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Saint Denny K, Lamore K, Nandrino JL, Rethore S, Prieur C, Mur S, Storme L. Parents' experiences of palliative care decision-making in neonatal intensive care units: An interpretative phenomenological analysis. Acta Paediatr 2024; 113:992-998. [PMID: 38229540 DOI: 10.1111/apa.17109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 01/18/2024]
Abstract
AIM This work explores the experiences and meaning attributed by parents who underwent the decision-making process of withholding and/or withdrawing life-sustaining treatment for their newborn. METHODS Audio-recorded face-to-face interviews were led and analysed using interpretative phenomenological analysis. Eight families (seven mothers and five fathers) whose baby underwent withholding and/or withdrawing of life-sustaining treatment in three neonatal intensive care units from two regions in France were included. RESULTS The findings reveal two paradoxes within the meaning-making process of parents: role ambivalence and choice ambiguity. We contend that these paradoxes, along with the need to mitigate uncertainty, form protective psychological mechanisms that enable parents to cope with the decision, maintain their parental identity and prevent decisional regret. CONCLUSION Role ambivalence and choice ambiguity should be considered when shared decision-making in the neonatal intensive care unit. Recognising and addressing these paradoxical beliefs is essential for informing parent support practices and professional recommendations, as well as add to ethical discussions pertaining to parental autonomy and physicians' rapport to uncertainty.
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Affiliation(s)
- Kelly Saint Denny
- Department of Neonatology, Lille University Hospital, Lille, France
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Kristopher Lamore
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Jean-Louis Nandrino
- Cognitive and Affective Sciences, SCALab UMR CNRS 9193, University of Lille, Lille, France
| | - Sabine Rethore
- Department of Neonatology, Valenciennes Hospital, Valenciennes, France
| | - Charlotte Prieur
- Regional Resource Team for Pediatric Palliative Care, Lille University Hospital, Lille, France
- Department of Neonatology, Lens Hospital, Lens, France
| | - Sebastien Mur
- Department of Neonatology, Lille University Hospital, Lille, France
| | - Laurent Storme
- Department of Neonatology, Lille University Hospital, Lille, France
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Darchinger B, Härlein J, Fley G. [Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review]. Pflege 2024. [PMID: 38651458 DOI: 10.1024/1012-5302/a000998] [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: 04/25/2024]
Abstract
Withdrawal of Life-Sustaining Treatment in the PICU From the Nursing Staff's Perspective: Integrative Review Abstract: Background: Withdrawal of life sustaining measures is a common mode of treatment prior to the death of a critically ill child and has implications for all involved. The perspective of nurses has not yet been considered in this context. Aim: How do nurses experience the termination of life-sustaining measures in the paediatric intensive care unit? What is their role in this process? Methods: An integrative review was conducted to answer the research question. The literature search was performed in October 2022 in the CINAHL, Medline and PsycINFO databases. Results: Three qualitative and five quantitative studies were included. The confrontation with emotions, uncertainties in the decision-making process, challenges and conflicts in collaboration, in interacting with those involved and in the provision of care determine the experience of nurses during treatment withdrawal. The nurses as involved in the decision-making process and representative of interests are influenced by intrarole conflicts. Conclusion: Nursing professionals need support to cope with their experiences in the context of treatment withdrawal in children. In addition to surveying the type and scope of support measures, interprofessional guidelines must be developed when life-sustaining measures are withdrawn. This includes future research to specify the role of nurses in treatment withdrawal and includes, for example, the description of specific tasks, necessary skills or the extent of involvement in decision-making.
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Affiliation(s)
- Britta Darchinger
- Kinder-Intensiv-Pflege-Station, Kinderklinik und Kinderpoliklinik, Dr. von Haunersches Kinderspital der LMU München, Deutschland
- Evangelische Hochschule für angewandte Wissenschaften Nürnberg, Deutschland
| | - Jürgen Härlein
- Evangelische Hochschule für angewandte Wissenschaften Nürnberg, Deutschland
| | - Gabriele Fley
- Evangelische Hochschule für angewandte Wissenschaften Nürnberg, Deutschland
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Hewitt J, Alsaba N, May K, Kang E, Cartwright C, Willmott L, White B, Marshall AP. End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland. Emerg Med Australas 2024. [PMID: 38361400 DOI: 10.1111/1742-6723.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/20/2023] [Accepted: 01/13/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. METHODS An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. RESULTS The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. CONCLUSIONS The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.
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Affiliation(s)
- Jayne Hewitt
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Law Futures Centre, Griffith University, Southport, Queensland, Australia
| | - Nemat Alsaba
- Emergency Department, Gold Coast University Hospital, Southport, Queensland, Australia
- Faculty of Health Science and Medicine, Bond University, Robina, Queensland, Australia
| | - Katya May
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Evelyn Kang
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
| | - Colleen Cartwright
- Office of the Deputy Vice Chancellor (Research), Southern Cross University, Lismore, New South Wales, Australia
| | - Lindy Willmott
- Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben White
- Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
- ARC Future Fellow, Brisbane, Queensland, Australia
| | - Andrea P Marshall
- School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia
- Nursing Education and Research Unit, Gold Coast University Hospital, Southport, Queensland, Australia
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De León-García A, Manrique Díaz M. Adequacy of therapeutic effort: Challenges in pediatrics. ARCH ARGENT PEDIATR 2023; 121:e202303004. [PMID: 37382512 DOI: 10.5546/aap.2023-03004.eng] [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] [Indexed: 06/30/2023]
Abstract
The term "therapeutic limitation" has been replaced by "adequacy of therapeutic effort" and is defined as the decision to withhold or withdraw diagnostic and therapeutic measures in response to the patient's condition, avoiding potentially inappropriate behaviors and redirectong treatment goals towards comfort and well-being. In the pediatric population, this decision is even more challenging given the nature of the physician-patient-family relationship and the paucity of guidelines to address treatment goals. The adequacy of therapeutic effort is framed by ethical and legal principles, but, in practice, there are several challenges. Each adequacy process is unique and dynamic, and should be addressed by taking into account with what measures, how, when, and in whom it should be implemented.
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Ul Hassan SS, Ali W, Khan H, Raja AR, Hassan M, Haque G, Ayub F, Waqar MA, Latif A. Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit. Omega (Westport) 2023:302228231198360. [PMID: 37632273 DOI: 10.1177/00302228231198360] [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: 08/27/2023]
Abstract
To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.
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Affiliation(s)
| | - Wajid Ali
- Dean's Clinical Research Fellow, Aga Khan University, Karachi, Pakistan
| | - Hamza Khan
- Dean's Clinical Research Fellow, Aga Khan University, Karachi, Pakistan
| | | | | | - Ghazal Haque
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | - Farwa Ayub
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
| | | | - Asad Latif
- Centre for Patient Safety, Aga Khan University, Karachi, Pakistan
- Department of Anesthesiology, Aga Khan University Hospital, Karachi, Pakistan
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, USA
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Rosenberg N, Mateyo KJ, Mokute KT, Otieno G, Hui K, Riviello E, Umuhire OF. Attitudes, beliefs, and practices toward end-of-life care among physicians in sub-Saharan Africa. Pan Afr Med J 2023; 45:167. [PMID: 37900203 PMCID: PMC10611914 DOI: 10.11604/pamj.2023.45.167.40855] [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] [Accepted: 08/01/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction as the opportunity to receive life-sustaining treatments expands in sub-Saharan Africa (SSA), so do potential ethical dilemmas. Little is known regarding the attitudes, beliefs, and practices of physicians in SSA regarding end-of-life care ethics. Methods we used validated survey items addressing physician end-of-life care views and added SSA-context specific items. We identified a convenience sample using the authors' existing African professional contacts and snowball recruitment. Participants were invited via email to an anonymous online survey. Results we contacted 78 physicians who practice critical care in Africa, and 68% (n=53) completed the survey. Of those, 66% were male, 55% were aged 36-45, 75% were Christian. They were from Kenya (30%), Zambia (28%), Rwanda (25%), Botswana (11%), and other countries (6%). Most (75%) agreed that competent patients can refuse even life-saving care. Only 32% agreed that their hospital had clear policies regarding withdrawing and withholding care, 11% agreed that their country had legal precedent for end-of-life care, and 43% believed that doctors could face legal or financial consequences for allowing patients to die by forgoing treatment. Pain control at the end of life, even if it may hasten death, was supported by 83%. However, 75% felt that clinicians undertreat pain due to fear of hastening death. Conclusion participants strongly supported patient autonomy and end-of-life pain control but expressed concern that inadequate policy and legal frameworks exist to guide care and that pain is undertreated. Humane and actionable end-of-life care frameworks are needed to guide decisions in SSA.
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Affiliation(s)
- Noah Rosenberg
- University of Botswana, Department of Emergency Medicine, Gaborone, Botswana
| | | | - Kago Thuto Mokute
- University of Botswana, Department of Emergency Medicine, Gaborone, Botswana
| | - George Otieno
- African Inland Church Kijabe Hospital, Kijabe, Kenya
| | - Kyle Hui
- University of Hong Kong, Hong Kong, China
- Harvard Medical School, Boston, Massachussets, United States of America
| | - Elisabeth Riviello
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachussets, United States of America
| | - Olivier Felix Umuhire
- Division of Clinical Services Northern Ontario School of Medicine University, Ontario, Canada
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Serrano-Pejenaute I, Carmona-Nunez A, Zorrilla-Sarriegui A, Martin-Irazabal G, Lopez-Bayon J, Sanchez-Echaniz J, Astigarraga I. How do hospitalised children die? The context of death and end-of-life decision-making. J Paediatr Child Health 2023; 59:625-630. [PMID: 36752181 DOI: 10.1111/jpc.16354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/11/2023] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
AIM The decrease in childhood mortality, the growing clinical complexity and the greater technification of intensive care units have changed the circumstances of death of paediatric patients. The aim of this study is to describe the context of death and end-of-life decision-making. METHODS Single-centre, retrospective, observational study of deaths in inpatients or home hospitalised children under 18 years old between 2011 and 2021. Demographic data, pathological history and circumstances of death were obtained from the medical record. The whole study period was divided into two halves for the analysis of the temporal trends. RESULTS A total of 358 patients died, 63.2% under the age of 1 year old; 86.9% had underlying life-limiting illnesses and 73.2% died in the intensive care unit, with no differences between the two time periods. Death at home was significantly higher in the second study period (3.8% vs. 9%). A total of 20.1% died during advanced cardiopulmonary resuscitation. Life-sustaining treatment was withheld or withdrawn in 53.6%, with no differences between the time courses. Life-sustaining treatment was withheld mainly in patients with neurological, metabolic and oncological conditions, and less frequently in patients with cardiovascular or respiratory diseases or who were previously healthy. Most patients coded as palliative care (PC) or followed up by PC teams had an advance care plan (ACP) recorded, while in the others it was infrequent. PC coding, following by PC teams and ACP recording increased in the last years of the study. CONCLUSIONS Death of children in our setting usually occurs in relation to complex underlying pathology and after the decision of withdrawing or withholding life-sustaining treatment. In this context, PC and ACP acquire greater importance. In our study, PC involvement resulted in better documentation of ACP and PC coding.
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Affiliation(s)
- Idoya Serrano-Pejenaute
- Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain.,Doctoral Programme in Medicine and Surgery, University of the Basque Country, Leioa, Bizkaia, Spain
| | | | | | | | - Julio Lopez-Bayon
- Pediatric Palliative Care and Home Hospitalisation, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Jesus Sanchez-Echaniz
- Pediatric Palliative Care and Home Hospitalisation, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Itziar Astigarraga
- Department of Pediatrics, Faculty of Medicine, University of the Basque Country, Leioa, Bizkaia, Spain.,Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain.,Pediatric Hematology and Oncology, Department of Pediatrics, Cruces University Hospital, Barakaldo, Bizkaia, Spain
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Batten JN, Blythe JA, Wieten SE, Dzeng E, Kruse KE, Cotler MP, Porter-Williamson K, Kayser JB, Harman SM, Magnus D. "No Escalation of Treatment" Designations: A Multi-institutional Exploratory Qualitative Study. Chest 2023; 163:192-201. [PMID: 36007596 PMCID: PMC9993335 DOI: 10.1016/j.chest.2022.08.2211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND No Escalation of Treatment (NoET) designations are used in ICUs internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied. RESEARCH QUESTION How do physicians understand and perceive NoET designations, especially regarding their usefulness and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations? STUDY DESIGN AND METHODS Qualitative study at seven US hospitals, employing semistructured interviews with 30 physicians and review of relevant institutional records (eg, hospital policies, screenshots of ordering menus in the electronic health record). RESULTS At all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (eg, a DNR/Do Not Escalate code status order); at the remaining hospitals, a variety of informal methods (eg, verbal hand-offs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) helping physicians navigate prearrest clinical decompensations, (3) helping surrogate decision-makers transition toward comfort care, (4) preventing patient harm from invasive measures, and (5) conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations. INTERPRETATION Despite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.
