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Fong C, Kueh WL, Lew SJW, Ho BCH, Wong YL, Lau YH, Chia YW, Tan HL, Seet YHC, Siow WT, MacLaren G, Agrawal R, Lim TJ, Lim SL, Lim TW, Ho VK, Soh CR, Sewa DW, Loo CM, Khan FA, Tan CK, Gokhale RS, Siau C, Lim NLSH, Yim CF, Venkatachalam J, Venkatesan K, Chia NCH, Liew MF, Li G, Li L, Myat SM, Zena Z, Zhuo S, Yueh LL, Tan CSF, Ma J, Yeo SL, Chan YH, Phua J. Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study. J Intensive Care 2024; 12:13. [PMID: 38528556 DOI: 10.1186/s40560-024-00725-3] [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: 01/14/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.
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Affiliation(s)
- Clare Fong
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore.
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Wern Lunn Kueh
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Sennen Jin Wen Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Benjamin Choon Heng Ho
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yu-Lin Wong
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Hui Ling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Ying Hao Christopher Seet
- Department of Neurology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wen Ting Siow
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Graeme MacLaren
- Cardiothoracic ICU, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Rohit Agrawal
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Tian Jin Lim
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Pre-Hospital and Emergency Research Center, Duke-NUS Medical School, 8 College Rd, Singapore, 16985, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Vui Kian Ho
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
- Department of Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chai Rick Soh
- Department of Anaesthesiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Roshni Sadashiv Gokhale
- Department of Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Noelle Louise Siew Hua Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chik-Foo Yim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Jonathen Venkatachalam
- Department of Respiratory and Critical Care Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Kumaresh Venkatesan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Naville Chi Hock Chia
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
- Yong Loo Lin School of Medicine, 10 Medical Dr, Singapore, 117597, Singapore
- Lee Kong Chian School of Medicine, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Mei Fong Liew
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Guihong Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Li Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Su Mon Myat
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zena Zena
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shuling Zhuo
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Ling Ling Yueh
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Caroline Shu Fang Tan
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jing Ma
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Siew Lian Yeo
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
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2
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López González UA, Bautista Rentero D, Crespo Gómez M, Cárcamo Ibarra P, Míguez Santiyán AM. Factors associated with limitation of life support: Post-ICU mortality case study of a tertiary hospital. Rev Esp Anestesiol Reanim (Engl Ed) 2024:S2341-1929(24)00027-1. [PMID: 38342305 DOI: 10.1016/j.redare.2024.02.007] [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] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/23/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Life-sustaining treatment limitation (LSV) is the medical act of withdrawing or not initiating measures that are considered futile in a patient's specific situation. LSV in critically ill patients remains a difficult topic to study, due to the multitude of factors that condition it. OBJECTIVE To determine factors related to LSV in ICU in cases of post-ICU in-hospital mortality, as well as factors associated with survival after discharge from ICU. DESIGN Retrospective longitudinal study. AMBIT Intensive care unit of a tertiary hospital. PATIENTS People who died in the hospitalization ward after ICU treatment between January 2014 and December 2019. INTERVENTIONS None. This is an observational study. VARIABLES OF INTEREST Age, sex, probability of death, type of admission, LSV in ICU, oncological disease, dependence, invasive mechanical ventilation, emergency hemodialysis, transfusion of blood products, nosocomial infection (NI), pre-ICU, intra-ICU and post-ICU stays. RESULTS Of 114 patients who died outside the ICU, 49 had LSV registered in the ICU (42.98%). Age and stay prior to ICU admission were positively associated with LSV (OR 1,03 and 1,08, respectively). Patients without LSV had a higher post-ICU stay, while it was lower for male patients. CONCLUSIONS Our results support that LSV established within the ICU can avoid complications commonly associated with unnecessary prolongation of stay, such as NI.
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Affiliation(s)
- U A López González
- Servicio de Medicina Preventiva, Hospital Universitario Doctor Peset, Valencia, Spain.
| | - D Bautista Rentero
- Servicio de Medicina Preventiva, Hospital Universitario Doctor Peset, Valencia, Spain
| | - M Crespo Gómez
- Servicio de Medicina Intensiva, Hospital Universitario Doctor Peset, Valencia, Spain
| | - P Cárcamo Ibarra
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - A M Míguez Santiyán
- Servicio de Medicina Preventiva, Hospital Universitario Doctor Peset, Valencia, Spain
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Beil M, van Heerden PV, Joynt GM, Lapinsky S, Flaatten H, Guidet B, de Lange D, Leaver S, Jung C, Forte DN, Bin D, Elhadi M, Szczeklik W, Sviri S. Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices. Ann Intensive Care 2023; 13:107. [PMID: 37884827 PMCID: PMC10603016 DOI: 10.1186/s13613-023-01189-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. METHODS Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. RESULTS This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. CONCLUSIONS This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.
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Affiliation(s)
- Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Stephen Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Hans Flaatten
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, Service MIR, Sorbonne Université, Paris, France
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniel Neves Forte
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Du Bin
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | | | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Ul. Wrocławska 1-3, 30 - 901, Kraków, Poland.
