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Hudgins K. When Life-Supporting Interventions Lead to Moral Distress. Crit Care Nurs Q 2024; 47:218-222. [PMID: 38860951 DOI: 10.1097/cnq.0000000000000509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Moral distress can impact nurses and the care team significantly. A profession dedicated to the principles of caring and compassion is often subjected to patients receiving futile treatment. With the proliferation of extreme life-prolonging measures come the difficulties in the withdrawal of those medical modalities. If a prognosis is poor and care is perceived as curative rather than palliative, providers may often feel conflicted and distressed by their interventions. The American Association of Colleges of Nursing has expressed growing concern about an increase in the use of inappropriate life-support treatments related to futile care. The compelling case of a severely beaten 69-year-old homeless man who had cardiac-arrested and was resuscitated after an unknown amount of down-time, provides the contextual framework for this report. Ethical conflicts can become very challenging, which inevitably increases the suffering of the patient and their caregivers. Research findings suggest that health care organizations can benefit from enacting processes that make ethical considerations an early and routine part of everyday clinical practice. A proactive approach to ethical conflicts may improve patient care outcomes and decrease moral distress.
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Affiliation(s)
- Kerstin Hudgins
- Author Affiliation: The School of Nursing, University of North Carolina Wilmington, Wilmington, NC
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Mirhosseini S, Aghayan SS, Basirinezhad MH, Ebrahimi H. Health Care Providers' Attitudes Toward Do-Not-Resuscitate Order in COVID-19 Patients: An Ethical Dilemma in Iran. OMEGA-JOURNAL OF DEATH AND DYING 2024; 88:908-918. [PMID: 35042392 PMCID: PMC8792911 DOI: 10.1177/00302228211057992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study aimed to investigate the health care providers' attitudes toward the Do-Not-Resuscitate order (DNR) in COVID-19 patients. This study was conducted on 332 health care providers (HCPs) at the COVID-19 referral hospital in Shahroud, Iran by convenience sampling method. The study tools included a demographic information form and the DNR attitude questionnaire. Significance level was considered 0.05 for all tests. The mean scores of attitudes toward DNR order, the procedure of DNR, some aspects of passive euthanasia, and religious and cultural factors were 25.27 ± 2.78, 40.61 ± 5.99, 11.26 ± 2.51, and 6.12 ± 1.27, respectively. The death of relatives due to COVID-19 and female gender were associated with high and low scores of attitudes toward DNR order, respectively. Extended working hours and more work experience were correlated with high scores of DNR procedure. The history of COVID-19 increased the mean score of attitudes toward some aspects of passive euthanasia. In addition, an increase in following COVID-19 news decreased the score of religious and cultural factors affecting DNR order. Despite the legal ban on implementation of the DNR in Iran, the attitude of Iranian HCPs toward this was positive in COVID-19 patients.
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Affiliation(s)
- Seyedmohammad Mirhosseini
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Psychiatric Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Shahrokh Aghayan
- Department of Clinical Sciences, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Mohammad Hasan Basirinezhad
- Department of Epidemiology and Biostatistics, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Hossein Ebrahimi
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
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3
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Warner BE, Lound A, Grailey K, Vindrola-Padros C, Wells M, Brett SJ. Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis. EClinicalMedicine 2023; 62:102144. [PMID: 37588625 PMCID: PMC10425683 DOI: 10.1016/j.eclinm.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
Background Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding HCA International and the NIHR Imperial Biomedical Research Centre.