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Affiliation(s)
- Jason N Batten
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA.
| | - Jacob A Blythe
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Sarah E Wieten
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Philosophy, Durham University, Durham, England
| | - Elizabeth Dzeng
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Katherine E Kruse
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Critical Care, Children's Minnesota, Minneapolis, MN
| | - Miriam P Cotler
- Department of Health Sciences, California State University Northridge, Northridge, CA
| | | | - Joshua B Kayser
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA
| | | | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA
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Muishout G, Topcu N, de la Croix A, Wiegers G, van Laarhoven HW. Turkish imams and their role in decision-making in palliative care: A Directed Content and Narrative analysis. Palliat Med 2022; 36:1006-1017. [PMID: 35848214 PMCID: PMC9174576 DOI: 10.1177/02692163221095200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Muslims are the largest religious minority in Europe. When confronted with life-threatening illness, they turn to their local imams for religious guidance. AIM To gain knowledge about how imams shape their roles in decision-making in palliative care. DESIGN Direct Content Analysis through a typology of imam roles. To explore motives, this was complemented by Narrative Analysis. SETTING/PARTICIPANTS Ten Turkish imams working in the Netherlands, with experience in guiding congregants in palliative care. RESULTS The roles of Jurist, Exegete, Missionary, Advisor and Ritual Guide were identified. Three narratives emerged: Hope can work miracles, Responsibility needs to be shared, and Mask your grief. Participants urged patients not to consent to withholding or terminating treatment but to search for a cure, since this might be rewarded with miraculous healing. When giving consent seemed unavoidable, the fear of being held responsible by God for wrongful death was often managed by requesting fatwa from committees of religious experts. Relatives were urged to hide their grief from dying patients so they would not lose hope in God. CONCLUSION Imams urge patients' relatives to show faith in God by seeking maximum treatment. This attitude is motivated by the fear that all Muslims involved will be held accountable by God for questioning His omnipotence to heal. Therefore, doctors may be urged to offer treatment that contradicts medical standards for good palliative care. To bridge this gap, tailor-made palliative care should be developed in collaboration with imams. Future research might include imams of other Muslim organizations.
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Affiliation(s)
- George Muishout
- Department of History, European Studies and Religious Studies, Amsterdam School for Historical Studies, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Anne de la Croix
- Research in Education, Amsterdam UMC, Faculty of Medicine, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerard Wiegers
- Department of History, European Studies and Religious Studies, Amsterdam School for Historical Studies, University of Amsterdam, Amsterdam, The Netherlands
| | - Hanneke Wm van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Chatziioannidis I, Pouliakis A, Cuttini M, Boutsikou T, Giougi E, Volaki V, Sokou R, Xanthos T, Iliodromiti Z, Iacovidou N. Nurses' involvement in end-of-life decisions in neonatal intensive care units. Nurs Ethics 2022; 29:569-581. [PMID: 35142573 DOI: 10.1177/09697330211035505] [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: 10/19/2022]
Abstract
BACKGROUND End-of-life decision-making for terminally ill neonates raises important legal and ethical issues. In Greece, no recent data on nurses' attitudes and involvement in end-of-life decisions are available. RESEARCH QUESTION/AIM To investigate neonatal nurses' attitudes and involvement in end-of-life decisions and the relation to their socio-demographic and work-related background data. RESEARCH DESIGN A survey was carried out in 28 neonatal intensive care units between September 2018 and January 2019. A structured questionnaire was distributed by post. PARTICIPANTS AND RESEARCH CONTEXT The questionnaire was answered anonymously by 312 nurses (response rate, 71.1%) and returned to the investigators. ETHICAL CONSIDERATIONS The study was approved by the Bioethics and Research Committee of Aretaieio Hospital in accordance with the Helsinki Declaration. FINDINGS Nurses more often reported involvement in various end-of-life decisions, such as continuation of treatment without adding further therapeutic interventions for terminally ill neonates, while less reported were mechanical ventilation withdrawal and drug administration to end life. Nurses with a high attitude score, reflecting a more quality-of-life approach, were more likely to be involved in setting limits to intensive care. α low score was consistent with life preservation. Nurses' religiousness (p = 0.097), parenthood (p = 0.093), involvement in daily practice (p = 0.03), and position on the existing legal framework (p < 0.002) influenced their attitude score. DISCUSSION The likelihood of nurses to support interventions in neonates with poor prognosis in neonatal intensive care units was related to their attitudes. After adjusting for potential confounders, the most important predictors for nurses' attitudes were parenthood, involvement in daily practice, and position supporting current legislation reform. CONCLUSION Variability in involvement in end-of-life decisions among nurses exists on a national level.
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Blythe JA, Kentish-Barnes N, Debue AS, Dohan D, Azoulay E, Covinsky K, Matthews T, Curtis JR, Dzeng E. An Interprofessional Process for the Limitation of Life-Sustaining Treatments at the End of Life in France. J Pain Symptom Manage 2022; 63:160-170. [PMID: 34157398 DOI: 10.1016/j.jpainsymman.2021.06.016] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT The provision of potentially non-beneficial life-sustaining treatments (LSTs) remains a challenging problem. In 2005, legislation in France established an interprofessional process by which non-beneficial LSTs could be withheld or withdrawn, permitting exploration of the effects of such a legally-protected process and its implementation. OBJECTIVES To characterize intensive care unit (ICU) interprofessional team decision-making and consensus-building practices regarding withholding and withdrawing of LSTs in two Parisian hospitals and to explore physician and nurse perceptions of and experiences with these practices. METHODS This was an exploratory qualitative study utilizing thematic analysis of semi-structured, in-depth interviews of physicians and nurses purposively sampled based on level of training and experience from two hospitals in Paris, France. RESULTS A total of 25 participants were interviewed. Participants reported that the two Parisian hospitals in this study have each created an interprofessional process for withholding or withdrawing non-beneficial LSTs, providing insight into how norms of decision-making respond to systems-level legal changes. Participants reported that these processes tended to be consistent across several domains: maintaining unified messaging with patients, empowering nurses to participate in end-of-life decision-making, reducing moral distress provoked by end-of-life decisions, and shaping the ethical milieu within which end-of-life decision-making takes place. CONCLUSIONS The architecture of the interprofessional process created at two Parisian hospitals and its perceived benefits may be useful to clinicians and policy-makers attempting to establish processes, policies, or legislation directed at withholding or withdrawing potentially non-beneficial LSTs in the United States and elsewhere.
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Affiliation(s)
- Jacob A Blythe
- Stanford University School of Medicine (J.A.B.), Stanford, California, USA
| | - Nancy Kentish-Barnes
- Assistance Publique Hôpitaux de Paris (APHP) (N.K.-B.), Hôpital Saint Louis, Famiréa Research Group, Paris, France
| | - Anne-Sophie Debue
- Assistance Publique Hôpitaux de Paris (APHP) (A.-S.D.), Hôpitaux Universitaires Paris Centre (HUPC), Hôpital Cochin, Medical Intensive Care Unit, Paris, France; UVSQ, INSERM, Équipe Recherches en éthique et épistémologie (A.-S.D.), CESP, Université Paris-Saclay, Paris, France
| | - Daniel Dohan
- Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA
| | - Elie Azoulay
- Médecine Intensive et Réanimation (E.A.), Hôpital Saint-Louis, APHP, Paris, France; Université de Paris (E.A), Paris, France
| | - Ken Covinsky
- University of California (K.C.), San Francisco, California, USA
| | - Thea Matthews
- Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA
| | - J Randall Curtis
- Division of Pulmonary (R.C.), Department of Medicine, Division of Geriatrics, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.C.), University of Washington, Seattle, Washington, USA
| | - Elizabeth Dzeng
- Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA; Division of Hospital Medicine (E.D.), Department of Medicine, University of California, San Francisco, California, USA.
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Stoevelaar R, Stoppelenburg A, van Bruchem-Visser RL, van Driel AG, Theuns DA, Lokker ME, Bhagwandien RE, Heide AVD, Rietjens JA. Advance care planning and end-of-life care in patients with an implantable cardioverter defibrillator: The perspective of relatives. Palliat Med 2021; 35:904-915. [PMID: 33845683 PMCID: PMC8114448 DOI: 10.1177/02692163211001288] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Little is known about the last phase of life of patients with implantable cardioverter defibrillators and the practice of advance care planning in this population. AIM To describe the last phase of life and advance care planning process of patients with an implantable cardioverter defibrillator, and to assess relatives' satisfaction with treatment and care. DESIGN Mixed-methods study, including a survey and focus group study. SETTING/PARTICIPANTS A survey among 170 relatives (response rate 59%) reporting about 154 deceased patients, and 5 subsequent focus groups with 23 relatives. RESULTS Relatives reported that 38% of patients had a conversation with a healthcare professional about implantable cardioverter defibrillator deactivation. Patients' and relatives' lack of knowledge about device functioning and the perceived lack of time of healthcare professionals were frequently mentioned barriers to advance care planning. Twenty-four percent of patients experienced a shock in the last month of life, which were, according to relatives, distressing for 74% of patients and 73% of relatives. Forty-two to sixty-one percent of relatives reported to be satisfied with different aspects of end-of-life care, such as the way in which wishes of the patient were respected. Quality of death was scored higher for patients with a deactivated device than those with an active device (6.74 vs 5.67 on a 10-point scale, p = 0.012). CONCLUSIONS Implantable cardioverter defibrillator deactivation was discussed with a minority of patients. Device shocks were reported to be distressing to patients and relatives. Relatives of patients with a deactivated device reported a higher quality of death compared to relatives of patients with an active device.
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Affiliation(s)
- Rik Stoevelaar
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Arianne Stoppelenburg
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Anne Geert van Driel
- Rotterdam University of Applied Sciences, Rotterdam, The Netherlands.,Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Dominic Amj Theuns
- Department of Cardiology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Martine E Lokker
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rohit E Bhagwandien
- Department of Cardiology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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Zhu Y, Zhu X, Xu L, Deng M. Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study. Front Pediatr 2021; 9:601782. [PMID: 33898354 PMCID: PMC8058173 DOI: 10.3389/fped.2021.601782] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: End-of-life(EOL) care decision-making for infants and children is a painful experience. The study aimed to explore the clinical factors influencing the EOL care to withhold/withdraw life-sustaining treatment (WLST) in Chinese pediatric intensive care unit (PICU). Methods: A 14-year retrospective study (2006-2019) for pediatric patients who died in PICU was conducted. Based on the mode of death, patients were classified into WLST group (death after WLST) and fCPR group (death after full intervention, including cardiopulmonary resuscitation). Intergroup differences in the epidemiological and clinical factors were determined. Results: There were 715 patients enrolled in this study. Of these patients, 442 (61.8%) died after WLST and 273 (38.2%) died after fCPR. Patients with previous hospitalizations or those who had been transferred from other hospitals more frequently chose WLST than fCPR (both P < 0.01), and the mean PICU stay duration was significantly longer in the WLST group (P < 0.05). WLST patients were more frequently complicated with chronic underlying disease, especially tumor (P < 0.01). Sepsis, diarrhea, and cardiac attack (all P < 0.05) were more frequent causes of death in the fCPR group, whereas tumor as a direct cause of death was more frequently seen in the WLST group. Logistic regression analysis demonstrated that previous hospitalization and underlying diseases diagnosed before admission were strongly associated with EOL care with WLST decision (OR: 1.6; P < 0.05 and OR: 1.6; P < 0.01, respectively). Conclusions: Pediatric patients with previous hospitalization and underlying diseases diagnosed before admission were associated with the EOL care to WLST.
