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Won YW, Kim HJ, Kwon JH, Lee HY, Baek SK, Kim YJ, Kim DY, Ryu H. Life-Sustaining Treatment States in Korean Cancer Patients after Enforcement of Act on Decisions on Life-Sustaining Treatment for Patients at the End of Life. Cancer Res Treat 2021; 53:908-916. [PMID: 34082495 PMCID: PMC8524027 DOI: 10.4143/crt.2021.325] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/31/2021] [Indexed: 11/21/2022] Open
Abstract
PURPOSE In Korea, the "Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life" was enacted on February 4, 2018. This study was conducted to analyze the current state of life-sustaining treatment decisions based on National Health Insurance Service (NHIS) data after the law came into force. MATERIALS AND METHODS The data of 173,028 cancer deaths were extracted from NHIS qualification data between November 2015 and January 2019. RESULTS The number of cancer deaths complied with the law process was 14,438 of 54,635 cases (26.4%). The rate of patient self-determination was 49.0%. The patients complying with the law process have used a hospice center more frequently (28% vs. 14%). However, the rate of intensive care unit (ICU) admission was similar between the patients who complied with and without the law process (ICU admission, 23% vs. 21%). There was no difference in the proportion of patients who had undergone mechanical ventilation and hemodialysis in the comparative analysis before and after the enforcement of the law and the analysis according to the compliance with the law. The patients who complied with the law process received cardiopulmonary resuscitation at a lower rate. CONCLUSION The law has positive effects on the rate of life-sustaining treatment decision by patient's determination. However, there was no sufficient effect on the withholding or withdrawing of life-sustaining treatment, which could protect the patient from unnecessary or harmful interventions.
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Affiliation(s)
- Young-Woong Won
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri,
Korea
| | - Hwa Jung Kim
- Department of Preventive Medicine, Ulsan University College of Medicine, Seoul,
Korea
| | - Jung Hye Kwon
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong,
Korea
| | - Ha Yeon Lee
- Division of Hematology and Oncology, Department of Internal Medicine, National Medical Center, Seoul,
Korea
| | - Sun Kyung Baek
- Division of Hematology and Oncology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul,
Korea
| | - Yu Jung Kim
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Do Yeun Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang,
Korea
| | - Hyewon Ryu
- Division of Hematology and Oncology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon,
Korea
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Mack JW, Fisher L, Kushi L, Chao CR, Vega B, Rodrigues G, Josephs I, Brock KE, Buchanan S, Casperson M, Cooper RM, Fasciano KM, Kolevska T, Lakin JR, Lefebvre A, Schwartz CM, Shalman DM, Wall CB, Wiener L, Altschuler A. Patient, Family, and Clinician Perspectives on End-of-Life Care Quality Domains and Candidate Indicators for Adolescents and Young Adults With Cancer. JAMA Netw Open 2021; 4:e2121888. [PMID: 34424305 PMCID: PMC8383130 DOI: 10.1001/jamanetworkopen.2021.21888] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE End-of-life care quality indicators specific to adolescents and young adults (AYAs) aged 12 to 39 years with cancer have not been developed. OBJECTIVE To identify priority domains for end-of-life care from the perspectives of AYAs, family caregivers, and clinicians, and to propose candidate quality indicators reflecting priorities. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted from December 6, 2018, to January 5, 2021, with no additional follow-up. In-depth interviews were conducted with patients, family caregivers, and clinicians and included a content analysis of resulting transcripts. A multidisciplinary advisory group translated priorities into proposed quality indicators. Interviews were conducted at the Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an AYA cancer support community (lacunaloft.org). Participants included 23 AYAs, 28 caregivers, and 29 clinicians. EXPOSURE Stage IV or recurrent cancer. MAIN OUTCOMES AND MEASURES Care priorities. RESULTS Interviews were conducted with 23 patients (mean [SD] age, 29.3 [7.3] years; 12 men [52%]; 18 White participants [78%]), 28 family caregivers (23 women [82%]; 14 White participants [50%]), and 29 clinicians (20 women [69%]; 13 White participants [45%]). Caregivers included 22 parents (79%), 5 spouses or partners (18%), and 1 other family member (4%); the 29 clinicians included 15 physicians (52%), 6 nurses or nurse practitioners (21%), and 8 social workers or psychologists (28%). Interviews identified 7 end-of-life priority domains: attention to physical symptoms, attention to quality of life, psychosocial and spiritual care, communication and decision-making, relationships with clinicians, care and treatment, and independence. Themes were consistent across the AYA age range and participant type. Although some domains were represented in quality indicators developed for adults, unique domains were identified, as well as AYA-specific manifestations of existing domains. For example, quality of life included global quality of life; attainment of life goals, legacy, and meaning; support of personal relationships; and normalcy. Within communication and decision-making, domains included communication early in the disease course, addressing prognosis and what to expect at the end of life, and opportunity for AYAs to hold desired roles in decision-making. Care and treatment domains relevant to cancer therapy, use of life-prolonging measures, and location of death emphasized the need for preference sensitivity rather than a standard path. This finding differs from existing adult indicators that propose that late-life chemotherapy, intensive measures, and hospital death should be rare. CONCLUSIONS AND RELEVANCE The findings of this qualitative study suggest that AYAs with cancer have priorities for care at the end of life that are not fully encompassed in existing indicators for adults. Use of new indicators for this young population may better reflect patient- and family-centered experiences of quality care.
