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Piscitello GM, Lyons PG, Koch VG, Parker WF, Huber MT. Hospital Policy Variation in Addressing Decisions to Withhold and Withdraw Life-Sustaining Treatment. Chest 2024; 165:950-958. [PMID: 38184166 PMCID: PMC11026167 DOI: 10.1016/j.chest.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 11/28/2023] [Accepted: 12/23/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Sociodemographic disparities in physician decisions to withhold and withdraw life-sustaining treatment exist. Little is known about the content of hospital policies that guide physicians involved in these decisions. RESEARCH QUESTION What is the prevalence of US hospitals with policies that address withholding and withdrawing life-sustaining treatment; how do these policies approach ethically controversial scenarios; and how do these policies address sociodemographic disparities in decisions to withhold and withdraw life-sustaining treatment? STUDY DESIGN AND METHODS This national cross-sectional survey assessed the content of hospital policies addressing decisions to withhold or withdraw life-sustaining treatment. We distributed the survey electronically to American Society for Bioethics and Humanities members between July and August 2023 and descriptively analyzed responses. RESULTS Among 93 respondents from hospitals or hospital systems representing all 50 US states, Puerto Rico, and Washington, DC, 92% had policies addressing decisions to withhold or withdraw life-sustaining treatment. Hospitals varied in their stated guidance, permitting life-sustaining treatment to be withheld or withdrawn in cases of patient or surrogate request (82%), physiologic futility (81%), and potentially inappropriate treatment (64%). Of the 8% of hospitals with policies that addressed patient sociodemographic disparities in decisions to withhold or withdraw life-sustaining treatment, these policies provided opposing recommendations to either exclude sociodemographic factors in decision-making or actively acknowledge and incorporate these factors in decision-making. Only 3% of hospitals had policies that recommended collecting and maintaining information about patients for whom life-sustaining treatment was withheld or withdrawn that could be used to identify disparities in decision-making. INTERPRETATION Although most surveyed US hospital policies addressed withholding or withdrawing life-sustaining treatment, these policies varied widely in criteria and processes. Surveyed policies also rarely addressed sociodemographic disparities in these decisions.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA; Palliative Research Center, University of Pittsburgh, Pittsburgh, PA.
| | - Patrick G Lyons
- Department of Medicine, Oregon Health and Science University, Portland, OR; Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, OR
| | - Valerie Gutmann Koch
- Health Law & Policy Institute, The University of Houston Law Center, Houston, TX; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| | - William F Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL; Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL; Public Health Sciences, University of Chicago, Chicago, IL
| | - Michael T Huber
- Division of Geriatrics and Palliative Medicine, University of Miami, Miami, FL; Institute of Bioethics and Health Policy, University of Miami, Miami, FL
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Piscitello GM, Parker WF. Do-Not-Resuscitate Orders by COVID-19 Status Throughout the First Year of the COVID-19 Pandemic. Chest 2024; 165:601-609. [PMID: 37778695 PMCID: PMC10925541 DOI: 10.1016/j.chest.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/13/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND At the beginning of the COVID-19 pandemic, whether performing CPR on patients with COVID-19 would be effective or increase COVID-19 transmission to health care workers was unclear. RESEARCH QUESTION Did the prevalence of do-not-resuscitate (DNR) orders by COVID-19 status change over the first year of the pandemic as risks such as COVID-19 transmission to health care workers improved? STUDY DESIGN AND METHODS This cross-sectional study assessed DNR orders for all adult patients admitted to ICUs at two academic medical centers in Chicago, IL, between April 2020 and April 2021. DNR orders by COVID-19 status were assessed using risk-adjusted mixed-effects logistic regression and propensity score matching by patient severity of illness. RESULTS The study population of 3,070 critically ill patients were 46% Black, 53% male, with median age (interquartile range [IQR]) 63 (50-73) years. Eighteen percent were COVID-19 positive and 27% had a DNR order. Black and Latinx patients had higher absolute rates of DNR orders than White patients (30% vs 29% vs 23%; P = .006). After adjustment for patient characteristics, illness severity, and hospital location, DNR orders were more likely in patients with COVID-19 in the nonpropensity score-matched (n = 3,070; aOR, 2.01; 95% CI, 1.64-2.38) and propensity score-matched (n = 1,118; aOR, 1.91; 95% CI, 1.45-2.52) cohorts. The prevalence of DNR orders remained higher for patients with COVID-19 than patients without COVID-19 during all months of the study period (difference in prevalence over time, P = .751). INTERPRETATION In this multihospital study, DNR orders remained persistently higher for patients with COVID-19 vs patients without COVID-19 with similar severity of illness during the first year of the pandemic. The specific reasons why DNR orders remained persistently elevated for patients with COVID-19 should be assessed in future studies, because these changes may continue to affect COVID-19 patient care and outcomes.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA; Palliative Research Center, University of Pittsburgh, Pittsburgh, PA.