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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4
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Beil M, de Lange D, Leaver S, Szczeklik W, Fjolner J, Nachshon A, van Heerden PV, Joskowicz L, Jung C, Hyams G, Sviri S. The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU. Ann Intensive Care 2023; 13:40. [PMID: 37162595 PMCID: PMC10170430 DOI: 10.1186/s13613-023-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. METHODS This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. RESULTS The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. CONCLUSIONS Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, service MIR, Paris, France
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Akiva Nachshon
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Christian Jung
- Division of Cardiology, Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
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5
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Rholl EL, Baughman KR, Leuthner SR. Withdrawing and Withholding Life-Sustaining Medical Therapies in the Neonatal Intensive Care Unit: Case-Based Approaches to Clinical Controversies. Clin Perinatol 2022; 49:127-135. [PMID: 35209995 DOI: 10.1016/j.clp.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In cases whereby the continuation of life-sustaining medical therapies is not in the infant's best interest and does not align with the parents' goals, it is ethically and morally advisable to withhold/withdraw life-sustaining medical therapies. Withdrawing/withholding artificial nutrition hydration is not morally or ethically different from other medical treatments. Determination of what and when to withdraw should occur through shared decision-making considering the parents' values and the infant's physiology and comfort. The practice of physician recommendations followed by parental informed nondissent should be considered in these instances.
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Affiliation(s)
- Erin L Rholl
- Division of Hospital Medicine, PANDA Palliative Care Team, Children's National Medical Center, 111 Michigan Avenue, Washington, DC 20010, USA
| | - Katie R Baughman
- Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, 8915 W. Connell Court, Milwaukee, WI 53226, USA
| | - Steven R Leuthner
- Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, 999 North 92nd Street, Suite C410, Wauwatosa, WI 53226, USA.
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Borovecki A, Curkovic M, Nikodem K, Oreskovic S, Novak M, Rubic F, Vukovic J, Spoljar D, Gordijn B, Gastmans C. Attitudes about withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide, and physician assisted suicide: a cross-sectional survey among the general public in Croatia. BMC Med Ethics 2022; 23:13. [PMID: 35172812 PMCID: PMC8851732 DOI: 10.1186/s12910-022-00751-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 02/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. METHODS A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson's coefficient) and multiple regression analysis for data analysis. RESULTS 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person's autonomous decisions regarding end-of-life procedures. CONCLUSIONS The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people's views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia.
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Affiliation(s)
- Ana Borovecki
- School of Medicine, Center for Palliative Medicine, Medical Ethics and Communication Skills, University of Zagreb, Salata 2, 10000, Zagreb, Croatia.
| | - Marko Curkovic
- School of Medicine, University Psychiatric Hospital Vrapče, University of Zagreb, Zagreb, Croatia
| | - Krunoslav Nikodem
- Faculty of Humanities and Social Sciences, Department of Sociology, University of Zagreb, Zagreb, Croatia
| | - Stjepan Oreskovic
- School of Medicine, Department of Medical Sociology, University of Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Filip Rubic
- School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Jurica Vukovic
- School of Medicine, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Diana Spoljar
- School of Medicine, University Hospital Dubrava, University of Zagreb, Zagreb, Croatia
| | - Bert Gordijn
- Institute of Ethics, School of Theology, Philosophy, and Music, Dublin City University, Dublin, Ireland
| | - Chris Gastmans
- Centre for Biomedical Ethics and Law, Faculty of Medicine, KU Leuven, Leuven, Belgium
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7
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Aelbrecht-Meurisse C, Ryckewaert T, Pannier D, Gamblin V, Garcia V, Aelbrecht S, Penel N. [ Withholding or withdrawing life-sustaining treatments in acute oncology situations: History and regulatory aspects in France]. Bull Cancer 2021; 108:415-423. [PMID: 33678409 DOI: 10.1016/j.bulcan.2020.11.020] [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: 07/02/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
The management of oncology patients, especially hospitalized patients, can lead to almost daily discussions regarding therapeutic limitations. Here, we review the history and propose a summary of the texts framing the notion of "withholding and withdrawing life-sustaining treatment" in oncology practice in France. This decision is regulated by the Claeys-Léonetti Law of February 2, 2016 recommending a collegial discussion and its documentation in the medical record. The decision to withhold or withdraw life-sustaining treatments is the subject of discussion between the patient, his physicians and his family and may take place at any time during his management. The work of intensive-care physicians provides many useful recommendations for acute oncology situations, however articles specific for oncology practice are scarce; this is a topic that oncologists must take up.
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Affiliation(s)
| | - Thomas Ryckewaert
- Centre Oscar Lambret, département d'oncologie médicale, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Diane Pannier
- Centre Oscar Lambret, département d'oncologie médicale, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Vincent Gamblin
- Centre Oscar Lambret, département de soins palliatifs, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Vincent Garcia
- Centre Oscar Lambret, département d'anesthésie-réanimation, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Stéphane Aelbrecht
- EHPAD Les Myosotis, 160, rue Augustin Tirmont, 59283 Raimbeaucourt, France
| | - Nicolas Penel
- Centre Oscar Lambret, département d'oncologie médicale, 3, rue Frédéric Combemale, 59000 Lille, France
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El Jawiche R, Hallit S, Tarabey L, Abou-Mrad F. Withholding and withdrawal of life-sustaining treatments in intensive care units in Lebanon: a cross-sectional survey of intensivists and interviews of professional societies, legal and religious leaders. BMC Med Ethics 2020; 21:80. [PMID: 32859185 PMCID: PMC7456082 DOI: 10.1186/s12910-020-00525-y] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU). Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate). Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.
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Affiliation(s)
- Rita El Jawiche
- Anesthesia Department, Bahman Hospital, Haret Hreik, near Masjed El Hassanein, Beirut, Lebanon.
