Respecting Choice in Definitions of Death

The definition of death was clearer one hundred years ago than it is today. People were declared dead if diagnosed with permanent cessation of both cardio-circulatory function and respiratory function. But the definition has been muddled by the development of new technologies and interventions-first by cardiopulmonary resuscitation and ventilators, which were introduced in the mid-twentieth century, and now by extracorporeal membrane oxygenation, which creates the ability to keep oxygenated blood circulating, with or without a beating heart or functioning lungs. In Defining Death: The Case for Choice, Robert Veatch and I argue that the definition of death should focus on "what change in a human being is so fundamental that we can say the individual is no longer with us as a member of the human community bearing rights such as the right not to be killed." We assert that this decision is a normative issue about which different stakeholders may believe that different changes are fundamental, and we therefore propose that the optimal policy solution may be to allow stakeholders to choose their own definition within a reasonable range of options. There are three caveats that need to be highlighted regarding this approach.

Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan

Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.

Changes in the Use of Intensive and Supportive Procedures for Patients With Stroke in Taiwan in the Last Month of Life Between 2000 and 2010

CONTEXT

Stroke is the second leading cause of death and the primary cause of disability worldwide. It is uncertain what care patients with stroke receive in their end of life and what trends in care are in recent years.

OBJECTIVES

The objective of this study was to investigate the changes in the use of intensive and supportive procedures for Taiwanese patients with stroke in their last month of life during 2000-2010.

METHODS

Analysis of claims data of 55,930 patients with stroke obtained from the National Health Insurance Research Database was performed to investigate the changes in the use of intensive and supportive procedures for Taiwanese patients with stroke in their last month of life during 2000-2010.

RESULTS

Over the whole study period, 25.4% of patients with stroke were admitted to intensive care units in their last month of life. The percentages of patients receiving mechanical ventilation (77.4%-67.9%), cardiopulmonary resuscitation (53.8%-35.8%), and inotropic agents (73.5%-64.3%) decreased over time. The percentages of patients receiving artificial hydration and nutrition (65.9%-73.3%) and sedative or analgesic agents (34.7%-38.6%) increased over time. Patients under 85 years old were more likely to be admitted to intensive care units. Men were more likely to receive mechanical ventilation and cardiopulmonary resuscitation than women.

CONCLUSION

Over time, the use of supportive procedures increased, and the use of intensive procedures decreased in patients with stroke in the last month of life. This study highlights a need for research, guidelines, and training in how to provide palliative care for end-stage patients with stroke.

[Rehabilitation and nursing-care robots]

In the extremely aged society, rehabilitation staff will be required to provide ample rehabilitation training for more stroke patients and more aged people with disabilities despite limitations in human resources. A nursing-care robot is one potential solution from the standpoint of rehabilitation. The nursing-care robot is defined as a robot which assists aged people and persons with disabilities in daily life and social life activities. The nursing-care robot consists of an independent support robot, caregiver support robot, and life support robot. Although many nursing-care robots have been developed, the most appropriate robot must be selected according to its features and the needs of patients and caregivers in the field of nursing-care.

Significant social events and increasing use of life-sustaining treatment: trend analysis using extracorporeal membrane oxygenation as an example

BACKGROUND

Most studies have examined the outcomes of patients supported by extracorporeal membrane oxygenation as a life-sustaining treatment. It is unclear whether significant social events are associated with the use of life-sustaining treatment. This study aimed to compare the trend of extracorporeal membrane oxygenation use in Taiwan with that in the world, and to examine the influence of significant social events on the trend of extracorporeal membrane oxygenation use in Taiwan.

METHODS

Taiwan's extracorporeal membrane oxygenation uses from 2000 to 2009 were collected from National Health Insurance Research Dataset. The number of the worldwide extracorporeal membrane oxygenation cases was mainly estimated using Extracorporeal Life Support Registry Report International Summary July 2012. The trend of Taiwan's crude annual incidence rate of extracorporeal membrane oxygenation use was compared with that of the rest of the world. Each trend of extracorporeal membrane oxygenation use was examined using joinpoint regression.