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Affiliation(s)
- Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mengyan Deng
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Gkiougki E, Chatziioannidis I, Pouliakis A, Iacovidou N. Periviable birth: A review of ethical considerations. Hippokratia 2021; 25:1-7. [PMID: 35221649 PMCID: PMC8877922] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Advances in perinatology and medical technology have pushed the limits of viability to unprecedented extremes, leading to a growing population of NICU "graduates" with a wide range of health issues. Although survival rates from 22 weeks of gestation onwards have improved over the last 30 years, the incidence of disabilities remains the same. Providing intensive care to a high-risk population with significant mortality and morbidity raises the fundamental conflict between sanctity and quality of life. Potential severe handicap and need for frequent tertiary care inevitably impact the whole family unit and may outweigh the benefit of survival. The aim of this study is to explore and summarize the ethical considerations in neonatal care concerning perivable birth. METHODS Eligible studies published on PubMed were included after a systematic search using the PICO methodology. RESULTS Forty-eight studies were systematically reviewed regarding guidelines, withholding or withdrawing treatment, parental involvement, and principles applied in marginal viability. As periviable birth raises an array of complex ethical and legal concerns, strict guidelines are challenging to implement. CONCLUSIONS Active life-sustaining interventions in neonatology should be balanced against the risk of putting infants through painful and futile procedures and survival with severe sequelae. More evidence is needed on better prediction of long-term outcomes in situations of imminent preterm delivery, while good collaboration between the therapeutic team and the parents for life-and-death decision-making is of utmost importance. HIPPOKRATIA 2021, 25 (1):1-7.
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Affiliation(s)
- E Gkiougki
- Pediatric and Neonatal Department, Centre Hospitalier Reine Astrid, Malmedy, Belgium
| | - I Chatziioannidis
- 2 Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki
| | - A Pouliakis
- 2 Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, University General Hospital "Attikon"
| | - N Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital Athens, Greece
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Sathianathen NJ, Oestreich MC, Brown SJ, Gupta S, Konety BR, Dahm P, Kunath F. Abiraterone acetate in combination with androgen deprivation therapy compared to androgen deprivation therapy only for metastatic hormone-sensitive prostate cancer. Cochrane Database Syst Rev 2020; 12:CD013245. [PMID: 33314020 PMCID: PMC8092456 DOI: 10.1002/14651858.cd013245.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Systemic androgen deprivation therapy (ADT), also referred to as hormone therapy,ÃÂ has long been the primary treatment for metastatic prostate cancer. Additional agents have been reserved for the castrate-resistant disease stage when ADT start becoming less effective. Abiraterone is an agent with an established role in that disease stage, which has only recently been evaluated in the hormone-sensitive setting. OBJECTIVES To assess the effects of early abiraterone acetate, in combination with systemic ADT, for newly diagnosed metastatic hormone-sensitive prostate cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, six other databases, two trials registries, grey literature, and conference proceedings, up to 15 May 2020. We applied no restrictions on publication language or status. SELECTION CRITERIA We included randomized trials, in which men diagnosed with hormone-sensitive prostate cancer were administered abiraterone acetate and prednisolone with ADT or ADTÃÂ alone. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model. We rated the quality of evidence according to the GRADE approach. MAIN RESULTS The search identified two randomized controlled trials (RCT), with 2201 men, who were assigned to receive either abiraterone acetate 1000 mg once daily and low dose prednisone (5mg) in addition to ADT, or ADT alone. In the LATITUDE trial, the median age and range of men in the intervention group was 68 (38 to 89) years, and 67 (33 to 92) years in the control group. Nearly all of the men in thisÃÂ study (97.6%) had prostate cancer with a Gleason score of at least 8 (ISUP grade group 4). Primary outcomes The addition of abiraterone acetate to ADT reduces the probability of death from any cause compared to ADT alone (hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.56 to 0.73; 2 RCTs, 2201 men; high certainty of evidence); this corresponds to 163 fewer deaths per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (210 fewer to 115 fewer) at five years. Abiraterone acetate in addition to ADT probably results in little to no differenceÃÂ in quality of life compared to ADT alone, measured with the Functional Assessment of Cancer Therapy-prostate total score (FACT-P; range 0 to 156; higher values indicates better quality of life),ÃÂ at 12 months (mean difference [MD] 2.90 points, 95% CI 0.11 to 5.60; 1 RCT, 838 men; moderate certainty of evidence). Secondary outcomes Abiraterone plus ADT increases the risk of grades III to V adverse events compared to ADT alone (risk ratio [RR] 1.34, 95% CI 1.22 to 1.47; 1 RCT, 1199 men; high certainty of evidence); this corresponds to 162 more grade III to VÃÂ events per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (105 more to 224 more) at a median follow-up of 30ÃÂ months. Abiraterone acetate in addition to ADT probably reduces the probability of death due to prostate cancer compared to ADT alone (HR 0.58, 95% CI 0.50 to 0.68; 2 RCTs, 2201 men; moderate certainty of evidence). This corresponds to 120 fewer death from prostate cancer per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (95% CI 145 fewer to 90 fewer) afterÃÂ a median follow-up of 30 months. The addition of abiraterone acetate to ADT probably decreases the probability of disease progression compared to ADT alone (HR 0.35, 95%CI 0.26 to 0.49; 2 RCTs, 2097 men; moderate certainty of evidence). This corresponds to 369 fewer incidences of disease progression per 1000 men with hormone-sensitive metastaticÃÂ prostate cancerÃÂ (456 fewer to 256 fewer)ÃÂ after a median follow-up of 30 months. The addition of abiraterone acetate to ADT probably increases the risk of discontinuing treatment due to adverse events compared to ADT alone (RR 1.50, 95% CI 1.17 to 1.92; 1 RCT, 1199 men; moderate certainty of evidence). This corresponds to 51 more men (95% CI 17 more to 93 more) discontinuing treatment because of adverse events per 1000 men treated with abiraterone acetate and ADT compared to ADT alone afterÃÂ a median follow-up of 30 months. AUTHORS' CONCLUSIONS The addition of abiraterone acetate to androgen deprivation therapy improves overall survival but probably not quality of life. ItÃÂ probably also extends disease-specific survival, and delays disease progression compared to androgen deprivation therapy alone. However, the risk of grades III to V adverse events is increased, and probably, so is the risk of discontinuing treatment due to adverse events.
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Affiliation(s)
| | - Makinna C Oestreich
- University of Minnesota Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah Jane Brown
- Health Sciences Libraries, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shilpa Gupta
- Department of Medicine, Division of Hematology, Oncology and Transplatation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Badrinath R Konety
- Department of Urology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Frank Kunath
- Department of Urology, University Hospital Erlangen, Erlangen, Germany
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Lee SI, Hong KS, Park J, Lee YJ. Decision-making regarding withdrawal of life-sustaining treatment and the role of intensivists in the intensive care unit: a single-center study. Acute Crit Care 2020; 35:179-188. [PMID: 32772037 PMCID: PMC7483019 DOI: 10.4266/acc.2020.00136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/29/2020] [Indexed: 11/30/2022] Open
Abstract
Background This study examined the experience of withholding or withdrawing life-sustaining treatment in patients hospitalized in the intensive care units (ICUs) of a tertiary care center. It also considers the role that intensivists play in the decision-making process regarding the withdrawal of life-sustaining treatment. Methods We retrospectively analyzed the medical records of 227 patients who decided to withhold or withdraw life-sustaining treatment while hospitalized at Ewha Womans University Medical Center Mokdong between April 9 and December 31, 2018. Results The 227 hospitalized patients included in the analysis withheld or withdrew from life-sustaining treatment. The department in which life-sustaining treatment was withheld or withdrawn most frequently was hemato-oncology (26.4%). Among these patients, the most common diagnosis was gastrointestinal tract cancer (29.1%). A majority of patients (64.3%) chose not to receive any life-sustaining treatment. Of the 80 patients in the ICU, intensivists participated in the decision to withhold or withdraw life-sustaining treatment in 34 cases. There were higher proportions of treatment withdrawal and ICU-to-ward transfers among the cases in whom intensivists participated in decision making compared to those cases in whom intensivists did not participate (50.0% vs. 4.3% and 52.9% vs. 19.6%, respectively). Conclusions Through their participation in end-of-life discussions, intensivists can help patients’ families to make decisions about withholding or withdrawing life-sustaining treatment and possibly avoiding futile treatments for these patients.
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Affiliation(s)
- Seo In Lee
- Department of Critical Care Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Kyung Sook Hong
- Department of Surgery and Critical Care Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jin Park
- Department of Neurology and Critical Care Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Young-Joo Lee
- Department of Anesthesiology and Critical Care Medicine, Ewha Womans University College of Medicine, Seoul, Korea
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Lee JS, Oh JS, Hong S, Kim YG, Lee CK, Yoo B. Six-month flare risk after discontinuing long-term methotrexate treatment in patients having rheumatoid arthritis with low disease activity. Int J Rheum Dis 2020; 23:1076-1081. [PMID: 33021334 DOI: 10.1111/1756-185x.13888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/21/2020] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We investigated the disease flare rate in patients with rheumatoid arthritis (RA) who achieved low disease activity following long-term methotrexate (MTX) treatment and the factors related to flare. METHODS This retrospective longitudinal cohort study included patients with RA and low disease activity who were exposed to MTX for >10 years. Disease flare was defined as an increase in Disease Activity Score of 28 joints (DAS28) of >1.2 within 6 months of discontinuation of MTX. Logistic regression analysis was performed to identify the factors associated with flare. RESULTS In total, 97 patients with RA were included in the study. The mean baseline DAS28 was 1.96 ± 0.56. The median cumulative MTX dose was 11.7 g; the median duration of exposure to MTX was 19 years. Following MTX discontinuation, flare occurred in 43 (44.3%) patients; the median time to flare was 99 (28-168) days. According to univariate logistic regression analysis, C-reactive protein, erythrocyte sedimentation rate (ESR) at discontinuation, the average ESR in the 6 months before discontinuation of MTX, a weekly dose of MTX before discontinuation, and use of other conventional synthetic disease-modifying antirheumatic drugs were associated with a higher risk of disease flare. In multivariable analysis, a weekly dose of MTX before discontinuation (odds ratio 1.014; 95% CI 1.014-1.342; P = .031) was significantly associated with flare risk. CONCLUSION Among patients with RA who achieved low disease activity with long-term treatment with MTX, more than half remained flare free after MTX discontinuation. A higher MTX dose before discontinuation was associated with a high flare risk.
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Affiliation(s)
- Jung Sun Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul Veterans Hospital, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Division of Rheumatology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Rationale: National guidelines have laid out a process to conflict resolution in cases of potentially inappropriate medical interventions. Objectives: To determine the association between information about a process-based approach and lay public perceptions of the appropriateness of withholding medically inappropriate interventions. Methods: Respondents from a nationwide sample completed a survey with two adult intensive care unit-based vignettes: one about advanced cancer where doctors told the family that additional chemotherapy would not be offered, and a second case of multiorgan failure after brain hemorrhage where dialysis would not be offered. Participants were randomly assigned to see or not see information about a detailed process for the determination to withhold (second opinion, ethics consultation, exploring transfer to another institution). The primary outcome was the perceived appropriateness of not providing the treatment (four-point scale, dichotomized for analysis, modified Poisson regression), and the secondary outcome was the negative emotional reaction to the case (positive and negative affect schedule, range 1-5, higher is greater negative emotional response, linear regression). Results: A total of 1,191 respondents were included. Providing detailed process information increased the perceived appropriateness of withholding treatment by approximately 10 percentage points in each vignette: (chemotherapy, 75.7-85.4%; dialysis, 68.0-79.3%). Process information remained associated with perceived appropriateness of withholding treatment after adjustment for order effects and prespecified respondent characteristics (chemotherapy: prevalence ratio, 1.13; 95% confidence interval [CI], 1.07-1.19) (dialysis: prevalence ratio, 1.17; 95% CI, 1.10-1.25). Process information was not associated with emotional response to the cases (chemotherapy: β = -0.04; 95% CI, -0.16 to 0.09) (dialysis: β = -0.02; 95% CI, -0.14 to 0.10; both adjusted for order effects). Conclusions: Providing process-based conflict resolution information increased public acceptance of determinations of medical futility, supporting the practice outlined in national consensus statements.
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Abstract
Description This poem is a reflection upon my personal experience of taking care of a young patient with post-partum sepsis and multi-organ failure following the delivery of her second child. She was able to spend one night at home with her family before suddenly decompensating and becoming encephalopathic. In her last moments awake, she relayed to the EMS her wishes of being placed in hospice. The poem narrates her spouse's internal struggle after respecting the patient's wishes of withdrawal of care.