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Affiliation(s)
- Bronwen E. Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Kate Grailey
- Centre for Health Policy, Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College London, UK
| | | | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Stephen J. Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust London, London, UK
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Principio de proporcionalidad terapéutica en la decisión de intubación orotraqueal y ventilación mecánica invasiva en paciente COVID-19 grave. ACTA COLOMBIANA DE CUIDADO INTENSIVO 2022. [PMCID: PMC7843031 DOI: 10.1016/j.acci.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
En medicina cuando se aplica el principio de proporcionalidad terapéutica se valoran los medios empleados y el fin previsible en cada paciente. Y se distingue entre tratamientos proporcionados o desproporcionados, valorando el beneficio y utilidad. Entre ellos su aplicación en el paciente COVID-19 grave que requiere intubación orotraqueal y ventilación mecánica invasiva. En ocasiones nos puede generar el dilema ético de proceder a realizar dicho procedimiento y no encontrar beneficio alguno, sino al contrario generar sufrimiento, dolor y prolongación de su posible agonía. Teniendo el deber ético en estos casos de no abandonar sino acompañar a través de los cuidados paliativos, siempre informando al familiar sobre la decisión que se tome. El analizar este principio de proporcionalidad terapéutica y su aplicación en las unidades de cuidado intensivo requiere de una conciencia moral por parte del grupo que tiene la responsabilidad de la toma de la decisiòn y dirimir el dilema ético que se presente. Recordando que a los pacientes que requieran intubación orotraqueal se les deben ofrecer todas las medidas requeridas en ventilación mecánica invasiva y no invasiva para mejoría de la hipoxemia. Se presenta un análisis y reflexión sobre el principio de proporcionalidad terapéutica y su fundamentación ética al igual que una revisión sistemática de la literatura médica relacionada con pacientes con COVID-19 en insuficiencia respiratoria aguda. Y se establecen unas consideraciones científicas y éticas a tener en cuenta en el paciente COVID-19. El principio de proporcionalidad terapéutica ante la decisión de intubación orotraqueal debe fundamentarse en un juicio de proporcionalidad, que garantice que se han hecho y utilizado todos los medios previsibles para evitar la intubación orotraqueal y como único fin útil para beneficiar al paciente será la ventilación mecánica invasiva.
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Neville TH, Wiley JF, Kardouh M, Curtis JR, Yamamoto MC, Wenger NS. Change in inappropriate critical care over time. J Crit Care 2020; 60:267-272. [PMID: 32932112 DOI: 10.1016/j.jcrc.2020.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 08/09/2020] [Accepted: 08/31/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Intensive care interventions that prolong life without achieving meaningful benefit are considered clinically "inappropriate". In 2012, the frequency of perceived-inappropriate critical care was 10.8% at one academic health system; and we aimed to re-evaluate this frequency. METHODS For 4 months in 2017, we surveyed critical care physicians daily and asked whether each patient was receiving appropriate, probably inappropriate, or inappropriate critical care. Patients were categorized into three groups: 1) patients for whom treatment was never inappropriate, 2) patients with at least one assessment that treatment was probably inappropriate, but no inappropriate treatment assessments, and 3) patients who had at least one assessment of inappropriate treatment. RESULTS Fifty-five physicians made 10,105 assessments on 1424 patients. Of these, 94 (6.6%) patients received at least one assessment of inappropriate critical care, which is lower than 2012 (10.8% (p < 0.01)). Comparing 2017 and 2012, patient age, MS-DRG, length of stay, and hospital mortality were not significantly different (p > 0.05). Inpatient mortality in 2017 was 73% for patients receiving inappropriate critical care. CONCLUSIONS Over five years the proportion of patients perceived to be receiving inappropriate critical care dropped by 40%. Understanding the reasons for such change might elucidate how to continue to reduce inappropriate critical care.
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Affiliation(s)
- Thanh H Neville
- UCLA, Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, USA.
| | - Joshua F Wiley
- Turner Institute for Brain and Mental Health and School of Psychological Sciences, Monash University, Australia
| | - Miramar Kardouh
- UCLA, Department of Medicine, David Geffen School of Medicine, USA
| | - J Randall Curtis
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, USA
| | - Myrtle C Yamamoto
- UCLA, Department of Medicine, Quality Improvement, David Geffen School of Medicine, USA
| | - Neil S Wenger
- UCLA, Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, USA
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Curtis JR, Kross EK, Stapleton RD. The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19). JAMA 2020; 323:1771-1772. [PMID: 32219360 DOI: 10.1001/jama.2020.4894] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Renee D Stapleton
- Larner College of Medicine, Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington
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Carter HE, Lee XJ, Gallois C, Winch S, Callaway L, Willmott L, White B, Parker M, Close E, Graves N. Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia. BMJ Open 2019; 9:e030955. [PMID: 31690607 PMCID: PMC6858125 DOI: 10.1136/bmjopen-2019-030955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN Retrospective multicentre cohort study. SETTING Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS 831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.