RESULTS

The measurement was the crude annual incidence rate of extracorporeal membrane oxygenation use. Each of the Taiwan's crude annual incidence rates was much higher than the worldwide one in the same year. Both the trends of Taiwan's and worldwide crude annual incidence rates have significantly increased since 2000. Joinpoint regression selected the model of the Taiwan's trend with one joinpoint in 2006 as the best-fitted model, implying that the significant social events in 2006 were significantly associated with the trend change of extracorporeal membrane oxygenation use following 2006. In addition, significantly social events highlighted by the media are more likely to be associated with the increase of extracorporeal membrane oxygenation use than being fully covered by National Health Insurance.

CONCLUSIONS

Significant social events, such as a well-known person's successful extracorporeal membrane oxygenation use highlighted by the mass media, are associated with the use of life-sustaining treatment such as extracorporeal membrane oxygenation.

The self-fulfilling prophecy in intensive care

Predictions of poor prognosis for critically ill patients may become self-fulfilling if life-sustaining treatment or resuscitation is subsequently withheld on the basis of that prediction. This paper outlines the epistemic and normative problems raised by self-fulfilling prophecies (SFPs) in intensive care. Where predictions affect outcome, it can be extremely difficult to ascertain the mortality rate for patients if all treatment were provided. SFPs may lead to an increase in mortality for cohorts of patients predicted to have poor prognosis, they may lead doctors to feel causally responsible for the deaths of their patients, and they may compromise honest communication with patients and families about prognosis. However, I argue that the self-fulfilling prophecy is inevitable when life-sustaining treatment is withheld or withdrawn in the face of uncertainty. SFPs do not necessarily make treatment limitation decisions problematic. To minimize the effects of SFPs, it is essential to carefully collect and appraise evidence about prognosis. Doctors need to be honest with themselves and with patients and their families about uncertainty and the limits of knowledge.

Documenting end of life decisions in residential aged care facilities in South Australia

OBJECTIVE

This research examined the provision of palliative care for residents with a non-cancer diagnosis including the use of advance directives and advance care planning as part of palliative care policies in residential aged care facilities in South Australia. There are no guidelines for recording residents' wishes if they are no longer competent.

METHODS

Stage 1 involved a survey of 90 randomly selected aged care facilities. Stage 2 involved case studies of 69 residents, appropriate for palliative care, from 17 facilities and interviews with 15 directors of care.

RESULTS

Most residential aged care facilities used forms to record residents' wishes about end of life care, but there was little consistency. Some had no palliative care policy and few facilities required a formal advance directive. Not all residents had formally appointed a proxy.

CONCLUSIONS

Residential aged care facilities should be required to develop and implement a palliative care policy acknowledging the Accreditation Standards and State legislation and including a simple tool for advance care planning. Case conferencing could assist in discussing and documenting the resident's wishes. Public education is essential to increase community and professional awareness in order to promote empowerment for the increasing number of older people who will die in residential aged care facilities.

[Technology of the future applied to the present: Life Support for Trauma and Transport (LSTAT)]

One of the most recent innovations coalescing computer technology and medical care is the development of integrated medical component technology coupled with a computer system. One such example is the patient transport system known as the Life Support for Trauma and Transport (LSTAT). LSTAT is a self-contained stretcher-based intensive care unit designed by the United States Army to provide care for critically injured patients during transport and in remote settings where resources are limited. It contains conventional medical equipment that has been reduced in size and integrated into a single platform. This article presents the latest technology applied to the field of medicine, which should not be limited to patients injured during warfare but should also be used to assist the injured civilian population who need transport from remote settings to urban trauma centers.

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil

OBJECTIVES

To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil.

METHODS

A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000).

SETTING

Three PICUs in Porto Alegre, southern Brazilian region.

PATIENTS

Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000.

RESULTS

The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000.