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Neal JB, Pearlman RA, White DB, Tolchin B, Sheth KN, Bernat JL, Hwang DY. Policies for Mandatory Ethics Consultations at U.S. Academic Teaching Hospitals: A Multisite Survey Study. Crit Care Med 2020; 48:847-853. [PMID: 32317595 PMCID: PMC10765238 DOI: 10.1097/ccm.0000000000004343] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated. DESIGN Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017. SETTING We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included. SUBJECTS The chair/director of each hospital's adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing. CONCLUSIONS Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.
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Affiliation(s)
- Jonathan B Neal
- University of Connecticut School of Medicine, Farmington, CT
| | - Robert A Pearlman
- National Center for Ethics in Health Care, Veterans Health Administration, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Benjamin Tolchin
- Department of Neurology, Yale School of Medicine, New Haven, CT
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - David Y Hwang
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT
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Penders YWH, Bopp M, Zellweger U, Bosshard G. Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study. J Gen Intern Med 2020; 35:126-132. [PMID: 31654360 PMCID: PMC6957664 DOI: 10.1007/s11606-019-05344-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 04/18/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies on forgoing treatment often ignore treatments that are continued until death. OBJECTIVE To investigate how often specific treatments are withdrawn or withheld before death and to describe the associated patient, physician, and care characteristics. DESIGN National mortality follow-back study in Switzerland in 2013/2014 using a standardized survey to collect information on the patient's end of life and demographics on the physician. PARTICIPANTS A random sample of adults who died non-suddenly without an external cause and who had met the physician completing the survey (N = 3051). MAIN MEASURES Any of nine specific treatments was continued until death, withdrawn, or withheld. KEY RESULTS In 2242 cases (84%), at least one treatment was either continued until death or withheld or withdrawn. The most common treatment was artificial hydration, which was continued in 23%, withdrawn in 4%, and withheld in 22% of all cases. The other eight treatments were withdrawn or withheld in 70-94% of applicable cases. The impact of physician characteristics was limited, but artificial hydration, antibiotics, artificial nutrition, and ventilator therapy were more likely to be withheld at home and in nursing homes than in the hospitals. CONCLUSIONS Large differences exist between care settings in whether treatments are continued, withdrawn, or withheld, indicating the different availability of treatment options or different philosophies of care. While certain patient groups are more likely to have treatment withheld rather than attempted, neither patient nor physician characteristics impact the decision to continue or withdraw treatment.
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Affiliation(s)
- Yolanda W H Penders
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Ueli Zellweger
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, and Center on Aging and Mobility, University of Zurich and City Hospital Waid, Zurich, Switzerland
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Trowse P. Voluntary stopping of eating and drinking in advance directives for adults with late-stage dementia. Australas J Ageing 2019; 39:142-147. [PMID: 31742862 DOI: 10.1111/ajag.12737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 09/10/2019] [Accepted: 09/14/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this paper is to explore the ethical and legal validity of advance directives that request the voluntary stopping of eating and drinking against a backdrop of late-stage dementia. METHOD Doctrinal research and analysis of primary and secondary materials including Australian legislation, Australian case law and journal articles was undertaken. RESULTS There is legal uncertainty in Australia around whether an advance directive to voluntarily stop eating and drinking will be followed should the adult become incompetent. CONCLUSION Voluntary stopping of eating and drinking should be viewed in law as a form of "treatment" that competent adults can nominate in advance directives, thereby providing dementia patients with the opportunity to choose in advance, if they wish, to end their life legally, with dignity and comfort, and in a manner that does not implicate others in criminal behaviour such as assisted suicide, acceleration of death or euthanasia.
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Affiliation(s)
- Philippa Trowse
- Queensland University of Technology, Brisbane, Queensland, Australia
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23
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Savulescu J, Cameron J. An Objective Approach to Decisions to Withdraw or Withhold Life-sustaining Medical Treatment. J Law Med 2019; 27:192-210. [PMID: 31682350] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Courts in England and Wales, Australia, and New Zealand have insisted the question of when it is acceptable to withdraw or withhold life-sustaining medical treatment from a child must be considered on a case-by-case basis. Over the last 40 years a number of cases have considered whether treatment is objectively in the child's best interests. This article seeks to identify whether there are factors identified and weighed in a consistent manner across cases. Thirty cases involving decisions about the provision of life-sustaining medical treatment to children three years old or younger were identified. Judges regularly refer to the need to weigh benefits and burdens and these factors were identified and assigned scores. Eight key factors were identified, and a scoring range was assigned to each. The factors focus on the condition and position of the child and the burdens of invasive medical treatment. The review demonstrates there are factors consistently identified and despite criticisms of the indeterminacy of the best interests test, there may be a broadly consistent approach to decision-making. Cognitive capacity and unavoidably imminent death appear to be the two most influential factors in determining whether life-sustaining treatment should be provided.
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Affiliation(s)
- Julian Savulescu
- Uehiro Chair in Practical Ethics; Director, Oxford Uehiro Centre for Practical Ethics; Co-Director, Wellcome Centre for Ethics and Humanities, University of Oxford; Law Faculty, University of Melbourne; Visiting Professorial Fellow, Murdoch Children's Research Institute
| | - James Cameron
- PhD Student, Law Faculty, University of Melbourne, supported by Australian Government Research Training Program Scholarship
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Stoevelaar R, Brinkman-Stoppelenburg A, van Driel AG, van Bruchem-Visser RL, Theuns DA, Bhagwandien RE, Van der Heide A, Rietjens JA. Implantable cardioverter defibrillator deactivation and advance care planning: a focus group study. Heart 2019; 106:190-195. [PMID: 31537636 PMCID: PMC6993024 DOI: 10.1136/heartjnl-2019-315721] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 11/20/2022] Open
Abstract
Objective Implantable cardioverter defibrillators can treat life-threatening arrhythmias, but may negatively influence the last phase of life if not deactivated. Advance care planning conversations can prepare patients for future decision-making about implantable cardioverter defibrillator deactivation. This study aimed at gaining insight in the experiences of patients with advance care planning conversations about implantable cardioverter defibrillator deactivation. Methods In this qualitative study, we held five focus groups with 41 patients in total. Focus groups were audio-recorded and transcribed. Transcripts were analysed thematically, using the constant comparative method, whereby themes emerging from the data are compared with previously emerged themes. Results Most patients could imagine deciding to have their implantable cardioverter defibrillator deactivated, for instance because the benefits of an active device no longer outweigh the harm of unwanted shocks, when having another life-limiting illness, or when relatives would think this would be in their best interest. Some patients expressed a need for advance care planning conversations with a healthcare professional about deactivation, but few had had these. Others did not, saying they solely focused on living. Some patients were hesitant to record their preferences about deactivation in advance care directives, because they were unsure whether their current preferences would reflect future preferences. Conclusions Although patients expressed a need for more information, advance care planning conversations about implantable cardioverter defibrillator deactivation seemed to be uncommon. Deactivation should be more frequently addressed by healthcare professionals, tailored to the disease stage of the patient and readiness to discuss this topic.
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Affiliation(s)
- Rik Stoevelaar
- Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Anne Geert van Driel
- Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands.,Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
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Cabañero-Martínez MJ, Ramos-Pichardo JD, Velasco-Álvarez ML, García-Sanjuán S, Lillo-Crespo M, Cabrero-García J. Availability and perceived usefulness of guidelines and protocols for subcutaneous hydration in palliative care settings. J Clin Nurs 2019; 28:4012-4020. [PMID: 31410903 DOI: 10.1111/jocn.15036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 06/25/2019] [Accepted: 08/04/2019] [Indexed: 01/21/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the availability of, adherence to, and perceived usefulness of guidelines and protocols for managing hydration and subcutaneous hydration in palliative care settings. BACKGROUND Hydration at the end of life and the use of a subcutaneous route to hydrate generate some controversy among health professionals for different reasons. Having guidelines and protocols to assist in decision-making and to follow a standard procedure may be relevant in clinical practice. DESIGN Cross-sectional telephone survey, with closed-ended and open-ended questions designed specifically for this study. METHODS Data were obtained from 327 professionals, each from a different palliative care service. Mean, standard deviation, minimum and maximum were calculated for continuous variables; frequency distributions were obtained for categorical variables. A qualitative content analysis was performed on the open-ended questions. The article adheres to the STROBE guidelines for reporting observational studies. RESULTS Only 24.8% of the participants had guidelines available to assist in making decisions regarding hydration, and 55.6% claimed to follow them 'always or almost always'. Of the participants, 38.8% had subcutaneous hydration protocols available, while 78.7% stated that they 'always or almost always' followed these protocols. The remaining participants considered the protocols as useful tools despite not having them available. CONCLUSIONS Only 25% of the participants' services had guidelines for hydration, and less than 40% had protocols for subcutaneous hydration. However, adherence was high, especially in cases where protocols existed. Among the participants who did not have guidelines and protocols, attitudes were mostly favourable, but mainly as a reference and support for an individualised clinical practice. RELEVANCE TO CLINICAL PRACTICE Guidelines and protocols on hydration in palliative care may be more useful as a solid reference and support for individualised practice than as instruments for standardising care. From this perspective, their development and availability in palliative care services are recommended.
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Xu CY, Song JF, Yao LH, Xu HL, Liu KX. Survival after cardiac arrest secondary to high-risk pulmonary embolism without reperfusion therapies: A case report. Medicine (Baltimore) 2019; 98:e16651. [PMID: 31374038 PMCID: PMC6708977 DOI: 10.1097/md.0000000000016651] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION High-risk pulmonary embolism (PE) needs reperfusion therapies. However, it is difficult to make medical decisions when thrombolysis is contraindicated, though pulmonary embolectomy and percutaneous catheter-directed treatment (CTD) are recommended for these patients. PATIENT CONCERNS We reported here a case of high-risk PE patient with cardiac arrest (CA), vertebral compression fracture, as well as scalp and frontal hematoma. DIAGNOSIS The diagnosis of PE was based on computed tomography pulmonary angiography (CTPA) which demonstrated filling defects in the right and left pulmonary arteries. INTERVENTIONS Cardiopulmonary resuscitation was performed until the patient returned to idioventricular rhythm 3 minutes after admitted. She suffered another half-hour of hemodynamic disturbance after her shock improved 3 days later. The diagnosis of PE was confirmed by CTPA at that time. The patient did not receive any reperfusion therapies because hemoglobin decreased significantly. Moreover, anticoagulation was postponed for 2 weeks when bleeding appeared to be stopped. She received overlapping treatment with low molecular weight heparin and warfarin for 5 days then warfarin alone and discharged. OUTCOMES She was discharged with normal vital signs and neurologically intact. She received anticoagulant therapy with warfarin and international normalized ratio regularly monitored after she was discharged, moreover, the pulmonary artery pressure turned normal, as determined by transthoracic echocardiography 1 month later. The warfarin treatment was discontinued after 12 months and no evidence of recurrence was seen until recently. CONCLUSIONS This is the first case report of PE combined with CA that did not receive reperfusion therapy. We hypothesized that there was a spontaneous resolution in pulmonary emboli.