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Affiliation(s)
- Jennifer W Mack
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lauren Fisher
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Larry Kushi
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Chun R Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Brenda Vega
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Gilda Rodrigues
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Katharine E Brock
- Divisions of Pediatric Oncology and Palliative Care, Emory University and Aflac Cancer & Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Susan Buchanan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Now with Agios Pharmaceuticals, Cambridge, Massachusetts
| | | | - Robert M Cooper
- Department of Pediatric Oncology, Kaiser Permanente Southern California, Pasadena
| | - Karen M Fasciano
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Tatjana Kolevska
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Joshua R Lakin
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Anna Lefebvre
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Corey M Schwartz
- Division of Medical Oncology, Kaiser Permanente Northern California, Oakland
| | - Dov M Shalman
- Department of Palliative Care, Kaiser Permanente Southern California, Pasadena
| | - Catherine B Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lori Wiener
- Psychosocial Support and Research Program, National Cancer Institute, Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
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Yan Y, Demertzi A, Xia Y, Wang J, Hu N, Zhang Z, Di H, Laureys S. Ethics of life-sustaining treatment in locked-in syndrome: A Chinese survey. Ann Phys Rehabil Med 2019; 63:483-487. [PMID: 31682940 DOI: 10.1016/j.rehab.2019.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 09/07/2019] [Accepted: 09/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Locked-in syndrome (LIS) characterizes individuals who have experienced pontine lesions, who have limited motor output but with preserved cognitive abilities. Despite their severe physical impairment, individuals with LIS self-profess a higher quality of life than generally expected. Such third-person expectations about LIS are shaped by personal and cultural factors in western countries. OBJECTIVE We sought to investigate whether such opinions are further influenced by the cultural background in East Asia. We surveyed attitudes about the ethics of life-sustaining treatment in LIS in a cohort of medical and non-medical Chinese participants. RESULTS The final study sample included 1545 respondents: medical professionals (n=597, 39%), neurologists (n=303, 20%), legal professionals (n=276, 18%) and other professionals (n=369, 24%), including 180 family members of individuals with LIS. Most of the participants (70%), especially neurologists, thought that life-sustaining treatment could not be stopped in individuals with LIS. It might be unnecessary to withdraw life-sustaining treatment, because the condition involved is not terminal and irreversible, and physical treatment can be beneficial for the patient. A significant proportion (59%) of respondents would like to be kept alive if they were in that condition; however, older people thought the opposite. Families experience the stress of caring for individuals with LIS. The mean (SD) quality of life score for relatives was 0.73 (2.889) (on a -5, +5 scale), which was significantly lower than that of non-relatives, 1.75 (1.969) (P<0.001). CONCLUSIONS Differences in opinions about end of life in LIS are affected by personal characteristics. The current survey did not identify a dissociation between personal preferences and general opinions, potentially because of a social uniformity in China where individualism is less pronounced. Future open-ended surveys could identify specific needs of caregivers so that strategic interventions to reduce ethical debasement are designed.
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Affiliation(s)
- Yifan Yan
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Athena Demertzi
- GIGA Research, GIGA-Consciousness, Physiology of Cognition Research Lab, University of Liège, Liège, Belgium
| | - Yinyan Xia
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Jing Wang
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Nantu Hu
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.
| | - Zhiliang Zhang
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China
| | - Haibo Di
- International Unresponsive Wakefulness and Consciousness Science Institute, Hangzhou Normal University, Hangzhou, China.
| | - Steven Laureys
- GIGA Research, GIGA-Consciousness, Coma Science Group, University & University Hospital of Liège, Liège, Belgium
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Toly VB, Blanchette JE, Al-Shammari T, Musil CM. Caring for technology-dependent children at home: Problems and solutions identified by mothers. Appl Nurs Res 2019; 50:151195. [PMID: 31668894 DOI: 10.1016/j.apnr.2019.151195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/03/2019] [Accepted: 10/13/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Valerie Boebel Toly
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 9501 Euclid Ave., Cleveland, OH 44106, United States of America.
| | - Julia E Blanchette
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 9501 Euclid Ave., Cleveland, OH 44106, United States of America.
| | - Tahani Al-Shammari
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 9501 Euclid Ave., Cleveland, OH 44106, United States of America.
| | - Carol M Musil
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 9501 Euclid Ave., Cleveland, OH 44106, United States of America.