CONCLUSION

We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

The ABC of resuscitation and the Dutch (re)treat

In 1982 the Netherlands made a unilateral decision to change the established airway-breathing-circulation (ABC) training sequence to a different approach that stressed efficiency in diagnosis and treatment. This Dutch approach became known as the CAB (circulation-airway-breathing) sequence. Twenty years later, being confronted with the new international guidelines (published 2000) that still use the ABC approach, the Netherlands Resuscitation Council (NRR) questioned again the validity of our persistence in using the "Dutch variant" of resuscitation. This resulted in revised national guidelines that conform again with the international guidelines. This article restates the main rationale and arguments behind the original decision to change to a Dutch (CAB) version of resuscitation over 20 years ago. The national decision to adopt the ABC approach once again was mainly to prevent resuscitation in the Netherlands from being isolated from the rest of the world and was not based on present knowledge of physiology and resuscitation. The authors hope that this article will open the discussion once again.

Update on advanced life support and resuscitation techniques

PURPOSE OF REVIEW

This article is a review of the most recent findings in resuscitation techniques in advanced cardiac life support. The article focuses particularly on the period after July 1, 2003, but relevant new findings before this period are also included.

RECENT FINDINGS

Randomized clinical trial results suggest that the current cardiopulmonary resuscitation and advanced cardiac life support guidelines may need to be modified. Early defibrillation during the electrical phase of cardiac arrest remains the most crucial intervention, but performing cardiopulmonary resuscitation before defibrillation may be more effective, as compared with immediate defibrillation, during the circulatory phase of cardiac arrest. Biphasic waveforms are superior to monophasic damped sine waveforms in achieving defibrillation. Novel cardiopulmonary resuscitation methods that increase negative intrathoracic pressure promote an increase in blood flow return to the heart. These devices have been correlated with improved short-term survival rates during the circulatory phase of cardiac arrest. Vasopressin administration, given alone or in combination with epinephrine, should be considered during the circulatory phase of out-of-hospital cardiac arrest, particularly in patients presenting with asystole as the initial rhythm. Induction of hypothermia during the metabolic phase in cardiac arrest survivors improves 6-month survival rates and neurologic outcomes.

SUMMARY

Strategies to improve the low survival outcomes of cardiac arrest victims are available. Clinical trials testing these strategies suggest benefit from certain interventions but are not definitive. These different therapeutic interventions should be performed in a phase-specific-oriented fashion according to the three-phase time-sensitive model of cardiac arrest.

Evaluation of Changes in Forgoing Life-Sustaining Treatment in Israeli ICU Patients

INTRODUCTION

Over the last several years, there have been legal decisions and changes in medical directives concerning end-of-life decisions in Israel.

METHODS

The data were compared to evaluate the changes in the frequency and types of forgoing of life-sustaining treatment (FLST) in patients who were admitted to the ICU during period I (November 1994 to July 1995) and period II (January 1998 to January 1999).

RESULTS

During period I, there were 385 ICU admissions, and during period II there were 627 ICU admissions. In period I, FLST or death occurred in 13.5% of patients, and in 12% in period II. There was no significant difference in cardiopulmonary resuscitation (9% vs 13%, respectively), withholding therapy (90% vs 91%, respectively), or withdrawing therapy (0% vs 0%, respectively) between the two study periods.

CONCLUSIONS

There was no significant change in the frequency or types of FLST in an Israeli ICU between 1994 and 1998, despite passage of a new Patients' Rights Law and the issuing of a Ministry of Health directive on the treatment of the terminally ill, both of which occurred in 1996, and recent district court decisions favoring the termination of life-sustaining therapies.

Discrepancies among patients, family members, and physicians in Korea in terms of values regarding the withholding of treatment from patients with terminal malignancies

BACKGROUND

The role of the physician in end-of-life decision-making is complicated. To analyze the controversies that surround therapeutic decision-making and the withholding of life-sustaining treatments, the authors compared values regarding therapeutic intervention that were held by physicians and family members of patients with terminal malignancies.

METHODS

One hundred fourteen patients with either advanced-stage or terminal disease were enrolled in the current study. Questionnaires were administered to the duty physician and to patients' family members. The questions covered issues such as the use of new anticancer agents with only partial efficacy (15%) and the use of opioid analgesics, intravenous nutrition, feeding tubes, antibiotics, and hemodialysis. In addition, participants were asked about the administration of cardiopulmonary resuscitation (CPR) and the use of ventilators, and when the patient's family consented, the same questionnaire was administered to the patient as well.