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon. .,INSPECT-LB: Institut National de Santé Publique, Epidemiologie Clinique et Toxicologie- Liban, Beirut, Lebanon.
| | - Lubna Tarabey
- Institute of Social Sciences and Medical School, Lebanese University, Hadath, Lebanon
| | - Fadi Abou-Mrad
- Neurology Division and Memory Clinic, Saint Charles Hospital, Baabda, Lebanon.,Division of Medical Ethics & Forensic Medicine, Lebanese University, Hadath, Lebanon
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9
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Wei L, Sha Z, Wang Y, Zhang G, Jia H, Zhou S, Li Y, Wang Y, Liu C, Jiao M, Sun S, Wu Q. Willingness and beliefs associated with reporting travel history to high-risk coronavirus disease 2019 epidemic regions among the Chinese public: a cross-sectional study. BMC Public Health 2020; 20:1164. [PMID: 32711503 PMCID: PMC7382320 DOI: 10.1186/s12889-020-09282-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 04/08/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The Coronavirus Disease 2019 (COVID-19) that first occurred in Wuhan, China, is currently spreading throughout China. The majority of infected patients either traveled to Wuhan or came into contact with an infected person from Wuhan. Investigating members of the public with a travel history to Wuhan became the primary focus of the Chinese government's epidemic prevention and control measures, but several instances of withheld histories were uncovered as localized clusters of infections broke out. This study investigated the public's willingness and beliefs associated with reporting travel history to high-risk epidemic regions, to provide effective suggestions and measures for encouraging travel reporting. METHODS A cross-sectional study was conducted online between February 12 and 19, 2020. Descriptive analysis, chi-squared test, and Fisher's exact test were used to identify socio-demographic factors and beliefs associated with reporting, as well as their impact on the willingness to report on travel history to high-risk epidemic regions. RESULTS Of the 1344 respondents, 91 (6.77%) expressed an inclination to deliberately withhold travel history. Those who understood the benefits of reporting and the legal consequences for deliberately withholding information, showed greater willingness to report their history (P < 0.05); conversely, those who believed reporting would stigmatize them and feared being quarantined after reporting showed less willingness to report (P < 0.05). CONCLUSIONS As any incident of withheld history can have unpredictable outcomes, the proportion of people who deliberately withhold information deserves attention. Appropriate public risk communication and public advocacy strategies should be implemented to strengthen the understanding that reporting on travel history facilitates infection screening and prompt treatment, and to decrease the fear of potentially becoming quarantined after reporting. Additionally, social support and policies should be established, and measures should be taken to alleviate stigmatization and discrimination against potential patients and reporters of travel history. Reinforcing the legal accountability of withholding travel history and strengthening systematic community monitoring are the measures that China is currently taking to encourage reporting on travel history to high-risk epidemic regions. These non-pharmaceutical interventions are relevant for countries that are currently facing the spread of the epidemic and those at risk of its potential spread.
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Affiliation(s)
- Lifeng Wei
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Zhuowa Sha
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Ying Wang
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Gangyu Zhang
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Haonan Jia
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Shuang Zhou
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Yuanheng Li
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Yameng Wang
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Chao Liu
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Mingli Jiao
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.
| | - Shufan Sun
- Heilongjiang Provincial Psychiatric Institute, Xiangfang District, Harbin, Heilongjiang, China
| | - Qunhong Wu
- Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
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10
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Shaw C, Connabeer K, Drew P, Gallagher K, Aladangady N, Marlow N. Initiating end-of-life decisions with parents of infants receiving neonatal intensive care. Patient Educ Couns 2020; 103:1351-1357. [PMID: 32111382 DOI: 10.1016/j.pec.2020.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 02/06/2020] [Accepted: 02/08/2020] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented. METHOD Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test. RESULTS When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030). CONCLUSION Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making. PRACTICE IMPLICATIONS Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making.
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Affiliation(s)
- Chloe Shaw
- UCL EGA Institute for Women's Health, University College London, London, UK.
| | | | - Paul Drew
- Department of Language & Linguistic Science, University of York, York, UK.
| | - Katie Gallagher
- UCL EGA Institute for Women's Health, University College London, London, UK.
| | - Narendra Aladangady
- Department of Neonatology, Homerton University Hospital, London, UK; Centre for Paediatrics, Barts and the London School of Medicine and Dentistry, QMUL, London, UK.
| | - Neil Marlow
- UCL EGA Institute for Women's Health, University College London, London, UK.
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11
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Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth 2020; 31:29-46. [PMID: 32284707 PMCID: PMC7144300 DOI: 10.1080/11287462.2020.1736243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [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: 01/07/2019] [Accepted: 02/15/2020] [Indexed: 11/12/2022] Open
Abstract
When it is ethically justifiable to stop medical treatment? For many Muslim patients, families, and clinicians this ethical question remains a challenging one as Islamic ethico-legal guidance on such matters remains scattered and difficult to interpret. In light of this gap, we conducted a systematic literature review to aggregate rulings from Islamic jurists and juridical councils on whether, and when, it is permitted to withdraw and/or withhold life-sustaining care. A total of 16 fatwās were found, 8 of which were single-author rulings, and 8 represented the collective view of a juridical council. The fatwās are similar in that nearly all judge that Islamic law, provided certain conditions are met, permits abstaining from life-sustaining treatment. Notably, the justifying conditions appear to rely on physician assessment of the clinical prognosis. The fatwās differ when it comes to what conditions justify withdrawing or withholding life- sustaining care. Our analyses suggest that while notions of futility greatly impact the bioethical discourse regarding with holding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. Therefore, clinicians, Islamic jurists, and bioethicists need to come together in order to unify a conception of medical futility and relate it to the ethics of withholding and/or withdrawal of treatment.
