grand Forks, ND; University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
| | | | - Allen H Roberts
- Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC
| | - James Giordano
- Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC; Department of Neurology, Georgetown University, Washington, DC
| | - G Kevin Donovan
- Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC
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4
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Sulmasy DP. Physicians, Spirituality, and Compassionate Patient Care. N Engl J Med 2024; 390:1061-1063. [PMID: 38502045 DOI: 10.1056/nejmp2310498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- Daniel P Sulmasy
- From the Kennedy Institute of Ethics and the Departments of Medicine and Philosophy, Georgetown University, Washington, DC
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Bernat JL, Khush KK, Shemie SD, Hartwig MG, Reese PP, Dalle Ave A, Parent B, Glazier AK, Capron AM, Craig M, Gofton T, Gordon EJ, Healey A, Homan ME, Ladin K, Messer S, Murphy N, Nakagawa TA, Parker WF, Pentz RD, Rodríguez-Arias D, Schwartz B, Sulmasy DP, Truog RD, Wall AE, Wall SP, Wolpe PR, Fenton KN. Knowledge gaps in heart and lung donation after the circulatory determination of death: Report of a workshop of the National Heart, Lung, and Blood Institute. J Heart Lung Transplant 2024:S1053-2498(24)01499-2. [PMID: 38432523 DOI: 10.1016/j.healun.2024.02.1455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 03/05/2024] Open
Abstract
In a workshop sponsored by the U.S. National Heart, Lung, and Blood Institute, experts identified current knowledge gaps and research opportunities in the scientific, conceptual, and ethical understanding of organ donation after the circulatory determination of death and its technologies. To minimize organ injury from warm ischemia and produce better recipient outcomes, innovative techniques to perfuse and oxygenate organs postmortem in situ, such as thoracoabdominal normothermic regional perfusion, are being implemented in several medical centers in the US and elsewhere. These technologies have improved organ outcomes but have raised ethical and legal questions. Re-establishing donor circulation postmortem can be viewed as invalidating the condition of permanent cessation of circulation on which the earlier death determination was made and clamping arch vessels to exclude brain circulation can be viewed as inducing brain death. Alternatively, TA-NRP can be viewed as localized in-situ organ perfusion, not whole-body resuscitation, that does not invalidate death determination. Further scientific, conceptual, and ethical studies, such as those identified in this workshop, can inform and help resolve controversies raised by this practice.
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Affiliation(s)
- James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New Hampshire.
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, PQ, Canada
| | - Matthew G Hartwig
- Division of Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, North Carolina
| | - Peter P Reese
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Dalle Ave
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia
| | - Brendan Parent
- Division of Medical Ethics and Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Alexandra K Glazier
- Brown University, School of Public Health, Providence, Rhode Island; New England Donor Services, Waltham, Massachusetts
| | - Alexander M Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Matt Craig
- Lung Biology and Disease Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Elisa J Gordon
- Department of Surgery, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Healey
- Department of Medicine McMaster University and William Osler Health System, Hamilton, Ontario, Canada
| | | | - Keren Ladin
- Research on Ethics, Aging, and Community Health (REACH Lab); Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts
| | - Simon Messer
- Department of Transplant, Golden Jubilee National Hospital, Clydebank, Scotland UK
| | - Nick Murphy
- Departments of Medicine and Philosophy, Western University, London, Ontario, Canada
| | - Thomas A Nakagawa
- University of Florida College of Medicine-Jacksonville, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Jacksonville, Florida
| | - William F Parker
- Department of Medicine and Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Rebecca D Pentz
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | | | - Bryanna Schwartz
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland; Department of Cardiology, Children's National Medical Center, Washington, District of Columbia
| | - Daniel P Sulmasy
- The Kennedy Institute of Ethics and the Departments of Medicine and Philosophy, Georgetown University, Washington, District of Columbia
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital; Center for Bioethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anji E Wall
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine; NYU Grossman School of Medicine and Department of Population Health, NYU, New York, New York
| | - Paul R Wolpe
- Center for Ethics, Department of Medicine, Emory University, Atlanta, Georgia
| | - Kathleen N Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, and Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Thomas C, Kulikowksi JD, Breitbart W, Alici Y, Bruera E, Blackler L, Sulmasy DP. Existential suffering as an indication for palliative sedation: Identifying and addressing challenges. Palliat Support Care 2024:1-4. [PMID: 38419195 DOI: 10.1017/s1478951524000336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Julia D Kulikowksi
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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7
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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024. [PMID: 38240387 DOI: 10.1111/jgs.18766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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8
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Nguyen NV, Riggan KA, Ennis JS, Tilburt JC, Smith AK, Kramer DB, Sulmasy DP, DeMartino ES. Estimating population impact of state triage policies restricting healthcare access for older adults with chronic conditions. J Am Geriatr Soc 2024; 72:294-296. [PMID: 37694828 PMCID: PMC10872914 DOI: 10.1111/jgs.18589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/19/2023] [Indexed: 09/12/2023]
Affiliation(s)
| | | | | | - Jon C. Tilburt
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
- Division of General Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Alexander K. Smith
- Department of Medicine, Division of Geriatrics, University of California, San Francisco, San Francisco, CA
- San Francisco Veterans Affairs Medical Center, San Francisco, CA
| | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
- Harvard Medical School Center for Bioethics, Boston MA
| | - Daniel P. Sulmasy
- Departments of Medicine and Philosophy, Georgetown University, Washington, DC
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - Erin S. DeMartino
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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9
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Dalle Ave AL, Sulmasy DP. Does Sedation Affect Patients' Spiritual Experience at the End of Life? An Intersection Between Medicine and Spirituality. J Pain Symptom Manage 2023:S0885-3924(23)00762-5. [PMID: 37871840 DOI: 10.1016/j.jpainsymman.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/03/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics (A.L.D.A.), Georgetown University, Washington, DC, USA.