RESULTS

Seventeen of 114 families refused to answer the questionnaire. Of the 97 available families, only 14 permitted access to the patient. Of those 14 patients, 5 refused to complete the questionnaire. Overall, 100% of families and 87% of patients had some knowledge regarding malignant disease, but only 69% of families and 37% of patients clearly understood the stage of the patient's disease. The use of a new agent with only partial efficacy (approximately 15%) was accepted by 41% of physicians and by 60% of families. The concordance rate between patients' physicians and family members regarding the same patient was 42%. The rankings of the acceptance of treatment by physicians were as follows: opioid analgesics, 100%; antibiotics, 91%; feeding tube, 87%; and intravenous nutrition, 78%. The rankings of the same items by family members were as follows: opioid analgesics, 92%; antibiotics, 89%; intravenous nutrition, 86%; and feeding tube, 75%. The concordance rates between patients' physicians and families were lowest for ventilator application (39%) and CPR (47%).

CONCLUSIONS

Values held on issues such as therapeutic decision-making and the withholding of life-sustaining treatment for patients with terminal malignancies were discordant between physicians and family members. To resolve controversies regarding the role of the physician in end-of-life decision-making, the values of physicians, patients, and family members should be considered in the final decision-making process.

Discrepancies between perceptions by physicians and nursing staff of intensive care unit end-of-life decisions

Several studies have pointed out ethical shortcomings in the decision-making process for withholding or withdrawing life-supporting treatments. We conducted a study to evaluate the perceptions of all caregivers involved in this process in the intensive care unit. A closed-ended questionnaire was completed by 3,156 nursing staff members and 521 physicians from 133 French intensive care units (participation rate, 42%). Decision-making processes were perceived as satisfactory by 73% of physicians and by only 33% of the nursing staff. More than 90% of caregivers believed that decision-making should be collaborative, but 50% of physicians and only 27% of nursing staff members believed that the nursing staff was actually involved (p < 0.001). Fear of litigation was a reason given by physicians for modifying information given to competent patients, families, and nursing staff. Perceptions by nursing staff may be a reliable indicator of the quality of medical decision-making processes and may serve as a simple and effective tool for evaluating everyday practice. Recommendations and legislation may help to build consensus and avoid conflicts among caregivers at each step of the decision-making process.

The ABCs of recording paediatric cardiac arrests

OBJECTIVE

To examine the quality and comprehensiveness of documentation in Paediatric 'cardiac arrests'.

DESIGN

Retrospective chart review.

SETTING

Tertiary care hospital wards, Paediatric Intensive Care and Accident and Emergency department.

SUBJECTS

41 children experiencing acute life-threatening events in hospital.

RESULTS

Overall documentation of details related to time, place and personnel was highly variable but generally present in over half of the cases reviewed. Data relating to specific drug-related and interventional therapies was insufficient, as was documentation of time intervals and consequent therapeutic decisions.

CONCLUSIONS

Documentation of critical resuscitation episodes in children is below recognised standards and this has potential quality of care and medicolegal implications. Current teaching needs to emphasise this essential aspect of clinical care from the earliest level of training.

Life Support for Trauma and Transport: first field use

During the Persian Gulf War, the U.S. Army Medical Department (AMEDD) found evacuation distances for patients increasing as a result of the fast movement of the forward line of troops. Thus, there is a need for a trauma and intensive care transport system that avoids the medical dangers that accompany such evacuation distances. In 1998, after a few years of research and development, the AMEDD introduced a prototype transport "trauma pod" called the LSTAT (Life Support for Trauma and Transport). In March 2000, the LSTAT was issued to the 212th Mobile Army Surgical Hospital that deployed to Camp Bondsteel, Kosovo, for its first real-world fielding. This article describes the initial Kosovo fielding phase, highlighting the LSTAT benefits, advantages to military medicine, and recommended enhancements.