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Affiliation(s)
| | - Jia-Fu Song
- Department of Respiratory Medicine, The First People's Hospital of Lianyungang City, Lianyungang, Jiangsu
| | - Li-Hong Yao
- State Key Laboratory of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | - Ke-Xi Liu
- Department of Intensive Care Medicine
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Close E, White BP, Willmott L, Gallois C, Parker M, Graves N, Winch S. Doctors' perceptions of how resource limitations relate to futility in end-of-life decision making: a qualitative analysis. J Med Ethics 2019; 45:373-379. [PMID: 31092631 DOI: 10.1136/medethics-2018-105199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility. SETTING Three tertiary hospitals in metropolitan Brisbane, Australia. DESIGN Qualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis. RESULTS Doctors' perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing. CONCLUSIONS Doctors' ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors' role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lindy Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Cindy Gallois
- Faculty of Social and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Malcolm Parker
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sarah Winch
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Stoevelaar R, Brinkman-Stoppelenburg A, van Driel AG, Theuns DA, Bhagwandien RE, van Bruchem-Visser RL, Lokker IE, van der Heide A, Rietjens JA. Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records. Eur J Cardiovasc Nurs 2019; 18:449-457. [PMID: 30995145 PMCID: PMC6661715 DOI: 10.1177/1474515119844660] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The implantable cardioverter defibrillator (ICD) might give unwanted shocks in the last month of life. Guidelines recommend deactivation of the ICD prior to death. AIMS The aims of this study were to examine trends in time (2007-2016) in how and when decisions are made about ICD deactivation, and to examine patient- and disease-related factors which may have influenced these decisions. In addition, care and ICD shock frequency in the last month of life of ICD patients are described. METHODS Medical records of a sample of deceased patients who had their ICD implanted in 1999-2015 in a Dutch university (n = 308) or general (n = 72) hospital were examined. RESULTS Median age at death was 71 years, and 88% were male. ICD deactivation discussions increased from 6% for patients who had died between 2007 and 2009 to 35% for patients who had died between 2013 and 2016. ICD deactivation rates increased in these periods from 16% to 42%. Presence of do-not-resuscitate (DNR) orders increased from 9% to 46%. Palliative care consultations increased from 0% to 9%. When the ICD remained active, shocks were reported for 7% of patients in the last month of life. Predictors of ICD deactivation were the occurrence of ICD deactivation discussions after implantation (OR 69.30, CI 26.45-181.59), DNR order (OR 6.83, CI 4.19-11.12), do-not-intubate order (OR 6.41, CI 3.75-10.96), and palliative care consultations (OR 8.67, CI 2.76-27.21). CONCLUSION ICD deactivation discussions and deactivation rates have increased since 2007. Nevertheless, ICDs remain active in the majority of patients at the end of life, some of whom experience shocks.
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Affiliation(s)
- Rik Stoevelaar
- 1 Department of Public Health, Erasmus University Medical Center Rotterdam, The Netherlands
| | | | - Anne Geert van Driel
- 2 Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands.,3 Rotterdam University of Applied Sciences, The Netherlands
| | - Dominic Amj Theuns
- 4 Department of Cardiology, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Rohit E Bhagwandien
- 4 Department of Cardiology, Erasmus University Medical Center Rotterdam, The Netherlands
| | | | - Ineke E Lokker
- 6 Department of Quality and Patient Care, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Agnes van der Heide
- 1 Department of Public Health, Erasmus University Medical Center Rotterdam, The Netherlands
| | - Judith Ac Rietjens
- 1 Department of Public Health, Erasmus University Medical Center Rotterdam, The Netherlands
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Philpot SJ. Should an Advance Care Directive Refusing Life-Sustaining Treatment Be Respected after an Attempted Suicide? Development of an Algorithm to Aid Health Care Workers. J Law Med 2019; 26:557-570. [PMID: 30958649] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
An advance care directive (ACD) is a written expression of a person's preferences in relation to health care, which can appoint a trusted substitute decision-maker, describe personal values, and make explicit decisions consenting to, or refusing, certain treatments. When a person with a directive refusing life-sustaining treatments attempts suicide, opinions are divided as to the degree to which health care staff are bound by such a directive. In this section, I will provide an example of a patient who presents to hospital after attempting suicide who has a valid ACD refusing life-sustaining treatment. I will then describe the legislation relevant to ACDs in Victoria, Australia and ethical arguments relating to the application of an ACD in this context. I will present a decision-making algorithm for health care staff faced with the difficult decisions arising from such a presentation.
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Affiliation(s)
- Steve John Philpot
- Student, Melbourne Law Masters program; Intensive Care Specialist, Cabrini Hospital, Malvern, Victoria; Senior Adjunct Lecturer, Monash University, Victoria; National Lead Trainer, Organ and Tissue Authority, Canberra, Australian Capital Territory
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Abstract
Goals-of-care discussions aim to establish patient values for shared medical decision-making. These discussions are relevant towards end-of-life as patients may receive non-beneficial treatments if they have never discussed preferences for care. End-of-life care is provided in Emergency Departments (EDs) but little is known regarding ED-led goals-of-care discussions. We aimed to explore practitioner perspectives on goals-of-care discussions for adult ED patients nearing end-of-life. We report the qualitative component of a mixed methods study regarding a 'Goals-of-Care' form in an Australian ED. Eighteen out of 34 doctors who completed the form were interviewed. We characterised ED-led goals-of-care consultations for the first time. Emergency doctors perceive goals-of-care discussions to be relevant to their practice and occurring frequently. They aim to ensure appropriate care is provided prior to review by the admitting team, focusing on limitations of treatment and clarity in the care process. ED doctors felt they could recognise end-of-life and that ED visits often prompt consideration of end-of-life care planning. They wanted long-term practitioners to initiate discussions prior to patient deterioration. There were numerous interpretations of palliative care concepts. Standardisation of language, education, collaboration and further research is required to ensure Emergency practitioners are equipped to facilitate these challenging conversations.
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Affiliation(s)
- Michele Levinson
- a Department of Medicine , Monash University , Melbourne , Australia
| | - Katherine J Walker
- b Emergency Department , Cabrini , Melbourne , Australia.,c Department of Epidemiology and Preventive Medicine , Monash University , Melbourne , Australia
| | - Jennifer Hanning
- b Emergency Department , Cabrini , Melbourne , Australia.,d Melbourne Medical School , University of Melbourne , Melbourne , Australia
| | - William Dunlop
- b Emergency Department , Cabrini , Melbourne , Australia
| | - Edward Cheong
- b Emergency Department , Cabrini , Melbourne , Australia
| | - Amber Mills
- a Department of Medicine , Monash University , Melbourne , Australia.,e Bolton Clarke
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Romano' M. The Role of Palliative Care in the Cardiac Intensive Care Unit. Healthcare (Basel) 2019; 7:E30. [PMID: 30791385 DOI: 10.3390/healthcare7010030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 12/22/2022] Open
Abstract
In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.
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Ziegler S, Schmid M, Bopp M, Bosshard G, Puhan MA. Continuous Deep Sedation Until Death-a Swiss Death Certificate Study. J Gen Intern Med 2018; 33:1052-1059. [PMID: 29560568 PMCID: PMC6025678 DOI: 10.1007/s11606-018-4401-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/14/2017] [Accepted: 03/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the last decade, the number of patients continuously deeply sedated until death increased up to fourfold. The reasons for this increase remain unclear. OBJECTIVE To identify socio-demographic and clinical characteristics of sedated patients, and concurrent possibly life-shortening medical end-of-life decisions. DESIGN Cross-sectional death certificate study in German-speaking Switzerland in 2001 and 2013. PARTICIPANTS Non-sudden and expected deaths (2001: N = 2281, 2013: N = 2256) based on a random sample of death certificates and followed by an anonymous survey on end-of-life practices among attending physicians. MAIN MEASURES Physicians' reported proportion of patients continuously deeply sedated until death, socio-demographic and clinical characteristics, and possibly life-shortening medical end-of life decisions. KEY RESULTS In 2013, physicians sedated four times more patients continuously until death (6.7% in 2001; 24.5.5% in 2013). Four out of five sedated patients died in hospitals, outside specialized palliative care units, or in nursing homes. Sedation was more likely among patients younger than 65 (odds ratio 2.24, 95% CI 1.6 to 3.2) and those dying in specialized palliative care (OR 2.2, 95% CI 1.3 to 3.8) or in hospitals (1.7, 95% CI 1.3 to 2.3). Forgoing life-prolonging treatment with the explicit intention to hasten or not to postpone death combined with intensified alleviation of symptoms was very strongly associated with continuous deep sedation (OR 6.8, 95% CI 4.7 to 9.8). CONCLUSIONS In Swiss clinical practice, continuously deeply sedated patients predominantly died outside specialized palliative care. The increasing trend over time appears to be related to changes in medical end-of-life practice rather than to patient's clinical characteristics.
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Affiliation(s)
- Sarah Ziegler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Margareta Schmid
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, Zurich, Switzerland
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
- City Hospital Waid, Zurich, Switzerland
| | - Milo Alan Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Scherrens AL, Beernaert K, Robijn L, Deliens L, Pauwels NS, Cohen J, Deforche B. The use of behavioural theories in end-of-life care research: A systematic review. Palliat Med 2018; 32:1055-1077. [PMID: 29569998 DOI: 10.1177/0269216318758212] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: It is necessary to understand behaviours that contribute to improvement in the quality of end-of-life care; use of behavioural theories allows identification of factors underlying end-of-life care behaviour, but little is known about the extent to which, and in what manner, these theories are used in an end-of-life care research context. Aim: To assess the number of end-of-life care studies that have used behavioural theories, which theories were used, to what extent main constructs were explored/measured and which behavioural outcomes were examined. Design: We conducted a systematic review. The protocol was registered on PROSPERO (CRD42016036009). Data sources: The MEDLINE (PubMed), PsycINFO, EMBASE, Web of Science and CINAHL databases were searched from inception to June 2017. We included studies aimed at understanding or changing end-of-life care behaviours and that explicitly referred to individual behavioural theories. Results: We screened 2231 records by title and abstract, retrieved 43 full-text articles and included 31 studies – 27 quantitative (of which four (quasi-)randomised controlled trials) and four qualitative – for data extraction. More than half used the Theory of Planned Behaviour (9), the Theory of Reasoned Action (4) or the Transtheoretical Model (8). In 9 of 31 studies, the theory was fully used, and 16 of the 31 studies focussed on behaviours in advance care planning. Conclusion: In end-of-life care research, the use of behavioural theories is limited. As many behaviours can determine the quality of care, their more extensive use may be warranted if we want to better understand and influence behaviours and improve end-of-life care.
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Affiliation(s)
- Anne-Lore Scherrens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,2 Health Education and Promotion Research Group, Department of Public Health, Ghent University, Ghent, Belgium
| | - Kim Beernaert
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,3 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Lenzo Robijn
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,3 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Luc Deliens
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium.,3 Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Nele S Pauwels
- 4 Knowledge Centre for Health Ghent, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- 1 End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Ghent, Belgium
| | - Benedicte Deforche
- 2 Health Education and Promotion Research Group, Department of Public Health, Ghent University, Ghent, Belgium
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Maamar A, Chevalier S, Fillâtre P, Botoc V, Le Tulzo Y, Gacouin A, Tadié JM. COPD is independently associated with 6-month survival in patients who have life support withheld in intensive care. Clin Respir J 2018; 12:2249-2256. [PMID: 29660241 DOI: 10.1111/crj.12899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 12/22/2017] [Accepted: 04/04/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND In-hospital outcomes following decisions of withholding or withdrawing in Intensive Care Unit (ICU) patients have been previously assessed, little is known about outcomes after ICU and hospital discharge. Our objective was to report the 6-month outcomes of discharged patients who had treatment limitations in a general ICU and to identify prognostic factors of survival. METHODS We retrospectively collected the data of patients discharged from the ICU for whom life support was withheld from 2009 to 2011. We assessed the survival status of all patients at 6 months post-discharge and their duration of survival. Survivors and non-survivors were compared using univariate and multivariate analyses by Cox's proportional hazard model. RESULTS One hundred fourteen patients were included. The survival rate at 6 months was 58.8%. Survival was associated with acute respiratory failure (48% vs 19%, P = .006), a history of COPD (40% vs 21%, P = .03) and a lower SAPS II score (44 vs 49, P = .006). We identified a history of COPD as a prognostic factor for survival in the multivariate analysis (HR = 2.1; IC 95% 1.02-4.36, P = .04). CONCLUSION A total of 58.8% of patients for whom life-sustaining therapies were withheld in the ICU survived for at least 6 months after discharge. Patients with COPD appeared to have a significantly higher survival rate. The decision to withhold life support in patients should not lead to a cessation of post-ICU care and to non-readmission of COPD patients.