| | - Daniel P Sulmasy
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics (D.P.S.), Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
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10
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Sulmasy DP, DeCock CA. Rethinking Brain Death-Why "Dead Enough" Is Not Good Enough: The UDDA Revision Series. Neurology 2023; 101:320-325. [PMID: 37429707 PMCID: PMC10437022 DOI: 10.1212/wnl.0000000000207407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/28/2023] [Indexed: 07/12/2023] Open
Abstract
The emergence of cases of so-called "chronic brain death" seems to undermine the biophilosophical justification of brain death as true death, which was grounded in the idea that death entails the loss of integration of the organism. Severely neurologically damaged patients who can persist for years with proper support seem to be integrated organisms, and common sense suggests that they are not dead. We argue, however, that mere integration is not enough for an organism to be alive, but that living beings must be substantially self-integrating (i.e., a living organism must itself be the primary source of its integration and not an external agent such as a scientist or physician). We propose that irreversible apnea and unresponsiveness are necessary but not sufficient to judge that a human being has lost enough capacity for self-integration to be considered dead. To be declared dead, the patient must also irrevocably have lost either (1) cardiac function or (2) cerebrosomatic homeostatic control. Even if such bodies can be maintained with sufficient technological support, one may reasonably judge that the locus of integration effectively has passed from the patient to the treatment team. While organs and cells may be alive, one may justifiably declare that there is no longer a substantially autonomous, whole, living human organism. This biophilosophical conception of death implies that the notion of brain death remains viable, but that additional testing will be required to ensure that the individual is truly brain dead by virtue of having irrevocably lost not only the capacity for spontaneous respiration and conscious responsiveness but also the capacity for cerebrosomatic homeostatic control.
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Affiliation(s)
- Daniel P Sulmasy
- From the The Kennedy Institute of Ethics (D.P.S.), Georgetown University, Washington, DC; and Essentia Health and The University of North Dakota School of Medicine and Health Sciences (C.A.D.), Fargo.
| | - Christopher A DeCock
- From the The Kennedy Institute of Ethics (D.P.S.), Georgetown University, Washington, DC; and Essentia Health and The University of North Dakota School of Medicine and Health Sciences (C.A.D.), Fargo
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11
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DeCock CA, Sulmasy DP, Alan Shewmon D, Camosy C, Accad M, Nguyen D. Where Brain Death Is Concerned-NOT Debate BUT Action. Linacre Q 2023; 90:231-233. [PMID: 37841385 PMCID: PMC10566488 DOI: 10.1177/00243639231184030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Affiliation(s)
- Christopher A. DeCock
- Department of Pediatrics, Essentia Health & University of North Dakota School of Medicine and Health Sciences,
Fargo, ND, USA
| | - Daniel P. Sulmasy
- The Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - D. Alan Shewmon
- Departments: Pediatrics and Neurology, David Geffen School of Medicine,
UCLA, Los Angeles, CA, USA
| | - Charlie Camosy
- Medical Humanities, Creighton University School of Medicine, Omaha, NE, USA
| | | | - Doyen Nguyen
- Universidade Católica Portuguesa, Lisbon, Portugal
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12
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Ennis JS, Riggan KA, Nguyen NV, Kramer DB, Smith AK, Sulmasy DP, Tilburt JC, Wolf SM, DeMartino ES. Triage Procedures for Critical Care Resource Allocation During Scarcity. JAMA Netw Open 2023; 6:e2329688. [PMID: 37642967 PMCID: PMC10466166 DOI: 10.1001/jamanetworkopen.2023.29688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/10/2023] [Indexed: 08/31/2023] Open
Abstract
Importance During the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination. Objective To analyze the role of comorbidities and long-term prognosis in state triage procedures. Design, Setting, and Participants This cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication. Main Outcomes and Measures Prevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival. Results Overall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state's list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term. Conclusions and Relevance In this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.
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Affiliation(s)
- Jackson S. Ennis
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
| | - Kirsten A. Riggan
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
| | | | - Daniel B. Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School Center for Bioethics, Boston, Massachusetts
| | - Alexander K. Smith
- Department of Medicine, Division of Geriatrics, University of California, San Francisco
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Daniel P. Sulmasy
- Departments of Medicine and Philosophy, Georgetown University, Washington, DC
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - Jon C. Tilburt
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
- Division of General Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Susan M. Wolf
- University of Minnesota Medical School, Minneapolis
- University of Minnesota Law School, Minneapolis
| | - Erin S. DeMartino
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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P Sulmasy D. Controversial arguments are controversial. Theor Med Bioeth 2023; 44:325-326. [PMID: 37462858 DOI: 10.1007/s11017-023-09635-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA.