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Bhattacharya S. Dilemmas faced by health professionals surrounding life-sustaining treatment. Br J Nurs 2019; 28:1162-1163. [PMID: 31647729 DOI: 10.12968/bjon.2019.28.19.1162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Sayantan Bhattacharya
- Senior Fellow, Upper Gastro-intestinal Surgery, Aintree University Hospital, Liverpool
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Bhattacharya S. Dilemmas faced by health professionals surrounding life-sustaining treatment. Br J Nurs 2019; 28:1262-1263. [PMID: 31680578 DOI: 10.12968/bjon.2019.28.19.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Sayantan Bhattacharya
- Senior Fellow, Upper Gastro-intestinal Surgery, Aintree University Hospital, Liverpool
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Abstract
The definition of death was clearer one hundred years ago than it is today. People were declared dead if diagnosed with permanent cessation of both cardio-circulatory function and respiratory function. But the definition has been muddled by the development of new technologies and interventions-first by cardiopulmonary resuscitation and ventilators, which were introduced in the mid-twentieth century, and now by extracorporeal membrane oxygenation, which creates the ability to keep oxygenated blood circulating, with or without a beating heart or functioning lungs. In Defining Death: The Case for Choice, Robert Veatch and I argue that the definition of death should focus on "what change in a human being is so fundamental that we can say the individual is no longer with us as a member of the human community bearing rights such as the right not to be killed." We assert that this decision is a normative issue about which different stakeholders may believe that different changes are fundamental, and we therefore propose that the optimal policy solution may be to allow stakeholders to choose their own definition within a reasonable range of options. There are three caveats that need to be highlighted regarding this approach.
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Lovadini GB, Fukushima FB, Schoueri JFL, dos Reis R, Fonseca CGF, Rodriguez JJC, Coelho CS, Neves AF, Rodrigues AM, Marques MA, Jacinto AF, Harrison Dening K, Bassett R, Moss AH, Steinberg KE, Vidal EIDO. Evaluation of the Interrater Reliability of End-of-Life Medical Orders in the Physician Orders for Life-Sustaining Treatment Form. JAMA Netw Open 2019; 2:e192036. [PMID: 30977852 PMCID: PMC6481595 DOI: 10.1001/jamanetworkopen.2019.2036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients' values and preferences into medical orders for care at the end of life remains to be studied. OBJECTIVE To assess the interrater reliability of the medical orders documented in POLST forms. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. MAIN OUTCOMES AND MEASURES Interrater reliability as measured by κ statistics. RESULTS Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients' mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). CONCLUSIONS AND RELEVANCE The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients' current treatment preferences.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Rick Bassett
- Center for Nursing Excellence, St Luke’s Health System, Kansas City, Missouri
| | - Alvin H. Moss
- Center for Health Ethics and Law, West Virginia University, Morgantown
| | - Karl E. Steinberg
- Institute for Palliative Care, California State University, Long Beach
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Toly VB, Blanchette JE, Alhamed A, Musil CM. Mothers' Voices Related to Caregiving: The Transition of a Technology-Dependent Infant from the NICU to Home. Neonatal Netw 2019; 38:69-79. [PMID: 31470369 DOI: 10.1891/0730-0832.38.2.69] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE The transition from the NICU to home is a complicated, challenging process for mothers of infants dependent on lifesaving medical technology, such as feeding tubes, supplemental oxygen, tracheostomies, and mechanical ventilation. The study purpose was to explore how these mothers perceive their transition experiences just prior to and during the first three months after initial NICU discharge. DESIGN A qualitative, descriptive, longitudinal design was employed. SAMPLE Nineteen mothers of infants dependent on lifesaving technology were recruited from a large Midwest NICU. MAIN OUTCOME VARIABLE Description of mothers' transition experience. RESULTS Three themes were identified pretransition: negative emotions, positive cognitive-behavioral efforts, and preparation for life at home. Two posttransition themes were negative and positive transition experiences. Throughout the transition, the mothers expressed heightened anxiety, fear, and stress about life-threatening situations that did not abate over time despite the discharge education received.