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Affiliation(s)
- Afshan Mohiuddin
- Initiative on Islam and Medicine, Program on Medicine and Religion, The University of Chicago, Chicago, IL, USA
- Department of Internal Medicine, University Hospitals Regional Medical Center, Macomb Township, MI, USA
| | | | - Shoaib Rasheed
- Department of Internal Medicine, Henry Ford Macomb Hospital, Chicago, IL, USA
| | - Aasim I. Padela
- Initiative on Islam and Medicine, Program on Medicine and Religion, The University of Chicago, Chicago, IL, USA
- Section of Emergency Medicine, Department of Medicine, The University of Chicago, Chicago, IL, USA
- MacLean Center for Clinical Medical Ethics, The University of Chicago, Chicago, IL, USA
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12
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Douplat M, Jacquin L, Tazarourte K, Le Coz P. Answer to the reply letter to: Physician's experience in decisions of withholding, withdrawing life-sustaining treatments: A multicentre survey in emergency departments. Anaesth Crit Care Pain Med 2019; 38:519-520. [PMID: 30807877 DOI: 10.1016/j.accpm.2019.02.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Marion Douplat
- Hospices civils de Lyon, hôpital Lyon Sud, service d'accueil des urgences, 65, chemin du Grand Revoyet, Pierre-Bénite 69495, France; UMR 7268 ADéS, Aix-Marseille Université/EFS/CNRS, Faculté de Médecine, 27, boulevard Jean-Moulin, Marseille 13005, France.
| | - Laurent Jacquin
- Hospices Civils de Lyon, Hôpital Edouard-Herriot, Service d'Accueil des urgences, 5, place d'Arsonval, Lyon 69003, France.
| | - Karim Tazarourte
- Hospices Civils de Lyon, Hôpital Edouard-Herriot, Service d'Accueil des urgences, 5, place d'Arsonval, Lyon 69003, France.
| | - Pierre Le Coz
- UMR 7268 ADéS, Aix-Marseille Université/EFS/CNRS, Faculté de Médecine, 27, boulevard Jean-Moulin, Marseille 13005, France.
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13
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Emmerich N, Gordijn B. Beyond the Equivalence Thesis: how to think about the ethics of withdrawing and withholding life-saving medical treatment. Theor Med Bioeth 2019; 40:21-41. [PMID: 30758767 DOI: 10.1007/s11017-019-09478-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
With few exceptions, the literature on withdrawing and withholding life-saving treatment considers the bare fact of withdrawing or withholding to lack any ethical significance. If anything, the professional guidelines on this matter are even more uniform. However, while no small degree of progress has been made toward persuading healthcare professionals to withhold treatments that are unlikely to provide significant benefit, it is clear that a certain level of ambivalence remains with regard to withdrawing treatment. Given that the absence of clinical benefit means treating patients is not only ethically questionable but also taxing on resources that could meet the needs of others, this ambivalence is troubling. Equally, the enduring ambivalence of professionals might be taken to indicate that the issue warrants further attention. In this paper, we review the academic literature on the ethical equivalence of withdrawing and withholding medical treatment. While we are not in outright disagreement with the arguments presented, we suggest that asserting theoretical and decontextualized claims about the ethical equivalence of withdrawing and withholding life-saving treatment does not fully illuminate the moral questions associated with the relevant clinical realities. We argue that what is required is a broader perspective, one rooted in an understanding that withdrawing and withholding life-saving treatment are different practices, the meanings of which are fully comprehensible only through an appreciation of their place within the practice of healthcare more generally. Such an account suggests that if one is to engage with the inappropriate protraction of life-saving treatment resulting from healthcare professionals' disinclination to withdraw it, then the differences between these practices should be taken seriously.
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Affiliation(s)
- Nathan Emmerich
- Medical School, Australian National University, Canberra, Australia.
- Institute of Ethics, Dublin City University, Dublin, Ireland.
- School of History, Anthropology, Politics and Philosophy, Queen's University Belfast, Belfast, UK.
| | - Bert Gordijn
- Institute of Ethics, Dublin City University, Dublin, Ireland
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14
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Janssens U, Lücking KM, Böll B, Burchardi H, Dannenberg K, Duttge G, Erchinger R, Gretenkort P, Hartog C, Jöbges S, Knochel K, Liebig M, Meier S, Michalsen A, Michels G, Mohr M, Nauck F, Radke P, Rogge A, Salomon F, Seidlein AH, Stopfkuchen H, Neitzke G. [Amendment to the documentation of decisions to withhold or withdraw life-sustaining therapies in consideration of wish to donate organs : Recommendation of the Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) in collaboration with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine (DGIIN)]. Med Klin Intensivmed Notfmed 2018; 114:53-55. [PMID: 30397763 DOI: 10.1007/s00063-018-0509-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.