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14
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Fisher MC, Parrillo E, Petchler C, Kub J, Hughes MT, Sulmasy DP, Baker D, Nolan MT. "They Would Lift My Spirits": Sources of Support for Family Surrogate Decision-Makers at the End of Life. J Hosp Palliat Nurs 2023; 25:119-123. [PMID: 36907841 PMCID: PMC10175176 DOI: 10.1097/njh.0000000000000939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Surrogate decision-makers make critical decisions for loved ones at the end of life, and some experience lasting negative psychological outcomes. Understanding whom they rely on for support and the types of support they value may inform nursing care and that of other health team members who work with surrogates. The purpose of the study was to explore decision support and other types of support provided to surrogate decision-makers at the end of life of their loved one and perceived usefulness of the support. This secondary analysis of data from a mixed-methods study involved the examination of the transcripts of qualitative interviews with 13 surrogate decision-makers in the United States, conducted between 2010 and 2014. A constant comparative method was used to identify common themes surrounding surrogate decision support at the end of life. Surrogates valued advance directives and conversations with their loved one about treatment preferences. Surrogates described involving many different types of people in decision-making and other types of support. Finally, surrogates appreciated being reassured that they were doing a good job in making decisions and seemed to seek out this type of affirmation from various sources including the health care team, family, and friends. Nurses are well-positioned to provide this affirmation because of the time that they spend caring for the patient and family. Future research should further explore the concept of affirmation of surrogates in their role as a means of support as they make decisions for a loved one.
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Affiliation(s)
- Marlena C. Fisher
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Elaina Parrillo
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Claire Petchler
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Joan Kub
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
| | | | - Daniel P. Sulmasy
- The Kennedy Institute of Ethics, Georgetown University, 3700 O St NW, Washington, D.C., 20057, USA
| | - Deborah Baker
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
- Johns Hopkins Hospital, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Marie T. Nolan
- Johns Hopkins School of Nursing, 525 N. Wolfe St., Baltimore, MD, 21205, USA
- Conway School of Nursing, The Catholic University of America, Washington, DC
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Sulmasy DP. The virtues and the vices of the outrageous. Theor Med Bioeth 2023; 44:107-108. [PMID: 36897553 DOI: 10.1007/s11017-023-09620-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA.
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Dalle Ave AL, Sulmasy DP. End-of-life Practices: An ethical framework for clinicians. Anaesth Crit Care Pain Med 2023; 42:101216. [PMID: 36933797 DOI: 10.1016/j.accpm.2023.101216] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/16/2023] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
Most hospitalized patients die following a decision to forgo life-sustaining treatment and/or focus on comfort care. Since "Do not kill" is a general ethical norm, many healthcare professionals (HCPs) are uncertain or troubled by such decisions. We propose an ethical framework to help clinicians to understand better their own ethical perspectives about four end-of-life practices: lethal injections, the withdrawal of life-sustaining therapies, the withholding of life-sustaining therapies, and the injection of sedatives and/or analgesics for comfort care. This framework identifies three broad ethical perspectives that may permit HCPs to examine their own attitudes and intentions. According to moral perspective A (absolutist), it is never morally permissible to be causally involved in the occurrence of death. According to moral perspective B (agential), it may be morally permissible to be causally involved in the occurrence of death, if HCPs do not have the intention to terminate the patient's life and if, among other conditions, they ensure respect for the person. Three of the four end-of-life practices, but not lethal injection, may be morally permitted. According to moral perspective C (consequentialist), all four end-of-life practices may be morally permissible if, among other conditions, respect for persons is ensured, even if one intends to hasten the dying process. This structured ethical framework may help to mitigate moral distress among HCPs by helping them to understand better their own fundamental ethical perspectives, as well as those of their patients and colleagues.
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Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics, The Pellegrino Center for Clinical Bioethics, Georgetown University, 3700 O St, NW, Healy Washington MD
- MS
- DC 424, 20057, United States.
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Depts. of Medicine and Philosophy, and the Pellegrino Center for Clinical Bioethics, Georgetown University, 3700 O St, NW, Healy 419, Washington, DC 20057, United States.