Improvement in resuscitation knowledge after a one-day paediatric life-support course

OBJECTIVE

To assess the effect of a one-day paediatric life-support course on the knowledge of paediatric trainees.

METHODS

A telephone survey was performed prior to and at set intervals following the course. Responses to individual questions before and after the course were analysed and an overall test score was calculated. The acquisition and retention of knowledge was measured by comparing test scores for the same group of trainees at time intervals after the course.

RESULTS

All candidates were surveyed. The median duration of paediatric training prior to the course was 3 years. Eighteen candidates (78%) had previously intubated a child and 13 (57%) had previously used an intraosseous needle. Prior to the course, few of the 23 candidates had adequate knowledge of either the management of the cervical spine in the seriously injured child (17%), fluid resuscitation in meningococcal septicemia (52%), shock dose in ventricular fibrillation (61%), or the management of anaphylactic shock (35%). There was a significant improvement in the knowledge of the group after the course, with median test scores increasing from 19 to a maximum of 22 (P < 0.001). This knowledge was retained at 4 months after the course.

CONCLUSION

Despite a high level of experience and previous training in paediatric resuscitation, many candidates lacked the basic knowledge necessary for the resuscitation of seriously ill or injured children. There was a significant improvement in this knowledge after the course, and this was maintained for 4 months. The paediatric life-support course is an important means of resuscitation training for junior doctors.

[Bioethics in the face of death]

We review death, thanatology and bioethics concepts and precepts, the value scale and hierarchization; the changes in death vision according to culture, religion and hierarchy, changes in perception of, according to culture, religion and mores in different communities and times, as well with scientific and technological advances. We analyzed patient's reactions to death, and the reactions of people close to them. We describe and analyze the principal bioethical dilemmas associated with death: therapeutic overkill or dysthanasia, passive and active euthanasia, assisted suicide, orthothanasia, and organ transplants. We discuss the relationship between death and science, bioethics and thanatology, as a necessary discipline today.

Recent progress in advanced cardiac life support

The revised guidelines for advanced cardiac life support (ACLS) from the American Heart Association are anticipated in the fall of 2000. Although dramatic changes in the approach to adult basic and ACLS are not anticipated, several controversies and new drugs on the horizon may radically change our approach to emergent cardiac resuscitation. This article features some of the evolving thinking on the emergent treatment of the adult with ventricular fibrillation or ventricular tachycardia, the critical rhythms seen in most cases of acute cardiac distress. Approaches to airway therapy drug administration and new agents also are described.

Death in two Canadian intensive care units: institutional difference and changes over time

OBJECTIVE

To study and compare the mode of death in two different institutions' intensive care units (ICUs) for the two time periods, 1988 and 1993.

DESIGN

Retrospective chart review.

SETTING

Medical/surgical/trauma ICUs in two tertiary care teaching hospitals.

PATIENTS

Patients dying in the medical/surgical/trauma ICUs between January 1, 1988 and December 31, 1988; and January 1, 1993 and December 31, 1993. Data collection included demographics, origin of admission, date of ICU admission, date of death, Acute Physiology and Chronic Health Evaluation (APACHE) III diagnostic categories, APACHE II physiologic variables, organ system failures present at the time of admission and 24 hrs before death, and mode of dying. APACHE II scores and mortality risk were calculated. Data analysis included a multiple analysis of variance to assess overall effect, with subsequent analyses of variance to assess the effect of institution and year on each individual dependent variable. All results are reported as mean +/- SEM values.

RESULTS

A total of 439 charts were reviewed. Gender, age, and origin of admission were not different between the 2 yrs or the two institutions. Mean APACHE II scores and organ system failures were lower at Hospital A in 1998 vs. Hospital B, as was predicted mortality. These factors increased at Hospital A in 1993 and were similar to those at Hospital B. Withdrawal of support was much more common in 1993 than 1988 at both institutions (43% at Hospital A and 46% at Hospital B in 1988 vs. 66% at A and 80% at B in 1993), increasing to a greater extent in 1993 at Hospital B (p<.05). Length of stay in the ICU was significantly longer at Hospital A than at Hospital B in 1988 (9.4+/-1.4 vs. 4.3+/-0.6 days; p<.05) and in 1993 (8.2+/-2.9 vs. 3.8+/-0.5 days; p < .05).