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Affiliation(s)
- Adel Maamar
- Medical intensive care unit, Hôpital Pontchaillou, CHU de Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Stéphanie Chevalier
- Intensive Care Unit, Centre Hospitalier de Saint-Malo, 1 Rue de la Marne, 35400 Saint-Malo, France
| | - Pierre Fillâtre
- Medical intensive care unit, Hôpital Pontchaillou, CHU de Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Rennes, France
| | - Vlad Botoc
- Intensive Care Unit, Centre Hospitalier de Saint-Malo, 1 Rue de la Marne, 35400 Saint-Malo, France
| | - Yves Le Tulzo
- Medical intensive care unit, Hôpital Pontchaillou, CHU de Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Rennes, France.,Faculté de Médecine, Université de Rennes 1, Unité INSERM CIC 1414, IFR 140, Rennes, France
| | - Arnaud Gacouin
- Medical intensive care unit, Hôpital Pontchaillou, CHU de Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Rennes, France.,Faculté de Médecine, Université de Rennes 1, Unité INSERM CIC 1414, IFR 140, Rennes, France
| | - Jean-Marc Tadié
- Medical intensive care unit, Hôpital Pontchaillou, CHU de Rennes, 2 rue Henri Le Guilloux, 35033 Rennes Cedex 9, France.,Faculté de Médecine, Université de Rennes 1, Rennes, France.,Faculté de Médecine, Université de Rennes 1, Unité INSERM CIC 1414, IFR 140, Rennes, France
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Mills AC, Levinson M, Dunlop WA, Cheong E, Cowan T, Hanning J, O'Callaghan E, Walker KJ. Testing a new form to document 'Goals-of-Care' discussions regarding plans for end-of-life care for patients in an Australian emergency department. Emerg Med Australas 2018; 30:777-784. [PMID: 29663697 DOI: 10.1111/1742-6723.12986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 02/14/2018] [Accepted: 03/06/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE There is limited literature to inform the content and format of Goals-of-Care forms, for use by doctors when they are undertaking these important conversations. METHODS This was a prospective, qualitative and quantitative study evaluating the utility of a new 'Goals-of-Care' form to doctors in a private, tertiary ED, used from December 2016 to February 2017 at Cabrini, Melbourne. A Goals-of-Care form was designed, incorporating medical aims of therapy and patient values and preferences. Doctors wishing to complete a Not-for-CPR form were also supplied with the trial Goals-of-Care form. Form use, content and patient progress were followed. Doctors completing a form were invited to interview. RESULTS Forms were used in 3% of attendances, 120 forms were taken for use and 108 were analysed. The median patient age was 91, 81% were Supportive and Palliative Care Indicators Tool (SPICT) positive and patients had a 48% 6-month mortality. A total of 34 doctors completed the forms, 16 were interviewed (two ED trainees, 11 senior ED doctors and three others). Theme saturation was only achieved for the senior doctors interviewed. Having a Goals-of-Care form was valued by 88% of doctors. The frequency of section use was: Aims-of-Care 91%; Quality-of-Life 75% (the term was polarising); Functional Impairments 35%; and Outcomes of Value 29%. Opinions regarding the ideal content and format varied. Some doctors liked free-text space and others tick-boxes. The median duration of the conversation and documentation was 10 min (interquartile range 6-20 min). CONCLUSIONS Having a Goals-of-Care form in emergency medicine is supported; the ideal contents of the form was not determined.
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Affiliation(s)
- Amber C Mills
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michele Levinson
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - William A Dunlop
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Edward Cheong
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Timothy Cowan
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Jennifer Hanning
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Erin O'Callaghan
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Katherine J Walker
- Emergency Department, Cabrini Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Abstract
Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.
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Affiliation(s)
- Olivier Lesieur
- Intensive Care Unit, Saint Louis Hospital, La Rochelle, France
| | - Liliane Genteuil
- Organ Procurement Organization, Bicêtre Hospital, Le Kremlin Bicêtre, France
| | - Maxime Leloup
- Intensive Care Unit, Saint Louis Hospital, La Rochelle, France
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Suzuki F, Takeuchi M, Tachibana K, Isaka K, Inata Y, Kinouchi K. Life-Sustaining Treatment Status at the Time of Death in a Japanese Pediatric Intensive Care Unit. Am J Hosp Palliat Care 2017; 35:767-771. [PMID: 29179574 DOI: 10.1177/1049909117743474] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU. METHODS We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group). RESULTS Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group. CONCLUSIONS Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.
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Affiliation(s)
- Fumiko Suzuki
- 1 Department of Anesthesiology and Palliative Care, Nissay Hospital, Osaka, Japan
| | - Muneyuki Takeuchi
- 2 Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazuya Tachibana
- 3 Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kanako Isaka
- 2 Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yu Inata
- 2 Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keiko Kinouchi
- 3 Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
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Abstract
BACKGROUND Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic and potentially life threatening condition resulting from excessive ovarian stimulation. Reported incidence of moderate to severe OHSS ranges from 0.6% to 5% of in vitro fertilization (IVF) cycles. The factors contributing to OHSS have not been completely explained. The release of vasoactive substances secreted by the ovaries under human chorionic gonadotrophin (hCG) stimulation may play a key role in triggering this syndrome. This condition is characterised by a massive shift of fluid from the intravascular compartment to the third space, resulting in profound intravascular depletion and haemoconcentration. OBJECTIVES To assess the effect of withholding gonadotrophins (coasting) on the prevention of ovarian hyperstimulation syndrome in assisted reproduction cycles. SEARCH METHODS For the update of this review, we searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE (PubMed), CINHAL, PsycINFO, Embase, Google, and clinicaltrials.gov to 6 July 2016. SELECTION CRITERIA We included only randomized controlled trials (RCTs) in which coasting was used to prevent OHSS. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials and extracted data. They resolved disagreements by discussion. They contacted study authors to request additional information or missing data. The intervention comparisons were coasting versus no coasting, coasting versus early unilateral follicular aspiration (EUFA), coasting versus gonadotrophin releasing hormone antagonist (antagonist), coasting versus follicle stimulating hormone administration at the time of hCG trigger (FSH co-trigger), and coasting versus cabergoline. We performed statistical analysis in accordance with Cochrane guidelines. Our primary outcomes were moderate or severe OHSS and live birth. MAIN RESULTS We included eight RCTs (702 women at high risk of developing OHSS). The quality of evidence was low or very low. The main limitations were failure to report live birth, risk of bias due to lack of information about study methods, and imprecision due to low event rates and lack of data. Four of the studies were published only as abstracts, and provided limited data. Coasting versus no coastingRates of OHSS were lower in the coasting group (OR 0.11, 95% CI 0.05 to 0.24; I² = 0%, two RCTs; 207 women; low-quality evidence), suggesting that if 45% of women developed moderate or severe OHSS without coasting, between 4% and 17% of women would develop it with coasting. There were too few data to determine whether there was a difference between the groups in rates of live birth (OR 0.48, 95% CI 0.14 to 1.62; one RCT; 68 women; very low-quality evidence), clinical pregnancy (OR 0.82, 95% CI 0.46 to 1.44; I² = 0%; two RCTs; 207 women; low-quality evidence), multiple pregnancy (OR 0.31, 95% CI 0.12 to 0.81; one RCT; 139 women; low-quality evidence), or miscarriage (OR 0.85, 95% CI 0.25 to 2.86; I² = 0%; two RCTs; 207 women; very low-quality evidence). Coasting versus EUFAThere were too few data to determine whether there was a difference between the groups in rates of OHSS (OR 0.98, 95% CI 0.34 to 2.85; I² = 0%; 2 RCTs; 83 women; very low-quality evidence), or clinical pregnancy (OR 0.67, 95% CI 0.25 to 1.79; I² = 0%; 2 RCTs; 83 women; very low-quality evidence); no studies reported live birth, multiple pregnancy, or miscarriage. Coasting versus antagonistOne RCT (190 women) reported this comparison, and no events of OHSS occurred in either arm. There were too few data to determine whether there was a difference between the groups in clinical pregnancy rates (OR 0.74, 95% CI 0.42 to 1.31; one RCT; 190 women; low-quality evidence), or multiple pregnancy rates (OR 1.00, 95% CI 0.43 to 2.32; one RCT; 98 women; very low-quality evidence); the study did not report live birth or miscarriage. Coasting versus FSH co-triggerRates of OHSS were higher in the coasting group (OR 43.74, 95% CI 2.54 to 754.58; one RCT; 102 women; very low-quality evidence), with 15 events in the coasting arm and none in the FSH co-trigger arm. There were too few data to determine whether there was a difference between the groups in clinical pregnancy rates (OR 0.92, 95% CI 0.43 to 2.10; one RCT; 102 women; low-quality evidence). This study did not report data suitable for analysis on live birth, multiple pregnancy, or miscarriage, but stated that there was no significant difference between the groups. Coasting versus cabergolineThere were too few data to determine whether there was a difference between the groups in rates of OHSS (OR 1.98, 95% CI 0.09 to 5.68; P = 0.20; I² = 72%; two RCTs; 120 women; very low-quality evidence), with 11 events in the coasting arm and six in the cabergoline arm. The evidence suggested that coasting was associated with lower rates of clinical pregnancy (OR 0.38, 95% CI 0.16 to 0.88; P = 0.02; I² =0%; two RCTs; 120 women; very low-quality evidence), but there were only 33 events altogether. These studies did not report data suitable for analysis on live birth, multiple pregnancy, or miscarriage. AUTHORS' CONCLUSIONS There was low-quality evidence to suggest that coasting reduced rates of moderate or severe OHSS more than no coasting. There was no evidence to suggest that coasting was more beneficial than other interventions, except that there was very low-quality evidence from a single small study to suggest that using FSH co-trigger at the time of HCG administration may be better at reducing the risk of OHSS than coasting. There were too few data to determine clearly whether there was a difference between the groups for any other outcomes.