| | - William F Parker
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
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Piscitello GM, Stein D, Arnold RM, Schenker Y. Rural Hospital Disparities in Goals of Care Documentation. J Pain Symptom Manage 2023; 66:578-586. [PMID: 37544552 PMCID: PMC10592198 DOI: 10.1016/j.jpainsymman.2023.07.020] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 07/21/2023] [Accepted: 07/29/2023] [Indexed: 08/08/2023]
Abstract
CONTEXT Goals of care conversations for seriously ill hospitalized patients are associated with high-quality patient-centered care. OBJECTIVES We aimed to assess the prevalence of documented goals of care conversations for rural hospitalized patients compared to nonrural hospitalized patients. METHODS We retrospectively assessed goals of care documentation using a template note for adult patients with predicted 90-day mortality greater than 30% admitted to eight rural and nine nonrural community hospitals between July 2021 and April 2023. We compared predictors and prevalence of goals of care documentation among rural and nonrural hospitals. RESULTS Of the 31,098 patients admitted during the study period, 21% were admitted to a rural hospital. Rural patients were more likely than nonrural patients to be >65 years old (89% vs. 86%, P = <.0001), more likely to live in a neighborhood classified in the highest quintile of socioeconomic disadvantage (40% vs. 16%, P = <.0001), and less likely to receive a palliative care consult (8% vs. 18%, P = <.0001). Goals of care documentation occurred less often for patients admitted to rural vs. nonrural community hospitals (2% vs. 7%, P < .0001). In the base multivariable logistic regression model adjusting for patient characteristics, the odds of goals care documentation were lower in rural vs. nonrural community hospitals (aOR 0.4, P = .0232). In a second multivariable logistic regression model including both patient characteristics and severity of illness, the odds of goals of care documentation in rural community hospitals were no longer statistically different than nonrural community hospitals (aOR 0.5, P = .1080). Patients who received a palliative care consult had a lower prevalence of goals of care documentation in rural vs. nonrural hospitals (16% vs. 37%, P = <.0001). CONCLUSION In this study of 17 rural and nonrural community hospitals, we found low overall prevalence of goals of care documentation with particularly infrequent documentation occurring within rural hospitals. Future study is needed to assess barriers to goals of care documentation contributing to low prevalence of goals of care conversations in rural hospital settings.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine (G.P., R.A., Y.S.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Palliative Research Center (G.P., R.A., Y.S.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | - Dillon Stein
- Butler Memorial Hospital (D.S.), Butler, Pennsylvania, USA
| | - Robert M Arnold
- Division of General Internal Medicine (G.P., R.A., Y.S.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Palliative Research Center (G.P., R.A., Y.S.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Division of General Internal Medicine (G.P., R.A., Y.S.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Palliative Research Center (G.P., R.A., Y.S.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Abstract