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Dalle Ave AL, Sulmasy DP. Death Lost in Translation. Am J Bioeth 2023; 23:17-19. [PMID: 36681911 DOI: 10.1080/15265161.2022.2159098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
- Anne L Dalle Ave
- Kennedy Institute of Ethics and the Pellegrino Center for Clinical Bioethics, Georgetown University
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics and the Pellegrino Center for Clinical Bioethics, Georgetown University
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Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KNG, Ferrell BR, Fitchett G, Koenig HG, Bain PA, Puchalski C, Steinhauser KE, Sulmasy DP, Koh HK. Spirituality in Serious Illness and Health. JAMA 2022; 328:184-197. [PMID: 35819420 DOI: 10.1001/jama.2022.11086] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Despite growing evidence, the role of spirituality in serious illness and health has not been systematically assessed. OBJECTIVE To review evidence concerning spirituality in serious illness and health and to identify implications for patient care and health outcomes. EVIDENCE REVIEW Searches of PubMed, PsycINFO, and Web of Science identified articles with evidence addressing spirituality in serious illness or health, published January 2000 to April 2022. Independent reviewers screened, summarized, and graded articles that met eligibility criteria. Eligible serious illness studies included 100 or more participants; were prospective cohort studies, cross-sectional descriptive studies, meta-analyses, or randomized clinical trials; and included validated spirituality measures. Eligible health outcome studies prospectively examined associations with spirituality as cohort studies, case-control studies, or meta-analyses with samples of at least 1000 or were randomized trials with samples of at least 100 and used validated spirituality measures. Applying Cochrane criteria, studies were graded as having low, moderate, serious, or critical risk of bias, and studies with serious and critical risk of bias were excluded. Multidisciplinary Delphi panels consisting of clinicians, public health personnel, researchers, health systems leaders, and medical ethicists qualitatively synthesized and assessed the evidence and offered implications for health care. Evidence-synthesis statements and implications were derived from panelists' qualitative input; panelists rated the former on a 9-point scale (from "inconclusive" to "strongest evidence") and ranked the latter by order of priority. FINDINGS Of 8946 articles identified, 371 articles met inclusion criteria for serious illness; of these, 76.9% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for serious illness: (1) incorporate spiritual care into care for patients with serious illness; (2) incorporate spiritual care education into training of interdisciplinary teams caring for persons with serious illness; and (3) include specialty practitioners of spiritual care in care of patients with serious illness. Of 6485 health outcomes articles, 215 met inclusion criteria; of these, 66.0% had low to moderate risk of bias. The Delphi panel review yielded 8 evidence statements supported by evidence categorized as strong and proposed 3 top-ranked implications of this evidence for health outcomes: (1) incorporate patient-centered and evidence-based approaches regarding associations of spiritual community with improved patient and population health outcomes; (2) increase awareness among health professionals of evidence for protective health associations of spiritual community; and (3) recognize spirituality as a social factor associated with health in research, community assessments, and program implementation. CONCLUSIONS AND RELEVANCE This systematic review, analysis, and process, based on highest-quality evidence available and expert consensus, provided suggested implications for addressing spirituality in serious illness and health outcomes as part of person-centered, value-sensitive care.
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Affiliation(s)
- Tracy A Balboni
- Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Tyler J VanderWeele
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Human Flourishing Program, Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts
| | - Stephanie D Doan-Soares
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Katelyn N G Long
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Human Flourishing Program, Institute for Quantitative Social Science, Harvard University, Cambridge, Massachusetts
| | - Betty R Ferrell
- Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, California
| | - George Fitchett
- Department of Religion, Health, and Human Values, Rush University Medical Center, Chicago, Illinois
| | - Harold G Koenig
- Departments of Psychiatry and Behavioral Sciences and Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Paul A Bain
- Harvard Medical School, Boston, Massachusetts
| | - Christina Puchalski
- The George Washington Institute for Spirituality and Health, Departments of Medicine and Health Care Sciences, George Washington University, Washington, DC
| | - Karen E Steinhauser
- Division of Palliative Medicine, Department of Medicine, Duke University Medical Center, Duke University, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC
| | - Howard K Koh
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- John F. Kennedy School of Government, Harvard University, Boston, Massachusetts
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Scire E, Jeong KY, Gaurke MK, Prusak B, Sulmasy DP. Response. Chest 2022; 161:e136. [PMID: 35131074 DOI: 10.1016/j.chest.2021.09.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Emily Scire
- School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Bernard Prusak
- Department of Philosophy and McGowan Center for Ethics and Social Responsibility, King's College, Wilkes-Barre, PA
| | - Daniel P Sulmasy
- School of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC.
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Prusak B, Gaurke M, Jeong KY, Scire E, Sulmasy DP. ICU Care in a Pandemic. Hastings Cent Rep 2021; 51:58. [PMID: 34904728 DOI: 10.1002/hast.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This letter to the editor responds to commentaries in the September-October 2021issue of the Hastings Center Report by Douglas B. White and Bernard Lo, by Govind Persad, and by Virginia A. Brown, which were themselves responding, in part, to the article "Life-Years and Rationing in the Covid-19 Pandemic: A Critical Analysis," by MaryKatherine Gaurke, Bernard Prusak, Kyeong Yun Jeong, Emily Scire, and Daniel P. Sulmasy.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Lausanne, Switzerland
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
- Departments of Medicine and Philosophy, and Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC
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Scire E, Jeong KY, Gaurke M, Prusak B, Sulmasy DP. Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans. Chest 2021; 161:504-513. [PMID: 34506791 PMCID: PMC8423769 DOI: 10.1016/j.chest.2021.08.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/10/2021] [Accepted: 08/31/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.
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Affiliation(s)
- Emily Scire
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Bernard Prusak
- Department of Philosophy and McGowan Center for Ethics and Social Responsibility, King's College, Wilkes-Barre, PA
| | - Daniel P Sulmasy
- School of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC.
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Abstract
Prominent bioethicists have promoted the preservation of life-years as a rationing strategy in response to the Covid-19 pandemic. Yet the philosophical justification for maximizing life-years is underdeveloped and has a complex history that is not reflected in recent literature. In this article, we offer a critical investigation of the use of life-years, arguing that evidence of public support for the life-years approach is thin and that organ transplantation protocols (heavily cited in pandemic-response protocols) do not provide a precedent for seeking to save the most life-years. We point out that many state emergency-response plans ultimately rejected or severely attenuated the meaning of saving the most life-years, and we argue that philosophical arguments in support of rationing by life-years are remarkably wanting. We conclude by offering a fair alternative that adheres to the standard duties of beneficence, respect for persons, and justice.