CONCLUSIONS

There has been an increase in withdrawal of life support, in recent years, at both the institutions studied. Differences exist between institutions with respect to end-of-life decisions in the ICU. These differences are likely representative of widely prevalent regional differences and are the result of many factors.

Circumstances of dying in hospitalized children

Conditions of dying in a tertiary children's hospital were assessed in a retrospective cohort study. Non-survivors, excluding newborns and emergency room patients, were allocated to four groups: brain death (BD), failed cardiopulmonary resuscitation (failed CPR), death following a do-not-resuscitate (DNR) order and death following withholding or withdrawal of therapy (W/W). In a 4-year period 190 (1.3%) of 14,903 admitted patients died. Of these 134 (71%) died on the paediatric intensive care unit, 42 (22%) on the ward and 14 (7%) in the operating room. W/W was found in 75 (39%), failed CPR in 57 (30%), BD in 32 (17%), and death following a DNR order in 26 (14%). Justifications for restrictions of treatment (W/W or DNR) were imminent death in 41 (41%), lack of future relational potential in 13 (13%) and excessive burden of disease in 47 (47%). In non-survivors analgesics and sedatives were frequently used to relieve suffering in the terminal phase. General principles for the approach of terminally ill children in whom death may become an option instead of a fate are discussed.

CONCLUSION

In the majority of children dying in hospital, death occurred following restrictions of life-sustaining treatment, comprising do-not-resuscitate or other forms of withholding or withdrawal of therapy.

Ethnicity and attitudes towards life sustaining technology

The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward foregoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support (p < 0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments (p < 0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR = 6.7, p < 0.0001); however, they did not want such technology personally (RR = 1.2, p = 0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR = 1.6, p = 0.06), but were the most likely to want to be kept alive on life-support (RR = 2.1, p = 0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.

Advanced life support for out-of-hospital cardiac arrest--the changing role of a hospital-based flying squad

The success of hospital-based flying squads in the management of out-of-hospital cardiac arrest has been well documented, but since the introduction of ambulance paramedics the need for such teams to deal with cardiac arrests has been questioned. We performed a 3-year retrospective study of non-traumatic arrests attended by Medic 1, the flying squad based at the Royal Infirmary of Edinburgh. There were 99 males and 46 females, mean age 57.6 years (range 17-86 years). Seventy-eight (53.9%) patients were pronounced dead at scene, 47 patients (32.4%) were admitted to hospital and 20 (13.7%) survived to hospital discharge. All but two of the survivors had return of spontaneous circulation prior to the arrival of Medic 1. Accident flying squads operating as a secondary response unit to victims of non-traumatic cardiac arrest are unlikely to have a significant effect upon overall survival.

Recent advances in pediatric cardiopulmonary resuscitation and advanced life support

The end point of uncorrected shock is cardiac arrest. Once cardiac arrest occurs, the outcome in children is typically poor, reflecting the fact that cardiac arrest does not occur until the child's physiologic reserves are exhausted. Despite more than 35 years of research in cardiac arrest, the optimal management and treatment remain uncertain. The optimal method of basic and advanced life support to restore cardiac function and preserve brain function is unclear, as is the appropriate application of pharmacologic agents to restart the heart and subsequently to manage postarrest shock. New techniques in basic life support merit evaluation in children, particularly interposed abdominal compression and active compression-decompression cardiopulmonary resuscitation. Epinephrine remains the pharmacologic agent of choice. The role of bicarbonate in the management of acidosis and the role of calcium in restarting the heart remain controversial. If and when the heart is restarted following cardiac arrest, the work is just beginning for the intensivist to manage the postarrest shock state. Dobutamine is useful in the normotensive child while epinephrine infusions are used to stabilize hypotensive, postarrest shock in the child.