OBJECTIVES A unilateral do-not-resuscitate (UDNR) order is a do-not-resuscitate order placed using clinician judgment which does not require consent from a patient or surrogate. This study assessed how UDNR orders were used during the COVID-19 pandemic. DESIGN We analyzed a retrospective cross-sectional study of UDNR use at two academic medical centers between April 2020 and April 2021. SETTING Two academic medical centers in the Chicago metropolitan area. PATIENTS Patients admitted to an ICU between April 2020 and April 2021 who received vasopressor or inotropic medications to select for patients with high severity of illness. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The 1,473 patients meeting inclusion criteria were 53% male, median age 64 (interquartile range, 54-73), and 38% died during admission or were discharged to hospice. Clinicians placed do not resuscitate orders for 41% of patients ( n = 604/1,473) and UDNR orders for 3% of patients ( n = 51/1,473). The absolute rate of UDNR orders was higher for patients who were primary Spanish speaking (10% Spanish vs 3% English; p ≤ 0.0001), were Hispanic or Latinx (7% Hispanic/Latinx vs 3% Black vs 2% White; p = 0.003), positive for COVID-19 (9% vs 3%; p ≤ 0.0001), or were intubated (5% vs 1%; p = 0.001). In the base multivariable logistic regression model including age, race/ethnicity, primary language spoken, and hospital location, Black race (adjusted odds ratio [aOR], 2.5; 95% CI, 1.3-4.9) and primary Spanish language (aOR, 4.4; 95% CI, 2.1-9.4) had higher odds of UDNR. After adjusting the base model for severity of illness, primary Spanish language remained associated with higher odds of UDNR order (aOR, 2.8; 95% CI, 1.7-4.7). CONCLUSIONS In this multihospital study, UDNR orders were used more often for primary Spanish-speaking patients during the COVID-19 pandemic, which may be related to communication barriers Spanish-speaking patients and families experience. Further study is needed to assess UDNR use across hospitals and enact interventions to improve potential disparities.
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Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Albina Tyker
- Division of Respirology, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Robert M Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
- Palliative Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mark Siegler
- Department of Medicine, University of Chicago, Chicago, IL
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
| | - William F Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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Piscitello GM, Rojas JC, Arnold RM. Equity in Using Artificial Intelligence to Target Serious Illness Conversations for Patients With Life-Limiting Illness. J Pain Symptom Manage 2023; 66:e299-e301. [PMID: 37054955 DOI: 10.1016/j.jpainsymman.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/01/2023] [Indexed: 04/15/2023]
Affiliation(s)
- Gina M Piscitello
- Division of General Internal Medicine (G.M.P., R.M.A.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (G.M.P. R.M.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary and Critical Care Medicine (J.C.R.), Rush University Medical Center, Chicago, IL, USA.
| | - Juan Carlos Rojas
- Division of General Internal Medicine (G.M.P., R.M.A.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (G.M.P. R.M.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary and Critical Care Medicine (J.C.R.), Rush University Medical Center, Chicago, IL, USA.
| | - Robert M Arnold
- Division of General Internal Medicine (G.M.P., R.M.A.), Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, Pennsylvania; Palliative Research Center (G.M.P. R.M.A.), University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary and Critical Care Medicine (J.C.R.), Rush University Medical Center, Chicago, IL, USA.