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Affiliation(s)
- Daniel P Sulmasy
- The Kennedy Institute of Ethics, Departments of Medicine and Philosophy, Georgetown University, Washington, DC
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Sulmasy DP, Maldonado F. COUNTERPOINT: Is It Ethically Permissible to Unilaterally Withdraw Life-Sustaining Treatments for Reallocation During Crisis Standards of Care? No. Chest 2021; 159:2167-2169. [PMID: 33539841 DOI: 10.1016/j.chest.2021.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022] Open
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC.
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Sulmasy DP, Maldonado F. Rebuttal From Drs Sulmasy and Maldonado. Chest 2021; 159:2170. [PMID: 33539843 PMCID: PMC8081567 DOI: 10.1016/j.chest.2021.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC.
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Doyle CK, DeMartino ES, Sperry BP, Unno S, Roberts LW, Dudzinski DM, Sulmasy DP, Mueller PS, Kramer DB, Siegler M. Statutes Governing Default Surrogate Decision Making for Mental Health Treatment. Psychiatr Serv 2021; 72:81-84. [PMID: 33050797 DOI: 10.1176/appi.ps.201900320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors sought to describe state-to-state variations in the scope of statutory authority granted to default surrogates who decide on mental health treatment for incapacitated patients. METHODS The authors investigated state statutes delineating the powers of default surrogates to make decisions about mental health treatment. Statutes in all 50 U.S. states and the District of Columbia were identified and analyzed independently by three reviewers. Research was conducted from August 2017 to November 2018 and updated in January 2020. RESULTS State statutes varied in approaches to default surrogate decision making for mental health treatment. Eight states' statutes delegate broad authority to surrogates, whereas 25 states prohibit surrogates from giving consent for specific therapies. Thirteen states are silent on whether surrogates may make decisions. CONCLUSIONS Heterogeneity among state statutory laws contributes to complexity of treating patients without decisional capacity. This variability encumbers efforts to support surrogates and clinicians and may contribute to health disparities.
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Affiliation(s)
- Cavan K Doyle
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Erin S DeMartino
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Beau P Sperry
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Sei Unno
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Laura Weiss Roberts
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - David M Dudzinski
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Daniel P Sulmasy
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Paul S Mueller
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Daniel B Kramer
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
| | - Mark Siegler
- Neiswanger Institute for Bioethics, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois (Doyle); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (DeMartino); David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (Sperry); School of Law, Loyola University Chicago, Chicago (Unno); Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California (Roberts); Department of Cardiology, Massachusetts General Hospital, Boston (Dudzinski); Departments of Medicine and Philosophy, Georgetown University, Washington, D.C. (Sulmasy); Department of General Internal Medicine, Mayo Clinic Health System, La Crosse, Wisconsin (Mueller); Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston (Kramer); MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (Siegler)
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Sulmasy DP. Correction to: Whole-brain death and integration: realigning the ontological concept with clinical diagnostic tests. Theor Med Bioeth 2020; 41:281-282. [PMID: 33331999 DOI: 10.1007/s11017-020-09533-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Healy 419, 3700 O Street NW, Washington, DC, 20057, USA.
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Sulmasy DP. Principled decisions and virtuous care: an ethical assessment of the SIAARTI Guidelines for allocating intensive care resources. Minerva Anestesiol 2020; 86:872-876. [DOI: 10.23736/s0375-9393.20.14691-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC
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Affiliation(s)
- Daniel P Sulmasy
- Departments of Medicine and Philosophy, Georgetown University, Washington, DC, USA
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Sulmasy DP. Why Dementia‐Specific Advance Directives Are a Misguided Idea. J Am Geriatr Soc 2020; 68:1603-1605. [DOI: 10.1111/jgs.16493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 11/29/2022]
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Abstract
Prestigious University is a large, private educational institution with a medical school, a university hospital, a law school, and graduate and undergraduate colleges all on a single campus. In the face of the Covid‐19 pandemic, students were told during spring break to return to campus only briefly to retrieve their belongings. Classes then went online. On March 23, 2020, the faculty, students, and staff were emailed the following by the university's director of infection control and public health:We have become aware that a Prestigious University staff member has tested positive for the virus that causes Covid‐19. The individual, who was last on campus on March 16, is now in isolation at their permanent residence and is doing well clinically. The university has already identified those members of our community who may have been in close contact with this individual, and we are working to notify them. Further, this individual's local health department has a protocol for identifying people who have been in direct contact with anyone testing positive for Covid‐19 (such as this Prestigious University staff member) so that they can self‐quarantine and watch for COVID‐19 symptoms for a period of 14 days from their last contact with the infected individual.
A professor in the Philosophy Department has asked the ethicists at the medical school whether such contact tracing suffices. “Don't the members of the community deserve to know who this is? Isn't there a mandate to identify this person in order to maximize public health benefits and slow the spread of this deadly virus?”
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Abstract
The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent.
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Affiliation(s)
- Anne L Dalle Ave
- Ethics Unit, University Hospital of Lausanne, Rue Du Bugnon 21, 1011, Lausanne, Switzerland.
- Institute for Biomedical Ethics, University Medical Center 1, Rue Michel-Servet, 1211, Geneva 14, Switzerland.