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Edmonds BT, Savage TA, Kimura RE, Kilpatrick SJ, Kuppermann M, Grobman W, Kavanaugh K. Prospective parents' perspectives on antenatal decision making for the anticipated birth of a periviable infant. J Matern Fetal Neonatal Med 2019; 32:820-825. [PMID: 29103318 PMCID: PMC6810652 DOI: 10.1080/14767058.2017.1393066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine prospective parents' perceptions of management options and outcomes in the context of threatened periviable delivery, and the values they apply in making antenatal decisions during this period. STUDY DESIGN Qualitative analysis of 46 antenatal interviews conducted at three tertiary-care hospitals with 54 prospective parents (40 pregnant women, 14 partners) who had received counseling for threatened periviable delivery (40 cases). RESULTS Participants most often recalled being involved in resuscitation, cerclage, and delivery mode decisions. Over half (63.0%) desired a shared decision-making role. Most (85.2%) recalled hearing about morbidity and mortality, with many reiterating terms like "brain damage", "disability", and "handicap". The potential for disability influenced decision making to variable degrees. In describing what mattered most, participant spoke of giving their child a "fighting chance"; others voiced concerns about "best interest", a "healthy baby", "pain and suffering", and religious faith. CONCLUSIONS Our findings underscore the importance of presenting clear information on disability and eliciting the factors that parents deem most important in making decisions about periviable birth.
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Affiliation(s)
- Brownsyne Tucker Edmonds
- Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN
| | - Teresa A. Savage
- University of Illinois at Chicago, Department of Women, Children & Family Health Science, Chicago, IL
| | - Robert E. Kimura
- Rush University Medical Center, Department of Pediatrics, Chicago, IL
| | - Sarah J. Kilpatrick
- Cedars-Sinai Medical Center, Department of Obstetrics and Gynecology, Los Angeles, CA
| | - Miriam Kuppermann
- University of California, San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA
| | - William Grobman
- Northwestern University Medical School, Obstetrics and Gynecology-Maternal Fetal Medicine, Chicago, IL
| | - Karen Kavanaugh
- Wayne State University College of Nursing and the Children’s Hospital of Michigan, Detroit, MI
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Abstract
The ability of intensive care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In patients with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made. Withdrawal of life support at the patient's request is lawful at common law and, in some states of Australia, by legal statute. In the intensive care setting though, it is more common for therapy to be withdrawn because the therapy is of no perceived benefit or not in the patient's best interests. However, in Australia there is little case law and very little legislation to direct the decision of whether to withdraw life-sustaining therapy on the grounds of futility or the patient's best interests. The legislation that does exist in Australia, as well as law from other jurisdictions, largely places responsibility for the decision to withdraw therapy on the doctor in charge of the patient's care. However much weight is frequently placed on the wishes of the family. Disagreements between family and clinicians over decisions to withdraw therapy are unusual and generally resolve over time. However if disagreement persists, it may be advisable to apply to the courts for a declaratory judgement, given the tenuous legal basis of withdrawal of life-sustaining therapy in Australia and the uncertainty over the courts’ view of the role of the patient's family in the decision-making process.
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Affiliation(s)
- R J Young
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, S.A. 5000
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Abstract
For nearly five years, bioethicists and neurologists debated whether Jahi McMath, an African American teenager, was alive or dead. While Jahi's condition provides a compelling study for analyzing brain death, circumscribing her life status to a question of brain death fails to acknowledge and respond to a chronic, if uncomfortable, bioethics problem in American health care-namely, racial bias and unequal treatment, both real and perceived. Bioethicists should examine the underlying, arguably broader social implications of what Jahi's medical treatment and experience represented. On any given day, disparities in the quality of health care and health outcomes for people of color in comparison to whites are evidenced in American hospitals and clinics. These disparities are not entirely explained by differences in patient education, insurance status, employment, income, expressed preference for treatments, and severity of disease. Instead, research indicates that, even for African Americans able to gain access to health care services and navigate institutional nuances, disparities persist across a broad range of services, including diagnostic screening and general medical care, mental health diagnosis and treatment, pain management, HIV-related care, and treatments for cancer, heart disease, diabetes, and kidney disease.
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Wen FH, Chen JS, Su PJ, Chang WC, Hsieh CH, Hou MM, Chou WC, Tang ST. Terminally Ill Cancer Patients' Concordance Between Preferred Life-Sustaining Treatment States in Their Last Six Months of Life and Received Life-Sustaining Treatment States in Their Last Month: An Observational Study. J Pain Symptom Manage 2018; 56:509-518.e3. [PMID: 30025938 DOI: 10.1016/j.jpainsymman.2018.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 03/19/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 12/29/2022]
Abstract
CONTEXT/OBJECTIVE The extent to which patients' preferences for end-of-life (EOL) care are honored may be distorted if preferences are measured long before death, a common approach of existing research. We examined the concordance between cancer patients' states of life-sustaining treatments (LSTs) received in their last month and LST preference states assessed longitudinally over their last six months. METHODS We examined states of preferred and received LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and nasogastric tube feeding) in 271 cancer patients' last six months by a transition model with hidden Markov modeling (HMM). The extent of concordance was measured by a percentage and a kappa value. RESULTS HMM identified four LST preference states: life-sustaining preferring, comfort preferring, uncertain, and nutrition preferring. HMM identified four LST states received in patients' last month: generally received LSTs, LSTs uniformly withheld, selectively received LSTs, and received intravenous nutrition only. LSTs received concurred poorly with patients' preferences estimated right before death (39.5% and kappa value: 0.06 [95% CI: -0.02, 0.13]). Patients in the life-sustaining-preferring, uncertain, and nutrition-preferring states primarily received no LSTs, and patients in three of four states received intravenous nutrition against their preferences. Concordance was strongest for comfort-preferring patients. CONCLUSIONS Concordance was poor between patients' preferred and received LST states. Interventions are needed to clarify patients' EOL care goals and to facilitate their understanding about LST's ineffectiveness in prolonging life at EOL. Such interventions might increase patients' comfort preference and ensure concordance between their preferred and received EOL care.