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Affiliation(s)
- Arianna D'Angelo
- Cardiff University School of MedicineObstetrics and GynaecologyCardiffWalesUK
| | - Nazar N Amso
- Cardiff University School of MedicineEmeritus ProfessorCardiffWalesUKCF14 4XN
| | - Rudaina Hassan
- Cardiff UniversityWales DeaneryHeath ParkCardiffUKCF14 4YS
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Abstract
BACKGROUND This is an updated version of the original Cochrane Review published in Issue 2, 2002 and its subsequent updates in 2010 and 2015.Epilepsy is a common neurological condition in which recurrent, unprovoked seizures are caused by abnormal electrical discharges from the brain. It is believed that with effective drug treatment, up to 70% of individuals with active epilepsy have the potential to become seizure-free and go into long-term remission shortly after starting drug therapy with a single antiepileptic drug in monotherapy.Worldwide, carbamazepine and phenytoin are commonly-used broad spectrum antiepileptic drugs, suitable for most epileptic seizure types. Carbamazepine is a current first-line treatment for partial onset seizures in the USA and Europe. Phenytoin is no longer considered a first-line treatment due to concerns over adverse events associated with its use, but the drug is still commonly used in low- to middle-income countries because of its low cost. No consistent differences in efficacy have been found between carbamazepine and phenytoin in individual trials, although the confidence intervals generated by these studies are wide. Differences in efficacy may therefore be shown by synthesising the data of the individual trials. OBJECTIVES To review the time to withdrawal, six- and 12-month remission, and first seizure with carbamazepine compared to phenytoin, used as monotherapy in people with partial onset seizures (simple partial, complex partial, or secondarily generalised tonic-clonic seizures), or generalised tonic-clonic seizures, with or without other generalised seizure types. SEARCH METHODS For the latest update we searched the Cochrane Epilepsy Group's Specialised Register (1st November 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 1st November 2016), MEDLINE (Ovid, 1946 to 1 November 2016), ClinicalTrials.gov (1 November 2016), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP, 1st November 2016). Previously we also searched SCOPUS (1823 to 16th September 2014) as an alternative to Embase, but this is no longer necessary, because randomised and quasi-randomised controlled trials in Embase are now included in CENTRAL. We handsearched relevant journals, contacted pharmaceutical companies, original trial investigators and experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) in children or adults with partial onset seizures or generalised onset tonic-clonic seizures, comparing carbamazepine monotherapy versus phenytoin monotherapy. DATA COLLECTION AND ANALYSIS This is an individual participant data (IPD) review. Our primary outcome was time to withdrawal of allocated treatment, and our secondary outcomes were time to six-month remission, time to 12-month remission, and time to first seizure post-randomisation. We used Cox proportional hazards regression models to obtain study-specific estimates of hazard ratios (HRs) with 95% confidence intervals (CIs) and the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS IPD were available for 595 participants out of 1192 eligible individuals, from four out of 12 trials (i.e. 50% of the potential data). For remission outcomes, HR greater than 1 indicates an advantage for phenytoin; and for first seizure and withdrawal outcomes, HR greater than 1 indicates an advantage for carbamazepine. The methodological quality of the four studies providing IPD was generally good and we rated it at low risk of bias overall in the analyses.The main overall results (pooled HR adjusted for seizure type) were time to withdrawal of allocated treatment: 1.04 (95% CI 0.78 to 1.39; three trials, 546 participants); time to 12-month remission: 1.01 (95% CI 0.78 to 1.31; three trials, 551 participants); time to six-month remission: 1.11 (95% CI 0.89 to 1.37; three trials, 551 participants); and time to first seizure: 0.85 (95% CI 0.70 to 1.04; four trials, 582 participants). The results suggest no overall statistically significant difference between the drugs for these outcomes. There is some evidence of an advantage for phenytoin for individuals with generalised onset seizures for our primary outcome (time to withdrawal of allocated treatment): pooled HR 0.42 (95% CI 0.18 to 0.96; two trials, 118 participants); and a statistical interaction between treatment effect and epilepsy type (partial versus generalised) for this outcome (P = 0.02). However, misclassification of seizure type for up to 48 individuals (32% of those with generalised epilepsy) may have confounded the results of this review. Despite concerns over side effects leading to the withdrawal of phenytoin as a first-line treatment in the USA and Europe, we found no evidence that phenytoin is more likely to be associated with serious side effects than carbamazepine; 26 individuals withdrew from 290 randomised (9%) to carbamazepine due to adverse effects, compared to 12 out of 299 (4%) randomised to phenytoin from four studies conducted in the USA and Europe (risk ratio (RR) 1.42, 95% CI 1.13 to 1.80, P = 0.014). We rated the quality of the evidence as low to moderate according to GRADE criteria, due to imprecision and potential misclassification of seizure type. AUTHORS' CONCLUSIONS We have not found evidence for a statistically significant difference between carbamazepine and phenytoin for the efficacy outcomes examined in this review, but CIs are wide and we cannot exclude the possibility of important differences. There is no evidence in this review that phenytoin is more strongly associated with serious adverse events than carbamazepine. There is some evidence that people with generalised seizures may be less likely to withdraw early from phenytoin than from carbamazepine, but misclassification of seizure type may have impacted upon our results. We recommend caution when interpreting the results of this review, and do not recommend that our results alone should be used in choosing between carbamazepine and phenytoin. We recommend that future trials should be designed to the highest quality possible, with considerations of allocation concealment and masking, choice of population, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolUKL9 7LJ
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolUKL9 7LJ
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
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Velarde-García JF, Luengo-González R, González-Hervías R, Cardenete-Reyes C, Álvarez-Embarba B, Palacios-Ceña D. Limitation of therapeutic effort experienced by intensive care nurses. Nurs Ethics 2016; 25:867-879. [PMID: 28027690 PMCID: PMC6238171 DOI: 10.1177/0969733016679471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Nurses who practice limitation of therapeutic effort become fully involved in emotionally charged situations, which can affect them significantly on an emotional and professional level. Objectives: To describe the experience of intensive care nurses practicing limitation of therapeutic effort. Method: A qualitative, phenomenological study was performed within the intensive care units of the Madrid Hospitals Health Service. Purposeful and snowball sampling methods were used, and data collection methods included semi-structured and unstructured interviews, researcher field notes, and participants’ personal letters. The Giorgi proposal for data analysis was used on the data. Ethical considerations: This study was approved by the Ethical Research Committee of the relevant hospital and by the Ethics Committee of the Rey Juan Carlos University and was guided by the ethical principles of voluntary enrollment, anonymity, privacy, and confidentiality. Results: In total, 22 nurses participated and 3 themes were identified regarding the nurses’ experiences when faced with limitation of therapeutic effort: (a) experiencing relief, (b) accepting the medical decision, and (c) implementing limitation of therapeutic effort. Conclusion: Nurses felt that, although they were burdened with the responsibility of implementing limitation of therapeutic effort, they were being left out of the final decision-making process regarding the same.
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Affiliation(s)
- Juan Francisco Velarde-García
- Juan Francisco Velarde-García, Red Cross Nursing College, Universidad Autónoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003 Madrid, Spain
| | - Raquel Luengo-González
- Juan Francisco Velarde-García, Red Cross Nursing College, Universidad Autónoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003 Madrid, Spain
| | - Raquel González-Hervías
- Escuela de Enfermería de Cruz Roja de Madrid, Spain.,Juan Francisco Velarde-García, Red Cross Nursing College, Universidad Autónoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003 Madrid, Spain
| | - César Cardenete-Reyes
- Universidad Europea de Madrid, Spain.,Juan Francisco Velarde-García, Red Cross Nursing College, Universidad Autónoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003 Madrid, Spain
| | - Beatriz Álvarez-Embarba
- Universidad Autónoma de Madrid, Spain.,Juan Francisco Velarde-García, Red Cross Nursing College, Universidad Autónoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003 Madrid, Spain
| | - Domingo Palacios-Ceña
- Universidad Rey Juan Carlos, Spain.,Juan Francisco Velarde-García, Red Cross Nursing College, Universidad Autónoma de Madrid, Avenida Reina Victoria 28, 4a planta, 28003 Madrid, Spain
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Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 1, 2006 of the Cochrane Database of Systematic Reviews.Epilepsy is a common neurological condition in which abnormal electrical discharges from the brain cause recurrent unprovoked seizures. It is believed that with effective drug treatment up to 70% of individuals with active epilepsy have the potential to become seizure-free and to go into long-term remission shortly after starting drug therapy with a single antiepileptic drug (AED) in monotherapy.The correct choice of first-line antiepileptic therapy for individuals with newly diagnosed seizures is of great importance. It is important that the choice of AEDs for an individual is made using the highest quality evidence regarding the potential benefits and harms of the various treatments. It is also important that the effectiveness and tolerability of AEDs appropriate to given seizure types are compared to one another.Carbamazepine or lamotrigine are first-line recommended treatments for new onset partial seizures and as a first- or second-line treatment for generalised tonic-clonic seizures. Performing a synthesis of the evidence from existing trials will increase the precision of the results for outcomes relating to efficacy and tolerability and may assist in informing a choice between the two drugs. OBJECTIVES To review the time to withdrawal, remission and first seizure with lamotrigine compared to carbamazepine when used as monotherapy in people with partial onset seizures (simple or complex partial and secondarily generalised) or generalised onset tonic-clonic seizures (with or without other generalised seizure types). SEARCH METHODS The first searches for this review were run in 1997. For the most recent update we searched the Cochrane Epilepsy Group Specialized Register (17 October 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online (CRSO, 17 October 2016) and MEDLINE (Ovid, 1946 to 17 October 2016). We imposed no language restrictions. We also contacted pharmaceutical companies and trial investigators. SELECTION CRITERIA Randomised controlled trials in children or adults with partial onset seizures or generalised onset tonic-clonic seizures comparing monotherapy with either carbamazepine or lamotrigine. DATA COLLECTION AND ANALYSIS This was an individual participant data (IPD) review. Our primary outcome was time to withdrawal of allocated treatment and our secondary outcomes were time to first seizure post-randomisation, time to six-month, 12-month and 24-month remission, and incidence of adverse events. We used Cox proportional hazards regression models to obtain trial-specific estimates of hazard ratios (HRs) with 95% confidence intervals (CIs), using the generic inverse variance method to obtain the overall pooled HR and 95% CI. MAIN RESULTS We included 13 studies in this review. Individual participant data were available for 2572 participants out of 3394 eligible individuals from nine out of 13 trials: 78% of the potential data. For remission outcomes, a HR < 1 indicated an advantage for carbamazepine and for first seizure and withdrawal outcomes a HR < 1 indicated an advantage for lamotrigine.The main overall results (pooled HR adjusted for seizure type) were: time to withdrawal of allocated treatment (HR 0.72, 95% CI 0.63 to 0.82), time to first seizure (HR 1.22, 95% CI 1.09 to 1.37) and time to six-month remission (HR 0.84, 95% CI 0.74 to 0.94), showing a significant advantage for lamotrigine compared to carbamazepine for withdrawal but a significant advantage for carbamazepine compared to lamotrigine for first seizure and six-month remission. We found no difference between the drugs for time to 12-month remission (HR 0.91, 95% CI 0.77 to 1.07) or time to 24-month remission (HR 1.00, 95% CI 0.80 to 1.25), however only two trials followed up participants for more than one year so the evidence is limited.The results of this review are applicable mainly to individuals with partial onset seizures; 88% of included individuals experienced seizures of this type at baseline. Up to 50% of the limited number of individuals classified as experiencing generalised onset seizures at baseline may have had their seizure type misclassified, therefore we recommend caution when interpreting the results of this review for individuals with generalised onset seizures.The most commonly reported adverse events for both of the drugs across all of the included trials were dizziness, fatigue, gastrointestinal disturbances, headache and skin problems. The rate of adverse events was similar across the two drugs.The methodological quality of the included trials was generally good, however there is some evidence that the design choice of masked or open-label treatment may have influenced the withdrawal rates of the trials. Hence, we judged the quality of the evidence for the primary outcome of treatment withdrawal to be moderate for individuals with partial onset seizures and low for individuals with generalised onset seizures. For efficacy outcomes (first seizure, remission), we judged the quality of evidence to be high for individuals with partial onset seizures and moderate for individuals with generalised onset seizures. AUTHORS' CONCLUSIONS Lamotrigine was significantly less likely to be withdrawn than carbamazepine but the results for time to first seizure suggested that carbamazepine may be superior in terms of seizure control. A choice between these first-line treatments must be made with careful consideration. We recommend that future trials should be designed to the highest quality possible with consideration of masking, choice of population, classification of seizure type, duration of follow-up, choice of outcomes and analysis, and presentation of results.
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Affiliation(s)
- Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Jennifer Weston
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolUKL9 7LJ
| | - Anthony G Marson
- Institute of Translational Medicine, University of LiverpoolDepartment of Molecular and Clinical PharmacologyClinical Sciences Centre for Research and Education, Lower LaneFazakerleyLiverpoolUKL9 7LJ
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Parker M, Willmott L, White B, Williams G, Cartwright C. Medical education and law: withholding/withdrawing treatment from adults without capacity. Intern Med J 2016; 45:634-40. [PMID: 25828677 DOI: 10.1111/imj.12759] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 03/19/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Law is increasingly involved in clinical practice, particularly at the end of life, but undergraduate and postgraduate education in this area remains unsystematic. We hypothesised that attitudes to and knowledge of the law governing withholding/withdrawing life-sustaining treatment from adults without capacity (the WWLST law) would vary and demonstrate deficiencies among medical specialists. AIMS We investigated perspectives, knowledge and training of medical specialists in the three largest (populations and medical workforces) Australian states, concerning the WWLST law. METHODS Following expert legal review, specialist focus groups, pre-testing and piloting in each state, seven specialties involved with end-of-life care were surveyed, with a variety of statistical analyses applied to the responses. RESULTS Respondents supported the need to know and follow the law. There were mixed views about its helpfulness in medical decision-making. Over half the respondents conceded poor knowledge of the law; this was mirrored by critical gaps in knowledge that varied by specialty. There were relatively low but increasing rates of education from the undergraduate to continuing professional development (CPD) stages. Mean knowledge score did not vary significantly according to undergraduate or immediate postgraduate training, but CPD training, particularly if recent, resulted in greater knowledge. Case-based workshops were the preferred CPD instruction method. CONCLUSIONS Teaching of current and evolving law should be strengthened across all stages of medical education. This should improve understanding of the role of law, ameliorate ambivalence towards the law and contribute to more informed deliberation about end-of-life issues with patients and families.