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Piscitello GM, Bermea RS, Stokes JW, Gannon WD, Kanelidis AJ, Konopka M, Shappell C, Frye LK, Lyons PG, Siegler M, Parker WF. Clinician Ethical Perspectives on Extracorporeal Membrane Oxygenation in Practice. Am J Hosp Palliat Care 2022; 39:659-666. [PMID: 34414798 PMCID: PMC8858336 DOI: 10.1177/10499091211041079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Extracorporeal membrane oxygenation (ECMO) is an expensive and scarce life sustaining treatment provided to certain critically ill patients. Little is known about the informed consent process for ECMO or clinician viewpoints on ethical complexities related to ECMO in practice. METHODS We sent a cross-sectional survey to all departments providing ECMO within 7 United States hospitals in January 2021. One clinician from each department completed the 42-item survey representing their department. RESULTS Fourteen departments within 7 hospitals responded (response rate 78%, N = 14/18). The mean time spent consenting patients or surrogate decision-makers for ECMO varied, from 7.5 minutes (95% CI 5-10) for unstable patients to 20 minutes (95% CI 15-30) for stable patients (p = 0.0001). Few clinician respondents (29%) report patients or surrogate decision-makers always possess informed consent for ECMO. Most departments (92%) have absolute exclusion criteria for ECMO such as older age (43%, cutoffs ranging from 60-75 years), active malignancy (36%), and elevated body mass index (29%). A significant minority of departments (29%) do not always offer the option to withdraw ECMO to patients or surrogate decision-makers. For patients who cannot be liberated from ECMO and are ineligible for heart or lung transplant, 36% of departments would recommend the patient be removed from ECMO and 64% would continue ECMO support. CONCLUSION Adequate informed consent for ECMO is a major ethical challenge, and the content of these discussions varies. Use of categorical exclusion criteria and withdrawal of ECMO if a patient cannot be liberated from it differ among departments and institutions.
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Affiliation(s)
| | - Rene S. Bermea
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John W. Stokes
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Whitney D. Gannon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Megan Konopka
- Division of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Claire Shappell
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Laura K. Frye
- Division of Allergy, Pulmonary, and Critical Care Medicine, University of Wisconsin, Madison, WI, USA
| | - Patrick G. Lyons
- Division of Pulmonary and Critical Care Medicine, Washington University in St. Louis, MO, USA
| | - Mark Siegler
- Department of Medicine, University of Chicago, IL, USA
- MacLean Center for Clinical Medical Ethics, University of Chicago, IL, USA
| | - William F. Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, IL, USA
- Section of Pulmonary and Critical Care, University of Chicago, IL, USA
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Piscitello GM, Siegler M, Parker WF. Ethics of Extracorporeal Membrane Oxygenation under Conventional and Crisis Standards of Care. The Journal of Clinical Ethics 2022. [DOI: 10.1086/jce2022331013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Piscitello GM, Siegler M, Parker WF. Ethics of Extracorporeal Membrane Oxygenation under Conventional and Crisis Standards of Care. J Clin Ethics 2022; 33:13-22. [PMID: 35100174 PMCID: PMC9648099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of life support for cardiac and/or pulmonary failure with unique ethical challenges compared to other forms of life support. Ethical challenges with ECMO exist when conventional standards of care apply, and are exacerbated during periods of absolute ECMO scarcity when "crisis standards of care" are instituted. When conventional standards of care apply, we propose that it is ethically permissible to withhold placing patients on ECMO for reasons of technical futility or when patients have terminal, short-term prognoses that are untreatable by ECMO. Under crisis standards of care, it is ethically permissible to broaden exclusionary criteria to also withhold ECMO from patients who have a low likelihood of recovery, to maximize the overall number of lives saved. Unilateral withdrawal of ECMO against a patient's preferences is unethical under conventional standards of care, but is ethical under crisis standards of care to increase access to ECMO to others in society. ECMO should only be rationed when true scarcity exists, and allocation protocols should be transparent to the public. When rationing must occur under crisis standards of care, it is imperative that oversight bodies assess for inequities in the allocation of ECMO and make frequent changes to improve any inequities.
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Affiliation(s)
- Gina M Piscitello
- Assistant Professor, Department of Internal Medicine, Section of Palliative Medicine; and Division of Hospital Medicine at Rush Medical College, Rush University, Chicago, Illinois USA.
| | - Mark Siegler
- Lindy Bergman Distinguished Service Professor of Medicine and Surgery, University of Chicago; Founding Director, University of Chicago's MacLean Center for Clinical Medical Ethics; and Executive Director of the Bucksbaum Institute for Clinical Excellence, Chicago, Illinois USA.
| | - William F Parker
- Assistant Professor of Medicine, Section of Pulmonary/Critical Care, University of Chicago Department of Medicine; and Assistant Director, MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois USA.