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Affiliation(s)
- Hannah Elizabeth Carter
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Xing Ju Lee
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- School of Psychology, Faculty of Health and Behavioural Sciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Womens Hospital, Herston, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben White
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Eliana Close
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Duke-NUS Medical School, Singapore, Singapore
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8
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Chamberlin P, Lambden J, Kozlov E, Maciejewski R, Lief L, Berlin DA, Pelissier L, Yushuvayev E, Pan CX, Prigerson HG. Clinicians' Perceptions of Futile or Potentially Inappropriate Care and Associations with Avoidant Behaviors and Burnout. J Palliat Med 2019; 22:1039-1045. [PMID: 30874470 DOI: 10.1089/jpm.2018.0385] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Futile or potentially inappropriate care (futile/PIC) for dying inpatients leads to negative outcomes for patients and clinicians. In the setting of rising end-of-life health care costs and increasing physician burnout, it is important to understand the causes of futile/PIC, how it impacts on care and relates to burnout. Objectives: Examine causes of futile/PIC, determine whether clinicians report compensatory or avoidant behaviors as a result of such care and assess whether these behaviors are associated with burnout. Design: Online, cross-sectional questionnaire. Setting/Subjects: Clinicians at two academic hospitals in New York City. Methods: Respondents were asked the frequency with which they observed or provided futile/PIC and whether they demonstrated compensatory or avoidant behaviors as a result. A validated screen was used to assess burnout. Measurements: Descriptive statistics, odds ratios, linear regressions. Results: Surveys were completed by 349 subjects. A majority of clinicians (91.3%) felt they had provided or "possibly" provided futile/PIC in the past six months. The most frequent reason cited for PIC (61.0%) was the insistence of the patient's family. Both witnessing and providing PIC were statistically significantly (p < 0.05) associated with compensatory and avoidant behaviors, but more strongly associated with avoidant behaviors. Provision of PIC increased the likelihood of avoiding the patient's loved ones by a factor of 2.40 (1.82-3.19), avoiding the patient by a factor of 1.83 (1.32-2.55), and avoiding colleagues by a factor of 2.56 (1.57-4.20) (all p < 0.001). Avoiding the patient's loved ones (β = 0.55, SE = 0.12, p < 0.001), avoiding the patient (β = 0.38, SE = 0.17; p = 0.03), and avoiding colleagues (β = 0.78, SE = 0.28; p = 0.01) were significantly associated with burnout. Conclusions: Futile/PIC, provided or observed, is associated with avoidance of patients, families, and colleagues and those behaviors are associated with burnout.
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Affiliation(s)
- Peter Chamberlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Jason Lambden
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Elissa Kozlov
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Renee Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
| | - Lindsay Lief
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David A Berlin
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Latrice Pelissier
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Elina Yushuvayev
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Cynthia X Pan
- New York Presbyterian/Queens, Division of Geriatrics and Palliative Care, Flushing, New York
| | - Holly G Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
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Jeanne Wirpsa M, Emily Johnson R, Bieler J, Boyken L, Pugliese K, Rosencrans E, Murphy P. Interprofessional Models for Shared Decision Making: The Role of the Health Care Chaplain. J Health Care Chaplain 2018; 25:20-44. [DOI: 10.1080/08854726.2018.1501131] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | | | - Joan Bieler
- Northwestern Memorial Hospital, Chicago, Illinois
| | - Lara Boyken
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Karen Pugliese
- Northwestern Medicine Central DuPage Hospital, Winfield, Illinois
| | - Emily Rosencrans
- Northwestern Medicine Lake Forest Hospital, Lake Forest, Illinois
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Salins N, Gursahani R, Mathur R, Iyer S, Macaden S, Simha N, Mani RK, Rajagopal MR. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report. Indian J Crit Care Med 2018; 22:249-262. [PMID: 29743764 PMCID: PMC5930529 DOI: 10.4103/ijccm.ijccm_165_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date. METHODOLOGY This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method. RESULTS Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Roli Mathur
- ICMR Bioethics Unit, National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
| | - Stanley Macaden
- Palliative Care Program of the Christian Medical Association of India, India
- Coordinator of the Palliative Care Program of Christian Medical Association of India and Honorary Palliative Medicine Consultant at Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Nagesh Simha
- Medical Director, Karunashraya Hospice, Bengaluru, Karnataka, India
| | - Raj Kumar Mani
- CEO and Chairman, Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - M. R. Rajagopal
- Chairman of Pallium India and Director of Trivandrum Institute of Palliative Sciences, Pallium, India
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
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11
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Brown CE, Benoit DD, Curtis JR. Focus on palliative care in the ICU. Intensive Care Med 2017; 43:1898-1900. [PMID: 28932878 DOI: 10.1007/s00134-017-4938-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/13/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Crystal E Brown
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Box 359762, Seattle, WA, 98104, USA
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Box 359762, Seattle, WA, 98104, USA.