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Affiliation(s)
- U Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital, Dechant-Decker-Str. 8, 52249, Eschweiler, Deutschland.
| | - K M Lücking
- Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - B Böll
- Klinik I für Innere Medizin, Uniklinik Köln, Köln, Deutschland
| | | | - K Dannenberg
- Medizinische Klinik, BG Klinikum Bergmannstrost, Halle, Deutschland
| | - G Duttge
- Abteilung für strafrechtliches Medizin- und Biorecht, Georg-August-Universität Göttingen, Göttingen, Deutschland
| | | | - P Gretenkort
- Simulations- und Notfallakademie, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - C Hartog
- Patienten- und Angehörigenzentrierte Versorgung, Klinik Bavaria Kreischa, Kreischa, Deutschland.,Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - S Jöbges
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - K Knochel
- Kinderpalliativzentrum München, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Klinikum der Universität München, München, Deutschland
| | - M Liebig
- Medizinische Klinik, Klinikum Görlitz, Görlitz, Deutschland
| | - S Meier
- Klinik für Anästhesiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - A Michalsen
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinik Tettnang, Tettnang, Deutschland
| | - G Michels
- Klinik III für Innere Medizin, Uniklinik Köln, Köln, Deutschland
| | - M Mohr
- Klinik für Anästhesiologie und Intensivmedizin, Ev. Diakonie-Krankenhaus, Bremen, Deutschland
| | - F Nauck
- Klinik für Palliativmedizin, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - P Radke
- Klinik für Kardiologie, Schön Klinik Neustadt, Neustadt in Holstein, Deutschland
| | - A Rogge
- Klinische Ethikberatung, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Deutschland
| | | | - A-H Seidlein
- Institut für Ethik und Geschichte in der Medizin, Ernst-Moritz-Arndt-Universität Greifswald, Greifswald, Deutschland
| | | | - G Neitzke
- Institut für Geschichte, Ethik und Philosophie der Medizin, Medizinische Hochschule Hannover, Hannover, Deutschland
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15
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Douplat M, Jacquin L, Tazarourte K, Michelet P, Le Coz P. Physicians' experience in decisions of withholding and withdrawing life-sustaining treatments: A multicenter survey into emergency departments. Anaesth Crit Care Pain Med 2018; 37:633-634. [PMID: 30268527 DOI: 10.1016/j.accpm.2018.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/16/2018] [Accepted: 09/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Marion Douplat
- Hospices civils de Lyon, hôpital Lyon sud, service d'accueil des urgences, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France; UMR 7268 ADéS Aix-Marseille université, EFS, CNRS, efaculté de médecine de Marseille , hôpital adultes La Timone, 27, boulevard Jean-Moulin 13005 Marseille, France.
| | - Laurent Jacquin
- Hospices civils de Lyon, hôpital Édouard-Herriot, service d'accueil des urgences, 5, place d'Arsonval, 69003 Lyon, France.
| | - Karim Tazarourte
- Hospices civils de Lyon, hôpital Édouard-Herriot, service d'accueil des urgences, 5, place d'Arsonval, 69003 Lyon, France.
| | - Pierre Michelet
- Assistance publique-Hôpitaux de Marseille, hôpital de la Timone, service d'accueil des urgences, 265, rue Saint-Pierre, 13005 Marseille, France.
| | - Pierre Le Coz
- UMR 7268 ADéS Aix-Marseille université, EFS, CNRS, efaculté de médecine de Marseille , hôpital adultes La Timone, 27, boulevard Jean-Moulin 13005 Marseille, France.
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16
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Emmerich N, Gordijn B. A Morally Permissible Moral Mistake? Reinterpreting a Thought Experiment as Proof of Concept. J Bioeth Inq 2018; 15:269-278. [PMID: 29516332 PMCID: PMC6422989 DOI: 10.1007/s11673-018-9845-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/15/2018] [Indexed: 06/08/2023]
Abstract
This paper takes the philosophical notion of suberogatory acts or morally permissible moral mistakes and, via a reinterpretation of a thought experiment from the medical ethics literature, offers an initial demonstration of their relevance to the field of medical ethics. That is, at least in regards to this case, we demonstrate that the concept of morally permissible moral mistakes has a bearing on medical decision-making. We therefore suggest that these concepts may have broader importance for the discourse on medical ethics and should receive fuller consideration by those working the field. The focus of the discussion we present is on a particular thought experiment originally presented by Sulmasy and Sugarman. Their case formed the basis of an exchange about the moral equivalence of withdrawing and withholding life-saving treatment. The analysis Sulmasy and Sugarman set out is significant because, contrary to common bioethical opinion, it implies that the difference between withdrawing and withholding life-saving treatment holds, rather than lacks, moral significance. Following a brief discussion of rejoinders to Sulmasy and Sugarman's article, we present a constructive reinterpretation of the thought experiment, one that draws on the idea of suberogatory acts or "morally permissible moral mistakes." Our analysis, or so we suggest, accounts for the differing moral intuitions that the case prompts. However, it also calls into question the degree to which this thought experiment can be thought of as illustrating the moral (non)equivalence of withdrawing and withholding life-saving treatment. Rather, we conclude that it primarily illuminates something about the ethical parameters of healthcare when family members, particularly parents, are involved in decision-making.
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Affiliation(s)
- Nathan Emmerich
- Institute of Ethics, Dublin City University, Dublin, Ireland.