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, The Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, 3700 O St, NW, Healy 419, Washington, DC, 20057, USA
| | - James L Bernat
- Neurology Department, Dartmouth-Hitchcock Medical Center, Lebanon, NH, 03756, USA
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Abstract
Increasingly, physicians are being asked to provide technical services that many (in some cases, most) believe are morally wrong or inconsistent with their beliefs about the meaning and purposes of medicine. This controversy has sparked persistent debate over whether practitioners should be permitted to decline participation in a variety of legal practices, most notably physician-assisted suicide and abortion. These debates have become heavily politicized, and some of the key words and phrases are being used without a clear understanding of their meaning. In this essay, I endeavor, firstly, to clarify the meaning of some of these terms: conscience, conscientious action, professional judgment, conscientious objection, conscience clauses, civil disobedience, and tolerance. I argue that use of the term conscientious objection to describe these refusals by health care professionals is mistaken and confusing. Secondly, relying on a proper understanding of the moral and technical character of medical judgment, the optimal deference that the state and markets ought to have toward professions, and general principles of Lockean tolerance for a diversity of practices and persons in a flourishing, pluralistic, democratic society, I offer a defense of tolerance with respect to the deeply held convictions of physicians and other health care professionals who hold minority views on contested but legal medical practices.
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Affiliation(s)
- Daniel P Sulmasy
- André Hellegers Professor of Biomedical Ethics, Kennedy Institute of Ethics, Georgetown University, 3700 O St. NW, Washington, DC, 20057, USA.
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Abstract
For decades, physicians, philosophers, theologians, lawyers, and the public considered brain death a settled issue. However, a series of recent cases in which individuals were declared brain dead yet physiologically maintained for prolonged periods of time has challenged the status quo. This signals a need for deeper reflection and reexamination of the underlying philosophical, scientific, and clinical issues at stake in defining death. In this paper, I consider four levels of philosophical inquiry regarding death: the ontological basis, actual states of affairs, epistemological standards, and clinical criteria for brain death. I outline several candidates for the states of affairs that may constitute death, arguing that we should strive for a single, unified ontological definition of death as a loss of integrated functioning as a unified organism, while acknowledging that two states of affairs (cardiopulmonary death and whole-brain death) may satisfy this concept. I argue that the clinical criteria for determining whole-brain death should be bolstered to meet the epistemic demand of sufficient certainty in defining death by adding indicators of cerebro-somatic dis-integration to the traditional triad of loss of consciousness, loss of brainstem function, and absence of confounding explanations.
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Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Healy 419, 3700 O Street NW, Washington, DC, 20057, USA.
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Affiliation(s)
- Daniel P Sulmasy
- The Kennedy Institute of Ethics, Departments of Medicine and Philosophy, Georgetown University, Washington, DC
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Sulmasy DP, Finlay I, Fitzgerald F, Foley K, Payne R, Siegler M. Physician-Assisted Suicide: Against Medical Neutrality. J Gen Intern Med 2019; 34:1372. [PMID: 31098979 PMCID: PMC6667721 DOI: 10.1007/s11606-019-05019-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Healy 419, Georgetown University, Washington, DC, USA.
| | | | | | - Kathleen Foley
- Emeritus, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard Payne
- Kennedy Institute of Ethics, Healy 419, Georgetown University, Washington, DC, USA
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Sulmasy DP. Engaging Pellegrino's philosophy of medicine: Can one of the founders of the field still help us today? Theor Med Bioeth 2019; 40:165-168. [PMID: 31368042 DOI: 10.1007/s11017-019-09488-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Healy 419, Georgetown University, 3700 O St, NW Washington, DC, 20057, USA.
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Abstract
Although Spanish is a major world language and increasingly common in North America, most instruments that measure quality of life (QOL) are written in English, limiting researchers’ ability to assess QOL in patients who speak only Spanish. In this article, we present a Spanish version of the McGill Quality of Life Questionnaire (MQOL), a validated instrument found particularly relevant for patients with life-threatening illness. A translation/ back-translation method, supplemented with review by a committee composed of lay persons and clinicians speaking Puerto Rican, Dominican, Mexican, Salvadoran, Ecuadorian, and Colombian Spanish, was used to achieve conceptual equivalence with the English version. Our initial review demonstrated face validity for the Spanish version of the MQOL. However, further testing is required to fully determine its psychometric properties and to provide a version that has been validated in use.
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Affiliation(s)
- Victorio R. Tolentino
- Saint Vincent Catholic Medical Centers, St. Vincent's Manhattan, and New York Medical College, Valhalla, New York, U.S.A
| | - Daniel P. Sulmasy
- Saint Vincent Catholic Medical Centers, St. Vincent's Manhattan, New York, and New York Medical College, Valhalla, New York, U.S.A
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DeMartino ES, Braus NA, Sulmasy DP, Bohman JK, Stulak JM, Guru PK, Fuechtmann KR, Singh N, Schears GJ, Mueller PS. Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations. Mayo Clin Proc 2019; 94:620-627. [PMID: 30853261 PMCID: PMC10893957 DOI: 10.1016/j.mayocp.2018.09.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 08/20/2018] [Accepted: 09/24/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology. PATIENTS AND METHODS We retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation. RESULTS Of 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death. CONCLUSION For most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.