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Gandhi R, Piscitello GM, Parker WF, Michelson K. Variation in COVID-19 Resource Allocation Protocols and Potential Implementation in the Chicago Metropolitan Area. AJOB Empir Bioeth 2021; 12:266-275. [PMID: 34596474 DOI: 10.1080/23294515.2021.1983667] [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] [Indexed: 10/20/2022]
Abstract
BACKGROUND Scarce resource allocation policies vary across the United States. Little is known about regional variation in resource allocation protocols and variation in their application. We sought to evaluate how Covid-19 scarce resource allocation policies vary throughout the Chicago metropolitan area and whether there are differences in policy application within hospitals when prioritizing hypothetical patients who need critical care resources. METHODS Two cross-sectional surveys were distributed to Chicago metropolitan area hospital representatives and triage officers. Survey responses and categorical variables are described by frequency of occurrence. Intra- and interhospital variation in ranking of hypothetical patients was assessed using Fleiss's Kappa coefficients. RESULTS Eight Chicago-area hospitals responded to the survey assessing scarce resource allocation protocols (N = 8/18, response rate 44%). For hospitals willing to describe their ventilator allocation protocol (N = 7), most used the sequential organ failure assessment (SOFA) score (N = 6/7, 86%) and medical comorbidities (N = 4/7, 57%) for initial scoring of patients. A majority gave priority in initial scoring to pre-defined groups (N = 5/7, 71%), all discussed withdrawal of mechanical ventilation for adult patients (N = 7/7, 100%), and a minority had exclusion criteria (N = 3/7, 43%). Forty-nine triage officers from nine hospitals responded to the second survey (N = 9/10 hospitals, response rate 90%). Their rankings of hypothetical patients showed only slight agreement amongst all hospitals (Kappa 0.158) and fair agreement within two hospitals with the most respondents (Kappa 0.21 and 0.25). Almost half used tiebreakers to rank patients (N = 23/49, 47%). CONCLUSIONS Although most respondents from Chicago-area hospitals described policies for resource allocation during the COVID-19 pandemic, the substance and application of these protocols varied. There was little agreement when prioritizing hypothetical patients to receive scarce resources, even among people from the same hospital. Variations in resource allocation protocols and their application could lead to inequitable distribution of resources, further exacerbating community distrust and disparities in health. Supplemental data for this article is available online at https://doi.org/10.1080/23294515.2021.1983667.
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Affiliation(s)
- Rupali Gandhi
- Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, Illinois, USA
| | | | - William F Parker
- Department of Medicine, University of Chicago, Chicago, Illinois, USA.,MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Kelly Michelson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Center for Bioethics & Medical Humanities, Northwestern University Feinberg School of Medicine Institute for Public Health and Medicine, Chicago, Illinois, USA.,Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Piscitello GM, Lamadrid VJ, Post Z, Kaur R, Gulczynski B, Baldeo R, Hudoba C, O'Mahony S, Chen E, Greenberg J. The Effect of Triggered Palliative Medicine Consults on Nurse Moral Distress in the Medical Intensive Care Unit. Am J Hosp Palliat Care 2021; 39:1039-1045. [PMID: 34587825 DOI: 10.1177/10499091211049398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Moral distress in the intensive care unit contributes to negative emotional experiences in nurses and adversely affects patient care. This prospective cohort study evaluates an intervention designed to improve nurse moral distress in the medical intensive care unit and assesses patient outcomes which may improve moral distress. METHODS Nurse moral distress was measured before and after an intervention of triggered palliative consults and scheduled family meetings in the intensive care unit during the COVID-19 pandemic. Patient outcomes in the intervention medical intensive care unit were compared to a control group. RESULTS Forty-eight nurses (n = 48/78, 62%) completed the pre-intervention survey and 33 (n = 33/78, 42%) completed the post-intervention survey. Nurse moral distress using the MMD-HP scale pre- and post-intervention (122.5 vs. 134.0, P = 0.1210) was not statistically different. Intervention group patients (n = 57/64, 89%) had earlier transition to do not resuscitate status (hazard ratio 2.1, 95% CI 1.1-4.0, P = 0.0294), higher rate of documented alternate decision makers (100% vs. 61%, P < 0.0001), and higher rate discharged to a facility (28% vs. 14%) or hospice (19% vs. 7%) (P = 0.0090). Intervention group patients with a do not resuscitate (DNR) order had lower median length of stay in the intensive care unit (4 days vs. 13 days, P = 0.0004) and hospital (10 days vs. 21 days, P = 0.0005), and lower median total hospital costs per patient ($39,067 vs. $116,476, P = 0.0029) when compared control group patients with a DNR order. CONCLUSION Triggered palliative consults with scheduled family meetings were not associated with change in nurse moral distress. More research is needed to uncover methods to improve nurse moral distress in the intensive care unit.