- School of History, Anthropology, Politics and Philosophy, Queen's University Belfast, Belfast, UK.
| | - Bert Gordijn
- Institute of Ethics, Dublin City University, Dublin, Ireland
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17
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Blazquez V, Rodríguez A, Sandiumenge A, Oliver E, Cancio B, Ibañez M, Miró G, Navas E, Badía M, Bosque MD, Jurado MT, López M, Llauradó M, Masnou N, Pont T, Bodí M. Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study. Med Intensiva 2018; 43:352-361. [PMID: 29747939 DOI: 10.1016/j.medin.2018.03.010] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/09/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN Prospective multicenter study. SETTING Eleven ICUs. PATIENTS All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.
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Affiliation(s)
- V Blazquez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain
| | - A Sandiumenge
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - E Oliver
- Transplant Coordination, University Hospital Bellvitge, Barcelona, Spain
| | - B Cancio
- Intensive Care Unit, University Hospital Moises Broggi, Barcelona, Spain
| | - M Ibañez
- Intensive Care Unit, University Hospital Verge de la Cinta de Tortosa, Tortosa, Spain
| | - G Miró
- Intensive Care Unit, Consorci Sanitari del Maresme, Mataró, Spain
| | - E Navas
- Intensive Care Unit, University Hospital Mutua de Terrassa, Terrassa, Spain
| | - M Badía
- Intensive Care Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - M D Bosque
- Intensive Care Unit, University Hospital General de Catalunya, Barcelona, Spain
| | - M T Jurado
- Intensive Care Unit, Hospital de Terrassa, Terrassa, Spain
| | - M López
- Intensive Care Unit, University Hospital de Vic, Vic, Spain
| | - M Llauradó
- International University of Catalunya, Barcelona, Spain
| | - N Masnou
- Transplant Coordination, University Hospital Dr. Trueta, Girona, Spain
| | - T Pont
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - M Bodí
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain.
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Morales Valdés G, Alvarado Romero T, Zuleta Castro R. [Limitation of therapeutic effort in Paediatric Intensive Care Units: Bioethical knowledge and attitudes of the medical profession]. ACTA ACUST UNITED AC 2016; 87:116-20. [PMID: 26787502 DOI: 10.1016/j.rchipe.2015.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 09/06/2015] [Accepted: 10/06/2015] [Indexed: 11/23/2022]
Abstract
UNLABELLED Paediatric intensive care is a relatively new specialty, with significant technological advances that lead to the prolongation of the dying process. One of the most common bioethical problems is limitation of treatment, which is the adequacy and/or proportionality treatment, trying to avoid obstinacy and futility. OBJECTIVE To determine the experience of physicians working in Paediatric Intensive Care Units (PICU) when faced with bioethical decisions. SUBJECTS AND METHOD An observational, descriptive and cross-sectional study was conducted using an anonymous questionnaire sent to physicians working in PICU. The data requested was related to potential ethical problems generated in the care of the critical child, and the procedure for their resolution. The study was approved by the Ethics Research Committee of the Faculty of Medicine UDD CAS. RESULTS A total of 126 completed questionnaires were received from physicians working in 34 PICU in Chile. Almost all (98.41%) of them acknowledged having taken therapeutic limitation decisions (TLD). The most common type of TLD mentioned was the Do Not Resuscitate order (n=119), followed by the establishment of no medications (n=113), limited admission to PICU (n=81), with the withdrawal of treatment being the least mentioned (n=81). Around one-third (34.13%) felt that there were no ethical difference between introducing or removing certain treatments. CONCLUSIONS Bioethical dilemmas are common in the PICU, with therapeutic limitation decisions being frequent. Many recognise not having expertise in clinical ethics, and they need continuing education in bioethics.
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Roger C, Morel J, Molinari N, Orban JC, Jung B, Futier E, Desebbe O, Friggeri A, Silva S, Bouzat P, Ragonnet B, Allaouchiche B, Constantin JM, Ichai C, Jaber S, Leone M, Lefrant JY, Rimmelé T. Practices of end-of-life decisions in 66 southern French ICUs 4 years after an official legal framework: A 1-day audit. Anaesth Crit Care Pain Med 2015; 34:73-7. [PMID: 25862305 DOI: 10.1016/j.accpm.2014.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 10/17/2014] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Since the implementation of two French laws in 2002 and 2005 and the implementation of guidelines about End-of-Life (EoL) decisions, few studies concerning EoL practices in French intensive care units (ICUs) have been reported. This study was aimed at assessing compliance with recommendations and current legislation concerning EoL decisions. METHOD Prospective observational study based on 1-day audit conducted from January to May 2009 in 66 southern French ICUs. RESULTS Six hundred and twenty-five patients were included (median age: 63 [52-76] years, median SAPS II: 46 [34-58]). The written designation of a surrogate decision-maker was reported for 87 (15%) patients. Advance directives were completed for only 4% of patients. The EoL decision-making process consisted in a multidisciplinary approach for 99 (47%) patients and was recorded in the medical chart for 63 (64%) cases. Families were informed about medical decisions in 58% of cases. This proportion was higher (87%) if a decision to forego life-sustaining therapy was made. EoL decisions consisted of withholding treatments for 72 (94%) patients and withdrawal of treatments for 5 (6%) patients. In the multivariate stepwise logistic regression, four variables were independently associated with a decision to forego life support: preexisting dependence on others (P<0.0001), advance directives (P=0.01), age (P=0.008) and the SAPS 2 score (P=0.009). CONCLUSION The major finding of the present study is the existence of a gap between the widely approved EoL recommendations made by scientific societies and the daily practice of southern French ICUs. Even if EoL decisions are mostly shared with relatives, their written documentation in medical charts remains insufficient. Concerning EoL practices, the withdrawal of treatment remains an uncommon decision.