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Affiliation(s)
- Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Po-Jung Su
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
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Superdock AK, Barfield RC, Brandon DH, Docherty SL. Exploring the vagueness of Religion & Spirituality in complex pediatric decision-making: a qualitative study. BMC Palliat Care 2018; 17:107. [PMID: 30208902 PMCID: PMC6134505 DOI: 10.1186/s12904-018-0360-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 08/31/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Medical advances have led to new challenges in decision-making for parents of seriously ill children. Many parents say religion and spirituality (R&S) influence their decisions, but the mechanism and outcomes of this influence are unknown. Health care providers (HCPs) often feel unprepared to discuss R&S with parents or address conflicts between R&S beliefs and clinical recommendations. Our study sought to illuminate the influence of R&S on parental decision-making and explore how HCPs interact with parents for whom R&S are important. METHODS A longitudinal, qualitative, descriptive design was used to (1) identify R&S factors affecting parental decision-making, (2) observe changes in R&S themes over time, and (3) learn about HCP perspectives on parental R&S. The study sample included 16 cases featuring children with complex life-threatening conditions. The length of study for each case varied, ranging in duration from 8 to 531 days (median = 380, mean = 324, SD = 174). Data from each case included medical records and sets of interviews conducted at least monthly with mothers (n = 16), fathers (n = 12), and HCPs (n = 108). Thematic analysis was performed on 363 narrative interviews to identify R&S themes and content related to decision-making. RESULTS Parents from 13 cases reported R&S directly influenced decision-making. Most HCPs were unaware of this influence. Fifteen R&S themes appeared in parent and HCP transcripts. Themes most often associated with decision-making were Hope & Faith, God is in Control, Miracles, and Prayer. Despite instability in the child's condition, these themes remained consistently relevant across the trajectory of illness. R&S influenced decisions about treatment initiation, procedures, and life-sustaining therapy, but the variance in effect of R&S on parents' choices ultimately depended upon other medical & non-medical factors. CONCLUSIONS Parents consider R&S fundamental to decision-making, but apply R&S concepts in vague ways, suggesting R&S impact how decisions are made more than what decisions are made. Lack of clarity in parental expressions of R&S does not necessarily indicate insincerity or underestimation of the seriousness of the child's prognosis; R&S can be applied to decision-making in both functional and dysfunctional ways. We present three models of how religious and spiritual vagueness functions in parental decision-making and suggest clinical applications.
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Affiliation(s)
- Alexandra K. Superdock
- School of Medicine, Duke University, Durham, NC USA
- Pediatrics Residency Program, University of Pittsburgh Medical Center, 4401 Penn Avenue, Pittsburgh, 15224 PA USA
| | - Raymond C. Barfield
- Division of Pediatric Hematology and Oncology, Duke University School of Medicine, 2 Chapel Drive, 0034 Westbrook, Durham, NC 27708 USA
| | - Debra H. Brandon
- Department of Pediatrics, Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710 USA
- School of Nursing, Duke University, 307 Trent Drive, Durham, NC 27710 USA
| | - Sharron L. Docherty
- Department of Pediatrics, Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710 USA
- School of Nursing, Duke University, 307 Trent Drive, Durham, NC 27710 USA
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Dzeng E, Dohan D, Curtis JR, Smith TJ, Colaianni A, Ritchie CS. Homing in on the Social: System-Level Influences on Overly Aggressive Treatments at the End of Life. J Pain Symptom Manage 2018; 55:282-289.e1. [PMID: 28865869 PMCID: PMC6329585 DOI: 10.1016/j.jpainsymman.2017.08.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [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: 04/07/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/28/2022]
Abstract
CONTEXT The American Medical System is programmed to a default setting of aggressive care for the terminally ill. Institutional norms of decision making have been shown to promote high-intensity care, regardless of consistency with patient preferences. There are myriad factors at a system, clinician, surrogate, and patient level that drive the culture of overly aggressive treatments in American hospitals. OBJECTIVE The objective of this study was to understand physician perspective of the ways systems-level factors influence patient, physician, and surrogate perceptions and consequent behavior. METHODS Semi-structured in-depth qualitative interviews with 42 internal medicine physicians across three American academic medical centers were conducted. This qualitative study was exploratory in nature, intended to enhance conceptual understanding of underlying phenomena that drive physician attitudes and behavior. RESULTS The interviews revealed many factors that contributed to overly aggressive treatments at the end of life. Systemic factors, which describe underlying cultures (including institutional, professional, or community-based cultures), typical practices of care, or systemic defaults that drive patterns of care, manifested its influence both directly and through its impact on patient, surrogate, and physician behaviors and attitudes. CONCLUSION Institutional cultures, social norms, and systemic defaults influence both normative beliefs regarding standards of care and treatments plans that may not benefit seriously ill patients.