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Affiliation(s)
- Gina M Piscitello
- Section of Palliative Medicine and Division of Hospital Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Vivien Joy Lamadrid
- Medical Intensive Care Unit, Rush University Medical Center, Chicago, IL, USA
| | - Zoë Post
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Ramandeep Kaur
- Department of Cardiopulmonary Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Barbara Gulczynski
- Medical Intensive Care Unit, Rush University Medical Center, Chicago, IL, USA
| | - Ryan Baldeo
- Section of Palliative Medicine and Division of Hospital Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Christine Hudoba
- Section of Palliative Medicine and Division of Hospital Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Sean O'Mahony
- Section of Palliative Medicine and Division of Hospital Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Elaine Chen
- Section of Palliative Medicine and Division of Hospital Medicine, Rush University Medical Center, Chicago, IL, USA.,Section of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA.,Are co-last authors
| | - Jared Greenberg
- Section of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, IL, USA.,Are co-last authors
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Piscitello GM, Kapania EM, Kanelidis A, Siegler M, Parker WF. The Use of Slow Codes and Medically Futile Codes in Practice. J Pain Symptom Manage 2021; 62:326-335.e5. [PMID: 33346066 PMCID: PMC8729118 DOI: 10.1016/j.jpainsymman.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT Slow codes, which occur when clinicians symbolically appear to conduct advanced cardiac life support but do not provide full resuscitation efforts, are ethically controversial. OBJECTIVES To describe the use of slow codes in practice and their association with clinicians' attitudes and moral distress. METHODS We conducted a cross-sectional survey at Rush University and University of Chicago in January 2020. Participants included physician trainees, attending physicians, nurses, and advanced practice providers who care for critically ill patients. RESULTS Of the 237 respondents to the survey (31% response rate, n = 237/753), almost half (48%) were internal medicine residents (46% response rate, n = 114/246). Over two-thirds of all respondents (69%) reported caring for a patient where a slow code was performed, with a mean of 1.3 slow codes (SD 1.7) occurring in the past year per participant. A narrow majority of respondents (52%) reported slow codes are ethical if the code is medically futile. Other respondents (46%) reported slow codes are not ethical, with 19% believing no code should be performed and 28% believing a full guideline consistent code should be performed. Most respondents reported moral distress when being required to run (75%), do chest compressions for (80%), or witness (78%) a cardiac resuscitation attempt they believe to be medically futile. CONCLUSION Slow codes occur in practice, even though many clinicians ethically disagree with their use. The use of cardiac resuscitation attempts in medically futile situations can cause significant moral distress to medical professionals who agree or are forced to participate in them.