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Affiliation(s)
- Erin S DeMartino
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN.
| | - Nicholas A Braus
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN
| | - Daniel P Sulmasy
- Department of Medicine, Georgetown University, Washington, DC; Department of Philosophy, Georgetown University, Washington, DC; Kennedy Institute of Ethics, Georgetown University, Washington, DC
| | - J Kyle Bohman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | - Gregory J Schears
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Paul S Mueller
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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Sulmasy DP. Ethics and Evidence. The Journal of Clinical Ethics 2019. [DOI: 10.1086/jce2019301056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Sulmasy DP. Ethics and Evidence. J Clin Ethics 2019; 30:56-66. [PMID: 30896445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Towards the end of the last century, bioethics underwent an "empirical turn," characterized by an increasing number of empirical studies about issues of bioethical concern. Taking a cue from the evidence-based medicine movement, some heralded this as a turn toward evidence-based ethics. However, it has never been clear what this means, and the strategies and goals of evidence-based ethics remain ambiguous. In this article, the author explores what the potential aims of this movement might be, ultimately arguing that, while the development of good empirical research can and should aid in ethical deliberation, one ought to avoid assuming or suggesting that empirical studies themselves determine normative prescriptions and proscriptions. The limits of the use of empirical studies in bioethics are explored in detail, and 10 potential ways that such studies can soundly contribute to bioethics are described. Good ethics depends upon sound facts, but ethics cannot be based on evidence alone.
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Affiliation(s)
- Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, District of Columbia USA.
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Abstract
This special issue of Theoretical Medicine and Bioethics takes up the question of palliative sedation as a source of potential concern or controversy among Christian clinicians and thinkers. Christianity affirms a duty to relieve unnecessary suffering yet also proscribes euthanasia. Accordingly, the question arises as to whether it is ever morally permissible to render dying patients unconscious in order to relieve their suffering. If so, under what conditions? Is this practice genuinely morally distinguishable from euthanasia? Can one ever aim directly at making a dying person unconscious, or is it only permissible to tolerate unconsciousness as an unintended side effect of treating specific symptoms? What role does the rule of double effect play in making such decisions? Does spiritual or psychological suffering ever justify sedation to unconsciousness? What are the theological and spiritual aspects of such care? This introduction describes how the authors in this special issue wrestle with such questions and shows how each essay relates to the author's individual position on palliative sedation, as developed in greater detail within his contribution.
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Affiliation(s)
- Daniel P Sulmasy
- Departments of Medicine and Philosophy, The Pellegrino Center for Clinical Bioethics, Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA.
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Abstract
A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient's consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.
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Affiliation(s)
- Daniel P Sulmasy
- The Pellegrino Center for Clinical Bioethics, The Kennedy Institute of Ethics, and the Departments of Medicine and Philosophy, Georgetown University, Washington, DC, USA.
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Sprung CL, Somerville MA, Radbruch L, Collet NS, Duttge G, Piva JP, Antonelli M, Sulmasy DP, Lemmens W, Ely EW. Physician-Assisted Suicide and Euthanasia. J Palliat Care 2018; 33:197-203. [DOI: 10.1177/0825859718777325] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Medical professional societies have traditionally opposed physician-assisted suicide and euthanasia (PAS-E), but this opposition may be shifting. We present 5 reasons why physicians shouldn’t be involved in PAS-E. 1. Slippery slopes: There is evidence that safeguards in the Netherlands and Belgium are ineffective and violated, including administering lethal drugs without patient consent, absence of terminal illness, untreated psychiatric diagnoses, and nonreporting; 2. Lack of self-determination: Psychological and social motives characterize requests for PAS-E more than physical symptoms or rational choices; many requests disappear with improved symptom control and psychological support; 3. Inadequate palliative care: Better palliative care makes most patients physically comfortable. Many individuals requesting PAS-E don’t want to die but to escape their suffering. Adequate treatment for depression and pain decreases the desire for death; 4. Medical professionalism: PAS-E transgresses the inviolable rule that physicians heal and palliate suffering but never intentionally inflict death; 5. Differences between means and ends: Proeuthanasia advocates look to the ends (the patient’s death) and say the ends justify the means; opponents disagree and believe that killing patients to relieve suffering is different from allowing natural death and is not acceptable. Conclusions: Physicians have a duty to eliminate pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS-E requests. They should not include changing medical practice to allow PAS-E.