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Affiliation(s)
- Elizabeth Dzeng
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA.
| | - Daniel Dohan
- Institute of Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington, USA
| | - Thomas J Smith
- Department of Oncology and Palliative Care, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Christine S Ritchie
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
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16
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Tang ST, Wen FH, Chang WC, Hsieh CH, Chou WC, Chen JS, Hou MM. Preferences for Life-Sustaining Treatments Examined by Hidden Markov Modeling Are Mostly Stable in Terminally Ill Cancer Patients' Last Six Months of Life. J Pain Symptom Manage 2017; 54:628-636.e2. [PMID: 28782702 DOI: 10.1016/j.jpainsymman.2017.07.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 05/02/2017] [Revised: 07/22/2017] [Accepted: 07/25/2017] [Indexed: 02/06/2023]
Abstract
CONTEXT Stability of life-sustaining treatment (LST) preferences at end of life (EOL) has not been well established for terminally ill cancer patients nor have transition probabilities been explored between different types of preferences. OBJECTIVE We assessed the stability of cancer patients' LST preferences at EOL by identifying distinct LST preference states and examining the probability of each state transitioning to other states between consecutive time points. METHODS Stability of LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, cardiac massage, intubation with mechanical ventilation, intravenous nutrition support, and nasogastric tube feeding) was examined among 303 cancer patients in their last six months by hidden Markov modeling. RESULTS Six distinct LST preference states (initial size) were identified: uniformly preferring (8.3%), uniformly rejecting (33.8%), and uniformly uncertain about (20.5%) LST, favoring intravenous nutrition support but rejecting other treatments (19.9%), and favoring (3.6%) or uncertain about (14.0%) nutrition support and ICU care while rejecting other treatments. Shifts between LST preference states were relatively small between any two time points (transition probability of staying at the same state was 92.1% to 97.5%), except for the state characterized by uncertainty about nutrition support and ICU care while rejecting other treatments, in which 8.3% of patients shifted LST preferences toward uniform uncertainty at a subsequent assessment. CONCLUSIONS Our patients' LST preferences remained stable without prominent shifts toward preferring less aggressive LSTs even when death approached. Clarifying patients' understanding and expectations about LST efficacy and tailoring interventions to the unique needs of patients in each state may provide personalized EOL care.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University, School of Nursing, Tao-Yuan, Taiwan, ROC; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, ROC; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, ROC
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
| | - Ming-Mo Hou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, ROC; Chang Gung University College of Medicine, Tao-Yuan, Taiwan, ROC
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Affiliation(s)
- Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, faculty of philosophy, University of Oxford, UK
- John Radcliffe Hospital, Oxford, UK
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Albayrak T, Şencan İ, Akça Ö, Koç EM, Aksoy H, Ünsal S, Bülbül İ, Bahadır A, Kasım İ, Kahveci R, Özkara A. The ideas about advanced life support and affecting factors at the end-stage of life in a hospital in Turkey. PLoS One 2017; 12:e0181456. [PMID: 28732071 PMCID: PMC5521791 DOI: 10.1371/journal.pone.0181456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 07/01/2017] [Indexed: 11/19/2022] Open
Abstract
Background The participation of the people in health decisions may be structured in various levels. One of these is participation in decisions for the treatment. “Advanced directives” is one of the examples for the participation in decisions for the treatment. Aim We wanted to determine the decisions on advanced life support at the end-stage of life in case of a life-threatening illness for the people themselves and their first degree relatives and the factors effecting these decisions. Design and setting The cross-sectional study was conducted with volunteers among patients and patient relatives who applied to all polyclinics of the Ankara Numune Training and Research Hospital except the emergency, oncology and psychiatry polyclinics between 15.12.2012 and 15.03.2013. Method A questionnaire, the Hospital Anxiety Depression (HAD) scale, and Templer’s Death Anxiety Scale (TDA) were applied to all individuals. SPSS for Win. Ver. 17.0 and MS-Excel 2010 Starter software bundles were used for all statistical analysis and calculations. Results The participants want both themselves and their first degree relatives included in end-stage decision-making process. Therefore, the patients and their families should be informed adequately during decision making process and quality communication must be provided. Conclusion Participants who have given their end-stage decisions previously want to be treated according to these decisions. This desire can just be possible by advanced directives.When moral and material loads of end-stage process are taken into consideration, countries, in which advanced directives are practiced, should be examined well and participants’ desire should be evaluated in terms of practicability.