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Affiliation(s)
- Gina M Piscitello
- Section of Palliative Medicine, Rush Medical College, Chicago, Illinois, USA.
| | - Esha M Kapania
- Department of Medicine, Rush Medical College, Chicago, Illinois, USA
| | - Anthony Kanelidis
- Section of Cardiology, University of Chicago, Chicago, Illinois, USA
| | - Mark Siegler
- Department of Medicine, University of Chicago, Chicago, Illinois, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - William F Parker
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA; Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
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Piscitello GM, Fukushima CM, Saulitis AK, Tian KT, Hwang J, Gupta S, Sheldon M. Family Meetings in the Intensive Care Unit During the Coronavirus Disease 2019 Pandemic. Am J Hosp Palliat Care 2020; 38:305-312. [PMID: 33207937 PMCID: PMC7859662 DOI: 10.1177/1049909120973431] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [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] [Indexed: 11/15/2022] Open
Abstract
Purpose: Visitor restrictions during the COVID-19 pandemic limit in-person family
meetings for hospitalized patients. We aimed to evaluate the quantity of
family meetings by telephone, video and in-person during the COVID-19
pandemic by manual chart review. Secondary outcomes included rate of change
in patient goals of care between video and in-person meetings, the timing of
family meetings, and variability in meetings by race and ethnicity. Methods: A retrospective cohort study evaluated patients admitted to the intensive
care unit at an urban academic hospital between March and June 2020.
Patients lacking decision-making capacity and receiving a referral for a
video meeting were included in this study. Results: Most patients meeting inclusion criteria (N = 61/481, 13%) had COVID-19
pneumonia (n = 57/61, 93%). A total of 650 documented family meetings
occurred. Few occurred in-person (n = 70/650, 11%) or discussed goals of
care (n = 233/650, 36%). For meetings discussing goals of care, changes in
patient goals of care occurred more often for in-person meetings rather than
by video (36% vs. 11%, p = 0.0006). The average time to the first goals of
care family meeting was 11.4 days from admission. More documented telephone
meetings per admission were observed for White (10.5, SD 9.5) and
Black/African-American (7.1, SD 6.6) patients compared to Hispanic or Latino
patients (4.9, SD 4.9) (p = 0.02). Conclusions: During this period of strict visitor restrictions, few family meetings
occurred in-person. Statistically significant fewer changes in patient goals
of care occurred following video meetings compared to in-person meetings,
providing support limiting in-person meetings may affect patient care.
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Affiliation(s)
- Gina M Piscitello
- Section of Palliative Medicine, 12245Rush Medical College, Chicago, IL, USA
| | | | | | - Katherine T Tian
- Department of Medicine, 12245Rush Medical College, Chicago, IL, USA
| | | | | | - Mark Sheldon
- Department of Philosophy, 3270Northwestern University, Evanston, IL, USA
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Piscitello GM, Kapania EM, Miller WD, Rojas JC, Siegler M, Parker WF. Variation in Ventilator Allocation Guidelines by US State During the Coronavirus Disease 2019 Pandemic: A Systematic Review. JAMA Netw Open 2020; 3:e2012606. [PMID: 32558916 PMCID: PMC7305526 DOI: 10.1001/jamanetworkopen.2020.12606] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE During the coronavirus disease 2019 pandemic, there may be too few ventilators to meet medical demands. It is unknown how many US states have ventilator allocation guidelines and how these state guidelines compare with one another. OBJECTIVE To evaluate the number of publicly available US state guidelines for ventilator allocation and the variation in state recommendations for how ventilator allocation decisions should occur and to assess whether unique criteria exist for pediatric patients. EVIDENCE REVIEW This systematic review evaluated publicly available guidelines about ventilator allocation for all states in the US and in the District of Columbia using department of health websites for each state and internet searches. Documents with any discussion of a process to triage mechanical ventilatory support during a public health emergency were screened for inclusion. Articles were excluded if they did not include specific ventilator allocation recommendations, were in draft status, did not include their state department of health, or were not the most up-to-date guideline. All documents were individually assessed and reassessed by 2 independent reviewers from March 30 to April 2 and May 8 to 10, 2020. FINDINGS As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%). CONCLUSIONS AND RELEVANCE These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.