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Affiliation(s)
- Charles L. Sprung
- General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Margaret A. Somerville
- Professor of Bioethics, School of Medicine, The University of Notre Dame Australia, Sydney, Australia; Samuel Gale Professor of Law Emerita, Professor Faculty of Medicine Emerita, Founding Director of the Centre for Medicine, Ethics and Law Emerita, McGill University Montreal, Canada
| | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Gunnar Duttge
- Center for Medical Law, Georg-August-University Göttingen, Göttingen, Germany
| | - Jefferson P. Piva
- Federal University of Rio Grande do Sul (Brazil), Medical Director-Pediatric Emergency and Critical Care, Department H Clinicas P. Alegre, Brazil
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore—Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Daniel P. Sulmasy
- Kennedy Institute of Ethics and Pellegrino Center, Departments of Medicine and Philosophy, Georgetown University, Washington D.C., United States
| | - Willem Lemmens
- Department of Philosophy, Centre for Ethics, University of Antwerp, Belgium
| | - E. Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center and Veteran’s Affair TN Valley Geriatric Research Education Clinical Center (GRECC), Nashville, TN, United States
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Affiliation(s)
- Daniel P Sulmasy
- Departments of Medicine and Philosophy, Pellegrino Center, and Kennedy Institute of Ethics, Georgetown University, Washington, DC
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Jansen LA, Mahadevan D, Appelbaum PS, Klein WMP, Weinstein ND, Mori M, Degnin C, Sulmasy DP. Perceptions of control and unrealistic optimism in early-phase cancer trials. J Med Ethics 2018; 44:121-127. [PMID: 28774957 DOI: 10.1136/medethics-2016-103724] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 04/25/2017] [Accepted: 06/13/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Recent research has found unrealistic optimism (UO) among patient-subjects in early-phase oncology trials. Our aim was to investigate the cognitive and motivational factors that evoke this bias in this context. We expected perceptions of control to be a strong correlate of unrealistic optimism. METHODS A study of patient-subjects enrolled in early-phase oncology trials was conducted at two sites in the USA. Respondents completed questionnaires designed to assess unrealistic optimism and several risk attribute variables that have been found to evoke the bias in other contexts. RESULTS One hundred and seventy-one patient-subjects agreed to be interviewed for our study. Significant levels of perceived controllability were found with respect to all nine research-related questions. Perceptions of control were found to predict unrealistic optimism. Two other risk attribute variables, awareness of indicators (p=0.024) and mental image (p=0.022), were correlated with unrealistic optimism. However, in multivariate regression analysis, awareness and mental image dropped out of the model and perceived controllability was the only factor independently associated with unrealistic optimism (p<0.0001). CONCLUSION Patient-subjects reported that they can, at least partially, control the benefits they receive from participating in an early-phase oncology trial. This sense of control may underlie unrealistic optimism about benefiting personally from trial participation. Effective interventions to counteract unrealistic optimism may need to address the psychological factors that give rise to distorted risk/benefit processing.
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Affiliation(s)
- Lynn A Jansen
- Madeline Brill Nelson Chair in Ethics Education, Oregon Health & Science University, Center for Ethics in Health Care, Portland, Oregon, USA
| | - Daruka Mahadevan
- Arizona Cancer Center, University of Arizona, Tucson, Arizona, USA
| | - Paul S Appelbaum
- Department of Psychiatry-Columbia, University College of Physicians and Surgeons, Columbia, South Carolina, USA
| | - William M P Klein
- Behavioral Research Program, National Institutes of Health/National Cancer Institute, Bethesda, Maryland, USA
| | - Neil D Weinstein
- Department of Human Ecology, Rutgers University, New Brunswick, New Jersey, USA
| | - Motomi Mori
- Departments of Public Health and Preventive Medicine and Medical Informatics and Clinical Epidemiology, Oregon Health & Science University/Knight Cancer Institute, Portland, Oregon, USA
| | | | - Daniel P Sulmasy
- Departments of Medicine and Philosophy, Georgetown University, Georgetown, Washington DC, USA
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Balboni MJ, Sullivan A, Smith PT, Zaidi D, Mitchell C, Tulsky JA, Sulmasy DP, VanderWeele TJ, Balboni TA. The Views of Clergy Regarding Ethical Controversies in Care at the End of Life. J Pain Symptom Manage 2018; 55:65-74.e9. [PMID: 28818632 PMCID: PMC5735011 DOI: 10.1016/j.jpainsymman.2017.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/19/2017] [Accepted: 05/09/2017] [Indexed: 11/22/2022]
Abstract
CONTEXT Although religion often informs ethical judgments, little is known about the views of American clergy regarding controversial end-of-life ethical issues including allowing to die and physician aid in dying or physician-assisted suicide (PAD/PAS). OBJECTIVE To describe the views of U.S. clergy concerning allowing to die and PAD/PAS. METHODS A survey was mailed to 1665 nationally representative clergy between 8/2014 to 3/2015 (60% response rate). Outcome variables included beliefs about whether the terminally ill should ever be "allowed to die" and moral/legal opinions concerning PAD/PAS. RESULTS Most U.S. clergy are Christian (98%). Clergy agreed that there are circumstances in which the terminally ill should be "allowed to die" (80%). A minority agreed that PAD/PAS was morally (28%) or legally (22%) acceptable. Mainline/Liberal Christian clergy were more likely to approve of the morality (56%) and legality (47%) of PAD/PAS, in contrast to all other clergy groups (6%-17%). Greater end-of-life medical knowledge was associated with moral disapproval of PAD/PAS (adjusted odds ratio [AOR], 1.51; 95% CI, 1.04-2.19, P = 0.03). Those reporting distrust in health care were less likely to oppose legalization of PAD/PAS (AOR 0.93; 95% CI, 0.87-0.99, P < 0.02). Religious beliefs associated with disapproval of PAD/PAS included "life's value is not tied to the patient's quality of life" (AOR 2.12; 95% CI, 0.1.49-3.03, P < 0.001) and "only God numbers our days" (AOR 2.60; 95% CI, 1.77-3.82, P < 0.001). CONCLUSION Most U.S. clergy approve of "allowing to die" but reject the morality or legalization of PAD/PAS. Respectful discussion in public discourse should consider rather than ignore underlying religious reasons informing end-of-life controversies.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Brown University, Providence, Rhode Island, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA
| | - Danish Zaidi
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Tyler J VanderWeele
- Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Departments of Epidemiology and Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts; and Brigham and Women's Hospital, Boston, Massachusetts, USA
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