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Affiliation(s)
- M Parker
- School of Medicine, Mayne Medical School, University of Queensland, Brisbane, Queensland, Australia
| | - L Willmott
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - B White
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, Queensland, Australia
| | - G Williams
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia
| | - C Cartwright
- Cartwright Consulting Australia Pty Ltd, Gold Coast, Queensland, Australia.,ASLaRC Aged Services Unit, Southern Cross University, Lismore, New South Wales, Australia
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Mehter HM, Wiener RS, Walkey AJ. "Do not resuscitate" decisions in acute respiratory distress syndrome. A secondary analysis of clinical trial data. Ann Am Thorac Soc 2014; 11:1592-6. [PMID: 25386717 DOI: 10.1513/AnnalsATS.201406-244BC] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Factors and outcomes associated with end-of-life decision-making among patients during clinical trials in the intensive care unit are unclear. OBJECTIVES We sought to determine patterns and outcomes of Do Not Resuscitate (DNR) decisions among critically ill patients with acute respiratory distress syndrome (ARDS) enrolled in a clinical trial. METHODS We performed a secondary analysis of data from the ARDS Network Fluid and Catheter Treatment Trial (FACTT), collected between 2000 and 2005. We calculated mortality outcomes stratified by code status, and compared baseline characteristics of patients who became DNR during the trial with participants who remained full code. MEASUREMENTS AND MAIN RESULTS Among 809 FACTT participants with a code status recorded, 232 (28.7%) elected DNR status. Specifically, 37 (15.9%) chose to withhold cardiopulmonary resuscitation alone, 44 (19.0%) elected to withhold some life support measures in addition to cardiopulmonary resuscitation, and 151 (65.1%) had life support withdrawn. Admission severity of illness as measured by APACHE III score was strongly associated with election of DNR status (odds ratio, 2.2; 95% confidence interval, 1.85-2.62; P < 0.0001). Almost all (97.0%; 225 of 232) patients who selected DNR status died, and 79% (225 of 284) of patients who died during the trial were DNR. Among patients who chose DNR status but did not elect withdrawal of life support, 91% (74 of 81) died. CONCLUSIONS The vast majority of deaths among clinical trial patients with ARDS were preceded by a DNR order. Unlike other studies of end-of-life decision-making in the intensive care unit, nearly all patients who became DNR died. The impact of variation of practice in end-of-life decision-making during clinical trials warrants further study.
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Mills BA, Janvier A, Argus BM, Davis PG, Frøisland DH. Attitudes of Australian neonatologists to resuscitation of extremely preterm infants. J Paediatr Child Health 2015; 51:870-4. [PMID: 25752752 DOI: 10.1111/jpc.12862] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2015] [Indexed: 11/30/2022]
Abstract
AIM We aimed to investigate how Australian neonatologists made decisions when incompetent patients of different ages needed resuscitation. METHODS A survey including vignettes of eight incompetent patients requiring resuscitation was sent to 140 neonatologists. Patients ranged from a very preterm infant to 80 years old. While some had existing impairments, all faced risk of death or neurological sequelae. Respondents indicated whether they would resuscitate, whether they believed resuscitation was in the patients' best interests, whether they would want intervention for a family member and whether they would comply with families' wishes to withhold resuscitation. They were also asked how they would rank the eight patients in a triage situation. RESULTS Seventy-eight per cent of specialists completed the survey. The majority of respondents gave priority to the resuscitation of children over adults. Less than 40% would agree to withhold resuscitation at families' request for all children except for the preterm infant, where 96% would comply with families' wishes to withhold intensive care despite 77% believing resuscitation to be in the infant's best interest. CONCLUSION This study found inconsistencies between physicians' perceptions of the patient's best interest regarding resuscitation and their willingness to comply with families' wishes to withhold resuscitation and give comfort care. Accepting a family's refusal of resuscitation was more marked for the premature infant, even among respondents who thought that resuscitation was in the patient's best interest. These findings are consistent with other international studies.
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Affiliation(s)
- Bernice A Mills
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Annie Janvier
- Department of Pediatrics and Clinical Ethics, Sainte-Justine Hospital, Université de Montréal, Montréal, Quebec, Canada
| | - Brenda M Argus
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Dag Helge Frøisland
- Department of Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Pediatrics, Innlandet Hospital Trust Lillehammer, Lillehammer, Norway
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Abstract
PURPOSE Little is known about the role family physicians play when a patient deliberately hastens death by voluntarily stopping eating and drinking (VSED). The purpose of this study was to gain more insight for family physicians when confronted with patients who wish to hasten death by VSED. We aimed to describe physicians' involvement in VSED, to describe characteristics and motives of their patients, and to describe the process of VSED in terms of duration, as well as common symptoms in the last 3 days of life. METHODS We undertook a survey of a random national sample of 1,100 family physicians (response rate 72%), and 500 of these physicians received questions about their last patient who hastened death by VSED. RESULTS Of the 978 eligible physicians, 708 responded (72.4%); 46% had cared for a patient who hastened death by VSED. Of the 500 physicians who received the additional questions, 440 were eligible and 285 (64.8%) responded; they described 99 cases of VSED. Seventy percent of these patients were aged older than 80 years, 76% had severe disease (27% with cancer), and 77% were dependent on others for everyday care. Frequent reasons for the patients' death wish were somatic (79%), existential (77%), and dependence (58%). Median time until death was 7 days, and the most common symptoms before death were pain, fatigue, impaired cognitive functioning, and thirst or dry throat. Family physicians were involved in 62% of cases. CONCLUSIONS Patients who hasten death by VSED are mostly in poor health. It is not unlikely for family physicians to be confronted with VSED. They can play an important role in caring for these patients and their proxies by informing them of VSED and by providing support and symptom management during VSED.
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Affiliation(s)
- Eva E Bolt
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn Hagens
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Dick Willems
- Department of General Practice, Section of Medical Ethics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
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van Beinum A, Hornby L, Ramsay T, Ward R, Shemie SD, Dhanani S. Exploration of Withdrawal of Life-Sustaining Therapy in Canadian Intensive Care Units. J Intensive Care Med 2015; 31:243-51. [PMID: 25680980 DOI: 10.1177/0885066615571529] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 12/03/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The process of controlled donation after circulatory death (cDCD) is strongly connected with the process of withdrawal of life-sustaining therapy. In addition to impacting cDCD success, actions comprising withdrawal of life-sustaining therapy have implications for quality of palliative care. We examined pilot study data from Canadian intensive care units to explore current practices of life-sustaining therapy withdrawal in nondonor patients and described variability in standard practice. DESIGN Secondary analysis of observational data collected for Determination of Death Practices in Intensive Care pilot study. SETTING Four Canadian adult intensive care units. PATIENTS Patients ≥18 years in whom a decision to withdraw life-sustaining therapy was made and substitute decision makers consented to study participation. Organ donors were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Prospective observational data on interventions withdrawn, drugs administered, and timing of life-sustaining therapy withdrawal was available for 36 patients who participated in the pilot study. Of the patients, 42% died in ≤1 hour; median length of time to death varied between intensive care units (39-390 minutes). Withdrawal of life-sustaining therapy processes appeared to follow a general pattern of vasoactive drug withdrawal followed by withdrawal of mechanical ventilation and extubation in most sites but specific steps varied. Approaches to extubation and weaning of vasoactive drugs were not consistent. Protocols detailing the process of life-sustaining therapy withdrawal were available for 3 of 4 sites and also exhibited differences across sites. CONCLUSIONS Standard practice of life-sustaining therapy withdrawal appears to differ between selected Canadian sites. Variability in withdrawal of life-sustaining therapy may have a potential impact both on rates of cDCD success and quality of palliative care.
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Affiliation(s)
- Amanda van Beinum
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Laura Hornby
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute Methods Center, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | | | - Sam D Shemie
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada Division of Critical Care, Montreal Children's Hospital, McGill University, Montréal, Canada
| | - Sonny Dhanani
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada CHEO Research Institute, Ottawa, Canada Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
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Abstract
Providing versus foregoing enteral nutrition is a central issue in end-of-life care, affecting patients, families, nurses, and other health professionals. The aim of this article is to examine Jewish ethical perspectives on nourishing the dying and to analyze their implications for nursing practice, education, and research. Jewish ethics is based on religious law, called Halacha. Many Halachic scholars perceive withholding nourishment in end of life, even enterally, as hastening death. This reflects the divide they perceive between allowing a fatal disease to naturally run its course until an individual's vitality (life force or viability) is lost versus withholding nourishment for the vitality that still remains. The latter they maintain introduces a new cause of death. Nevertheless, coercing an individual to accept enteral nourishment is generally considered undignified and counterproductive. A minority of Halachic scholars classify withholding enteral nutrition as refraining from prolonging life, permitted under certain circumstances, especially in situations where nutritional problems flow directly from a fatal pathology. In the very final stages of dying, moreover, there is a general consensus that enteral nourishment may be withheld, providing that this reflects the dying individuals' wishes. In the event of enteral nourishment becoming a source of overwhelming discomfort, two Halachic ethical mandates would come into conflict: sustaining life by providing nourishment and alleviating suffering. As in all moral conflicts, these would have to be resolved in practice. This article presents the issue of enteral nourishment as it unfolds in Halacha in comparison to secular and other religious perspectives. It is meant to serve as a foundation for nurses to reflect on their own practice and to explore the implications for nursing practice, education, and research. In a world that remains broadly religious, it is important to sensitize health practitioners to the similarities and differences among religions and between secular and religious approaches to ethical issues.
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Abstract
Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only relatively weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions.
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Affiliation(s)
- Dominic Wilkinson
- Women's and Children's Hospital, Adelaide University of Oxford, St Cross College, Oxford, and Oxford Uehiro Centre for Practical Ethics and Oxford Centre for Neuroethics
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Abstract
BACKGROUND Management of critically ill patients involves weighing potential benefit of advanced life support against preserving quality of life, avoidance of futile measures and rational use of resources. AIM Our study aims to identify the predisposing factors involved in the institution and maintenance of futile intensive care support in terminally ill cancer patients in whom no additional treatment for the malignant disease would be offered. DESIGN We retrospectively analysed the medical records of patients who died in a tertiary cancer hospital (Hospital A C Camargo, São Paulo, Brazil) during an eight month period. Medical futility was defined when a patient, despite having been stated in the hospital records as having no possible lifespan extending treatment, was admitted to intensive care and received advanced life support. These cases were compared to controls who received palliative end-of-life care. RESULTS Three hundred and forty-seven deaths were recorded, of which 238 did not undergo futile treatment, 71 received full code treatment and 38 received futile treatments. Statistically significant predisposing factors for medical futility were, in our analysis, lack of palliative care team consultation (p < 0.001) and hematologic malignancy (p = 0.036). Qualitative analysis of medical records traced futile treatments to physicians' lacking proactive attitudes in considering prognosis and talking to families. CONCLUSIONS We conclude that a significant minority of end-of-life care consists of futile treatments. Strategies to increase Oncologists' and Critical Care specialists' alertness to these issues and expand indications of Palliative Care consultations are recommended.
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Affiliation(s)
| | | | - Pedro Caruso
- ICU, AC Camargo Cancer Center, São Paulo, Brazil Disciplina de Pneumologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Shah RD, Rasinski KA, Alexander GC. The Influence of Surrogate Decision Makers on Clinical Decision Making for Critically Ill Adults. J Intensive Care Med 2013; 30:278-85. [PMID: 24362444 DOI: 10.1177/0885066613516597] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/22/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE Intensive care unit patients rarely have decisional capacity and often surrogates make clinical decisions on their behalf. Little is known about how surrogate characteristics may influence end-of-life decision making for these patients. This study sought to determine how surrogate characteristics impact physicians' approach to end-of-life decision making. METHODS From March 2011 to August 2011, a survey was fielded to 1000 randomly sampled critical care physicians using a modified Dillman approach. The survey included a hypothetical vignette to examine how physicians' approach varied based on patient age, patient-surrogate relationship, surrogate-staff relationship, basis for surrogate's stated preferences, and surrogate's understanding of patient's condition. Outcomes included physicians' beliefs regarding (1) appropriateness of cardiopulmonary resuscitation (CPR); (2) appropriate locus of decision making for the patient; (3) degree to which a physician would try to influence a surrogate if disagreement was present; and (4) physician strategies to discussing end-of-life with surrogates. RESULTS Of 922 eligible physicians, 608 (66%) participated. Across all vignettes, CPR was felt to be less appropriate and surrogates less likely to be given priority with an older rather than younger patient (15% vs 63% and 50% vs 65%, both P values <.001). Cardiopulmonary resuscitation was considered less appropriate when the surrogate-patient relationship was not close (34% vs 44%, P = .03) and the surrogate's understanding was poor (34% vs 43%, P = .05). No other surrogate characteristics examined yielded statistically significant associations. CONCLUSION Some surrogate characteristics may modify clinicians' beliefs and practices regarding end-of-life care, suggesting the nuances of the surrogate-physician relationship and clinical decision making for critically ill patients.
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Affiliation(s)
- Raj D Shah
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - Kenneth A Rasinski
- Chicago Consortium for School Research, University of Chicago, Chicago, IL, USA
| | - G Caleb Alexander
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Medicine, Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Pharmacy Practice, University of Illinois at Chicago School of Pharmacy, Chicago, IL, USA
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