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Affiliation(s)
| | | | - William D. Miller
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Juan C. Rojas
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Mark Siegler
- Department of Medicine, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
| | - William F. Parker
- Department of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois
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Abstract
Purpose: Spirituality and religion affect patient health. This topic is often not included in medical resident education. We aimed to evaluate resident knowledge, attitudes, and skill regarding spirituality, religion, and medicine and to develop, implement, and evaluate a curriculum to improve these measures. Methods: Internal medicine residents at a large, urban academic center were surveyed to determine their baseline knowledge, attitudes, and skill regarding spirituality and religion (37.4% response rate, n = 46/123). A lecture and discussion-based curriculum was implemented over 1 year, followed by another survey (41.4% response rate, n = 51/123); χ2 statistic was used to compare pre- and postsurveys to evaluate the curriculum. Results: Baseline resident attitudes toward spirituality, religion, and medicine were high with most agreeing chaplains are valuable in patient care (93.5%) and that patient spiritual and religious beliefs can affect health (93.5%). Resident self-reported knowledge and skill were low with few knowing the training chaplains receive (4.3%) or reporting competence taking a spiritual history (15.2%). After the curriculum, resident self-reported knowledge increased regarding the role of chaplains (56.5%-80.4%, P = .011) and the training chaplains receive (4.3%-27.5%, P = .002). No significant postcurriculum change was seen in attitudes or skill. Conclusions: Most internal medicine residents have positive attitudes toward spirituality, religion, and medicine. They do not have adequate knowledge or skill to care for patients in this area, however. Implementation of a curriculum in spirituality, religion, and medicine improved resident self-reported knowledge. Future work should focus on revising the curriculum to better improve resident knowledge and skill.
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Affiliation(s)
- Gina M. Piscitello
- Division of Geriatrics and Palliative Care, Department of Internal Medicine, Section of Palliative Medicine, Rush Medical College, Chicago, IL, USA
| | - Shannon Martin
- Department of Medicine, University of Chicago, Chicago, IL, USA
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Abstract
PURPOSE Family meetings in the medical intensive care unit can improve outcomes. Little is known about when meetings occur in practice. We aimed to determine the time from admission to family meetings in the medical intensive care unit and assess the relationship of meetings with mortality. METHODS We performed a prospective cohort study of critically ill adult patients admitted to the medical intensive care unit at an urban academic medical center. Using manual chart review, the primary outcome was any attempt at holding a family meeting within 72 hours of admission. Competing risk models estimated the time from admission to family meeting and to patient death or discharge. RESULTS Of the 131 patients who met inclusion criteria in the 12-month study period, the median time from admission to family meeting was 4 days. Fewer than half of patients had a documented family meeting within 72 hours of admission (n = 60/131, 46%), with substantial interphysician variability in meeting rates ranging from 28% to 63%. Patients with family meetings within 72 hours were 30 times more likely to die within 72 hours (32% vs 1%, P < .001). Of the 55 patients who died in the intensive care unit, 27 (49%) had their first family meeting within 1 day of death. CONCLUSIONS Family meetings occur considerably later than 72 hours and are often held in close proximity to a patient's death. This suggests for some physicians, family meetings may primarily be used to negotiate withdrawal of life support rather than to support the patient and family.
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Affiliation(s)
- Gina M Piscitello
- 1 Department of Medicine, University of Chicago, Chicago, IL, USA.,2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - William M Parham
- 3 Abbott Northwestern Hospital Critical Care Medicine, Minneapolis, MN, USA
| | - Michael T Huber
- 2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA.,4 Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Mark Siegler
- 1 Department of Medicine, University of Chicago, Chicago, IL, USA.,2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - William F Parker
- 1 Department of Medicine, University of Chicago, Chicago, IL, USA.,2 MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
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