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Affiliation(s)
- Claire Roger
- Pôle Anesthésie Réanimation Douleur Urgences, CHU de Nîmes, place du Pr-Debré, 30029 Nîmes, France.
| | - Jérome Morel
- Service d'Anesthésie Réanimation, Hôpital Nord, 42055 Saint-Étienne Cedex 2, France
| | - Nicolas Molinari
- UMR 729, Service DIM, CHRU de Montpellier, Hôpital la Colombière, 39, avenue Charles-Flahaut, 34091 Montpellier Cedex 5, France
| | - Jean Christophe Orban
- Réanimation Médico-Chirurgicale, Hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06001 Nice cedex 1, France
| | - Boris Jung
- Département d'Anesthésie Réanimation, Hôpital Saint-Eloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier Cedex 5, France; InsermU-1046, Université Montpellier I, Université Montpellier II, 34295 Montpellier cedex 5, France
| | - Emmanuel Futier
- Département d'Anesthésie Réanimation, Hôpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand Cedex 1, France
| | - Olivier Desebbe
- Hospices Civils de Lyon, Groupement Hospitalier est, Département d'Anesthésie Réanimation, Hôpital Louis-Pradel, Université Claude-Bernard Lyon 1, 59, boulevard Pinel, 69677 Bron, France
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Hôpital Lyon Sud, Département d'Anesthésie Réanimation, 165, chemin du Grand-Revoyet, 69495 Pierre Bénite, France
| | - Stein Silva
- Service d'Anesthésie Réanimation, Hôpital Purpan, place du Docteur-Baylac, 31059 Toulouse, France
| | - Pierre Bouzat
- Pôle Anesthésie Réanimation, CHU de Grenoble, 38700 La Tronche, Grenoble, France
| | - Benoit Ragonnet
- Service d'Anesthésie et de Réanimation, AP-HM, Hôpital Nord, Aix Marseille Université, 13915 Marseille cedex 20, France
| | - Bernard Allaouchiche
- Service d'Anesthésie Réanimation, Groupement Hospitalier Édouard-Herriot, 69003 Lyon, France
| | - Jean-Michel Constantin
- Département d'Anesthésie Réanimation, Hôpital Estaing, CHU de Clermont-Ferrand, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand Cedex 1, France
| | - Carole Ichai
- Réanimation Médico-Chirurgicale, Hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06001 Nice cedex 1, France
| | - Samir Jaber
- Département d'Anesthésie Réanimation, Hôpital Saint-Eloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier Cedex 5, France; InsermU-1046, Université Montpellier I, Université Montpellier II, 34295 Montpellier cedex 5, France
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, AP-HM, Hôpital Nord, Aix Marseille Université, 13915 Marseille cedex 20, France
| | - Jean-Yves Lefrant
- Pôle Anesthésie Réanimation Douleur Urgences, CHU de Nîmes, place du Pr-Debré, 30029 Nîmes, France
| | - Thomas Rimmelé
- Service d'Anesthésie Réanimation, Groupement Hospitalier Édouard-Herriot, 69003 Lyon, France
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20
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Barilan YM. Rethinking the withholding/withdrawing distinction: the cultural construction of "life-support" and the framing of end-of-life decisions. Multidiscip Respir Med 2015; 10:10. [PMID: 25949813 PMCID: PMC4422120 DOI: 10.1186/s40248-015-0004-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 02/02/2015] [Accepted: 02/06/2015] [Indexed: 11/10/2022] Open
Abstract
This paper is a theoretical and empirically informed examination of the naturalist distinction between withholding and withdrawing life-support. Drawing on the history of mechanical ventilation and on a recent Israeli law containing a novel approach to disconnecting life-support at the end of life, it is argued that the design of machines predicates the division line between “active” and “passive” interventions, and that the distinction itself might be morally self-defeating. Informed by insights from moral psychology, behavioral economics and philosophies of technology, the paper warns against the placement of this old distinction at the heart of the moral and legal regulation of life-support at the end of life.
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Abstract
A general rationale is presented for withholding and withdrawing medical treatment in end-of-life situations, and an argument is offered for the moral irrelevance of the distinction, both in the context of pharmaceutical treatments, such as chemotherapy in cancer, and in the context of life-sustaining treatments, such as the artificial ventilator in lateral amyotrophic sclerosis. It is argued that this practice is not equivalent to sanctioning voluntary active euthanasia and that it is not likely to favour it.
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Affiliation(s)
- Massimo Reichlin
- Faculty of Philosophy, University Vita-Salute San Raffaele, Milan, Italy
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Sprung CL, Paruk F, Kissoon N, Hartog CS, Lipman J, Du B, Argent A, Hodgson RE, Guidet B, Groeneveld ABJ, Feldman C. The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments. J Crit Care 2014; 29:890-5. [PMID: 25151218 DOI: 10.1016/j.jcrc.2014.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/23/2014] [Accepted: 06/21/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees. METHODS Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared. RESULTS Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent. CONCLUSIONS Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
| | - Fathima Paruk
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, Children's Hospital and Sunny Hill Health Centre for Children, University British Columbia, Vancouver, British Columbia, Canada
| | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine, Center for Sepsis Control and Care, Jena, Germany
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Womens Hospital and The University of Queensland, Herston, Queensland, Australia
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Andrew Argent
- School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - R Eric Hodgson
- Department of Anaesthesia and Critical Care, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal eThekwini-Durban, KwaZulu-Natal, South Africa
| | - Bertrand Guidet
- Service de réanimation médicale, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - A B Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Paruk F, Kissoon N, Hartog CS, Feldman C, Hodgson ER, Lipman J, Guidet B, Du B, Argent A, Sprung CL. The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation--the approach should be individualized. J Crit Care 2014; 29:902-7. [PMID: 24992878 DOI: 10.1016/j.jcrc.2014.05.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 02/20/2014] [Revised: 04/07/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support. MATERIALS AND METHODS Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation. RESULTS Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios. CONCLUSIONS Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized.