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12
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Neville TH, Tarn DM, Yamamoto M, Garber BJ, Wenger NS. Understanding Factors Contributing to Inappropriate Critical Care: A Mixed-Methods Analysis of Medical Record Documentation. J Palliat Med 2017; 20:1260-1266. [PMID: 28967808 DOI: 10.1089/jpm.2017.0023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Factors leading to inappropriate critical care, that is treatment that should not be provided because it does not offer the patient meaningful benefit, have not been rigorously characterized. OBJECTIVE We explored medical record documentation about patients who received inappropriate critical care and those who received appropriate critical care to examine factors associated with the provision of inappropriate treatment. DESIGN Medical records were abstracted from 123 patients who were assessed as receiving inappropriate treatment and 66 patients who were assessed as receiving appropriate treatment but died within six months of intensive care unit (ICU) admission. We used mixed methods combining qualitative analysis of medical record documentation with multivariable analysis to examine the relationship between patient and communication factors and the receipt of inappropriate treatment, and present these within a conceptual model. SETTING One academic health system. RESULTS Medical records revealed 21 themes pertaining to prognosis and factors influencing treatment aggressiveness. Four themes were independently associated with patients receiving inappropriate treatment according to physicians. When decision making was not guided by physicians (odds ratio [OR] 3.76, confidence interval [95% CI] 1.21-11.70) or was delayed by patient/family (OR 4.52, 95% CI 1.69-12.04), patients were more likely to receive inappropriate treatment. Documented communication about goals of care (OR 0.29, 95% CI 0.10-0.84) and patient's preferences driving decision making (OR 0.02, 95% CI 0.00-0.27) were associated with lower odds of receiving inappropriate treatment. CONCLUSIONS Medical record documentation suggests that inappropriate treatment occurs in the setting of communication and decision-making patterns that may be amenable to intervention.
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Affiliation(s)
- Thanh H Neville
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Derjung M Tarn
- 2 Department of Family Medicine, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Myrtle Yamamoto
- 3 Department of Medicine, Quality Improvement, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Bryan J Garber
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine , UCLA, Los Angeles, California
| | - Neil S Wenger
- 4 Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Health Ethics Center , RAND Health, David Geffen School of Medicine, UCLA, Los Angeles, California
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14
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Reason-Giving and Medical Futility: Contrasting Legal and Social Discourse in the United States With the United Kingdom and Ontario, Canada. Chest 2016; 150:714-21. [PMID: 27298070 DOI: 10.1016/j.chest.2016.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 11/24/2022] Open
Abstract
Disputes regarding life-prolonging treatments are stressful for all parties involved. These disagreements are appropriately almost always resolved with intensive communication and negotiation. Those rare cases that are not require a resolution process that ensures fairness and due process. We describe three recent cases from different countries (the United States, United Kingdom, and Ontario, Canada) to qualitatively contrast the legal responses to intractable, policy-level disputes regarding end-of-life care in each of these countries. In so doing, we define the continuum of clinical and social utility among different types of dispute resolution processes and emphasize the importance of public reason-giving in the societal discussion regarding policy-level solutions to end-of-life treatment disputes. We argue that precedential, publicly available, written rulings for these decisions most effectively help to move the social debate forward in a way that is beneficial to clinicians, patients, and citizens. This analysis highlights the lack of such rulings within the United States.
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