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Affiliation(s)
| | - İrfan Şencan
- Ankara Numune Training and Research Hospital, Department of Family Medicine, Ankara, Turkey
| | - Ömer Akça
- Kayseri Training and Research Hospital, Department of Internal Medicine, Kayseri, Turkey
| | - Esra Meltem Koç
- Izmır Katip Celebi University Medical Faculty, Department of Family Medicine, Izmir, Turkey
- * E-mail:
| | - Hilal Aksoy
- Pamukkale Pelitlibag Family Health Center, Denizli, Turkey
| | - Selim Ünsal
- Sefkat No 2 Family Health Center, Ankara, Turkey
| | | | - Adem Bahadır
- Kalkandere No 1 Family Health Center, Rize, Turkey
| | - İsmail Kasım
- Ankara Numune Training and Research Hospital, Department of Family Medicine, Ankara, Turkey
| | - Rabia Kahveci
- Ankara Numune Training and Research Hospital, Department of Family Medicine, Ankara, Turkey
| | - Adem Özkara
- Corum Hitit University Medical Faculty, Department of Family Medicine, Corum, Turkey
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Liu TW, Wen FH, Wang CH, Hong RL, Chow JM, Chen JS, Chiu CF, Tang ST. Terminally Ill Taiwanese Cancer Patients' and Family Caregivers' Agreement on Patterns of Life-Sustaining Treatment Preferences Is Poor to Fair and Declines Over a Decade: Results From Two Independent Cross-Sectional Studies. J Pain Symptom Manage 2017; 54:35-45.e4. [PMID: 28450219 DOI: 10.1016/j.jpainsymman.2017.02.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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: 09/16/2016] [Revised: 01/16/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT/OBJECTIVE Temporal changes have not been examined in patient-caregiver agreement on life-sustaining treatment (LST) preferences at end of life (EOL). We explored the extent of and changes in patient-caregiver agreement on LST-preference patterns for two independent cohorts of Taiwanese cancer patient-family caregiver dyads recruited a decade apart. METHODS We surveyed preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis among 1049 and 1901 dyads in 2003-2004 and 2011-2012, respectively. LST-preference patterns were examined by multi-group latent class analysis. Extent of patient-caregiver agreement on LST-preference patterns was determined by percentage agreement and kappa coefficients. RESULTS For both patients and family caregivers, we identified seven distinct LST-preference classes. Patient-caregiver agreement on LST-preference patterns was poor to fair across both study cohorts, indicated by 24.4%-43.5% agreement and kappa values of 0.06 (95% CI: 0.04, 0.09) to 0.27 (0.23, 0.30), and declined significantly over time. Agreement on LST-preference patterns was most likely when both patients and caregivers uniformly rejected LSTs. When patients disagreed with caregivers on LST-preference patterns, discrepancies were most likely when patients totally rejected LSTs but caregivers uniformly preferred LSTs or preferred nutritional support but rejected other treatments. CONCLUSION Patients and family caregivers had poor-to-fair agreement on LST-preference patterns, and agreement declined significantly over a decade. Encouraging an open dialogue between patients and their family caregivers about desired EOL care would facilitate patient-caregiver agreement on LST-preference patterns, thus honoring terminally ill cancer patients' wishes when they cannot make EOL-care decisions.
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Affiliation(s)
- Tsang-Wu Liu
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Cheng-Hsu Wang
- Division of Hematology-Oncology and Director of Cancer Center, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Ruey-Long Hong
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jyh-Ming Chow
- Section of Hematology and Medical Oncology, Wan-Fang Hospital, Taipei, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Chang-Fang Chiu
- Division of Hematology-Oncology and Comprehensive Cancer Center, China Medical University Hospital, Taichung, Taiwan
| | - Siew Tzuh Tang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Tao-Yuan, Taiwan.