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Affiliation(s)
- Fathima Paruk
- Department of Anaesthesiology and Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, Children's Hospital and Sunny Hill Health Centre for Children, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine and Center for Sepsis Control and Care (CSH), Jena University Hospital, Jena, Germany
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eric R Hodgson
- Department of Anaesthesia and Critical Care, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal eThekwini-Durban, KwaZulu-Natal, South Africa
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital and The University of Queensland, Queensland, Australia
| | - Bertrand Guidet
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital St-Antoine, Paris, France
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Andrew Argent
- School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine (CLS), Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Burnod A, Choquet C, Houissa H, Danis J, Pellenc Q, Duchateau FX. [Medical decision in a very elderly patient: a case report of application of the Leonetti law in emergency medicine]. Ann Fr Anesth Reanim 2014; 33:361-363. [PMID: 24821341 DOI: 10.1016/j.annfar.2014.03.011] [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] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 03/20/2014] [Indexed: 06/03/2023]
Abstract
Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.
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Affiliation(s)
- A Burnod
- Smur, hôpital Beaujon, hôpitaux universitaires Paris Nord Val-de-Seine, 100, boulevard du Général-Leclerc, 92110 Clichy, France; Unité de soins de supports et soins palliatifs, institut Curie, 75005 Paris, France.
| | - C Choquet
- Service d'accueil des urgences, hôpital Bichat, hôpitaux universitaires Paris Nord Val-de-Seine, 75018 Paris, France
| | - H Houissa
- Service d'anesthésie-réanimation chirurgicale, hôpital Bichat, hôpitaux universitaires Paris Nord Val-de-Seine, 75018 Paris, France
| | - J Danis
- Unité de soins de supports et soins palliatifs, institut Curie, 75005 Paris, France
| | - Q Pellenc
- Service de chirurgie vasculaire et thoracique, hôpital Bichat, hôpitaux universitaires Paris Nord Val-de-Seine, 75018 Paris, France
| | - F X Duchateau
- Smur, hôpital Beaujon, hôpitaux universitaires Paris Nord Val-de-Seine, 100, boulevard du Général-Leclerc, 92110 Clichy, France
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Garcia-Alix A, Arnaez J, Cortes V, Girabent-Farres M, Arca G, Balaguer A. Neonatal hypoxic-ischaemic encephalopathy: most deaths followed end-of-life decisions within three days of birth. Acta Paediatr 2013; 102:1137-43. [PMID: 24102859 DOI: 10.1111/apa.12420] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [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] [Received: 06/16/2013] [Revised: 08/01/2013] [Accepted: 09/09/2013] [Indexed: 11/30/2022]
Abstract
AIM To investigate the circumstances surrounding end-of life decisions (EoL) of infants with hypoxic-ischaemic encephalopathy (HIE) and examine changes over a 10-year period. METHODS Retrospective chart review of all infants with HIE who died during 2000-2004 and 2005-2009 in a Level III Neonatal Intensive Care Unit in Madrid, Spain. RESULTS Of 70 infants with HIE, 18 died during the neonatal period. The mean age of death was 64.4 ± 51 h. In 17 of the 18 infants (94%), death was preceded by an EoL decision, four after withholding therapy (WH) and 13 after withdrawal therapy (WDT). All infants with WH were previously stable and without respiratory support, while all 13 infants in the WDT group had respiratory support and three were unstable. The age of death was greater in the WH group than the WDT group (122 ± 63 h vs 50 ± 34; p < 0.001). After the EoL decision, 11 (65%) infants received sedatives. There were no differences between the time periods. CONCLUSION In our cohort, most deaths in newborns with HIE were preceded by EoL decisions mainly within the first 3 days after birth. We did not find changes over the first decade of the 21st century, and death was mainly determined by WDT.
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Affiliation(s)
- Alfredo Garcia-Alix
- Agrupacio Sanitaria Hospital Sant Joan de Déu-Hospital Clinic-Maternitat; University of Barcelona; Barcelona Spain
- Hospital Universitario La Paz; Autonoma University of Madrid; Madrid Spain
| | - Juan Arnaez
- Hospital Universitario La Paz; Autonoma University of Madrid; Madrid Spain
- Hospital Universitario de Burgos; Burgos Spain
| | - Veronica Cortes
- Agrupacio Sanitaria Hospital Sant Joan de Déu-Hospital Clinic-Maternitat; University of Barcelona; Barcelona Spain
| | | | - Gemma Arca
- Agrupacio Sanitaria Hospital Sant Joan de Déu-Hospital Clinic-Maternitat; University of Barcelona; Barcelona Spain
| | - Albert Balaguer
- Faculty of Medicine & Health Sciences; Universitat International de Catalunya; Barcelona Spain
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