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20
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Balboni MJ, Sullivan A, Enzinger AC, Smith PT, Mitchell C, Peteet JR, Tulsky JA, VanderWeele T, Balboni TA. U.S. Clergy Religious Values and Relationships to End-of-Life Discussions and Care. J Pain Symptom Manage 2017; 53:999-1009. [PMID: 28185893 PMCID: PMC5474165 DOI: 10.1016/j.jpainsymman.2016.12.346] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 12/27/2016] [Accepted: 12/29/2016] [Indexed: 11/24/2022]
Abstract
CONTEXT Although clergy interact with approximately half of U.S. patients facing end-of-life medical decisions, little is known about clergy-congregant interactions or clergy influence on end-of-life decisions. OBJECTIVE The objective was to conduct a nationally representative survey of clergy beliefs and practices. METHODS A mailed survey to a nationally representative sample of clergy completed in March 2015 with 1005 of 1665 responding (60% response rate). The primary predictor variable was clergy religious values about end-of-life medical decisions, which measured belief in miracles, the sanctity of life, trust in divine control, and redemptive suffering. Outcome variables included clergy-congregant end-of-life medical conversations and congregant receipt of hospice and intensive care unit (ICU) care in the final week of life. RESULTS Most U.S. clergy are Christian (98%) and affirm religious values despite a congregant's terminal diagnosis. Endorsement included God performing a miracle (86%), pursuing treatment because of the sanctity of life (54%), postponement of medical decisions because God is in control (28%), and enduring painful treatment because of redemptive suffering (27%). Life-prolonging religious values in end-of-life medical decisions were associated with fewer clergy-congregant conversations about considering hospice (adjusted odds ratio [AOR], 0.58; 95% CI 0.42-0.80), P < 0.0001), stopping treatment (AOR 0.58, 95% CI 0.41-0.84, P = 0.003), and forgoing future treatment (AOR 0.50, 95% CI 0.36-0.71, P < 0.001) but not associated with congregant receipt of hospice or ICU care. Clergy with lower medical knowledge were less likely to have certain end-of-life conversations. The absence of a clergy-congregant hospice discussion was associated with less hospice (AOR 0.45; 95% CI 0.29-0.66, P < 0.001) and more ICU care (AOR 1.67; 95% CI 1.14-2.50, P < 0.01) in the final week of life. CONCLUSION American clergy hold religious values concerning end-of-life medical decisions, which appear to decrease end-of-life discussions. Clergy end-of-life education may enable better quality end-of-life care for religious patients.
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Affiliation(s)
- Michael J Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA.
| | - Adam Sullivan
- Department of Biostatistics, Brown University, Providence, Rhode Island
| | - Andrea C Enzinger
- Departments of Medical Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Patrick T Smith
- Harvard Medical School Center for Bioethics, Boston, Massachusetts, USA; Gordon-Conwell Theological Seminary, S. Hamilton, Massachusetts, USA
| | - Christine Mitchell
- Department of Social and Behavioral Health, Harvard School of Public Health, Boston, Massachusetts, USA
| | - John R Peteet
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tyler VanderWeele
- Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Epidemiology and Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Tracy A Balboni
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Initiative on Health, Religion, and Spirituality within Harvard, Boston, Massachusetts, USA; Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Bandini JI, Courtwright A, Zollfrank AA, Robinson EM, Cadge W. The role of religious beliefs in ethics committee consultations for conflict over life-sustaining treatment. J Med Ethics 2017; 43:353-358. [PMID: 28137999 DOI: 10.1136/medethics-2016-103930] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 09/06/2016] [Revised: 12/23/2016] [Accepted: 01/10/2017] [Indexed: 06/06/2023]
Abstract
Previous research has suggested that individuals who identify as being more religious request more aggressive medical treatment at end of life. These requests may generate disagreement over life-sustaining treatment (LST). Outside of anecdotal observation, however, the actual role of religion in conflict over LST has been underexplored. Because ethics committees are often consulted to help mediate these conflicts, the ethics consultation experience provides a unique context in which to investigate this question. The purpose of this paper was to examine the ways religion was present in cases involving conflict around LST. Using medical records from ethics consultation cases for conflict over LST in one large academic medical centre, we found that religion can be central to conflict over LST but was also present in two additional ways through (1) religious coping, including a belief in miracles and support from a higher power, and (2) chaplaincy visits. In-hospital mortality was not different between patients with religiously versus non-religiously centred conflict. In our retrospective cohort study, religion played a variety of roles and did not lead to increased treatment intensity or prolong time to death. Ethics consultants and healthcare professionals involved in these cases should be cognisant of the complex ways that religion can manifest in conflict over LST.
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Affiliation(s)
- Julia I Bandini
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
| | - Andrew Courtwright
- Institute for Patient Care, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angelika A Zollfrank
- Department of Spiritual Care, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Ellen M Robinson
- Institute for Patient Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wendy Cadge
- Department of Sociology, Brandeis University, Waltham, Massachusetts, USA
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22
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Ryu JY, Bae H, Kenji H, Xiaomei Z, Kwon I, Ahn KJ. Physicians' attitude toward the withdrawal of life-sustaining treatment: A comparison between Korea, Japan, and China. Death Stud 2016; 40:630-637. [PMID: 27572742 DOI: 10.1080/07481187.2016.1203375] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
End-of-life care decision making has become a matter of serious ethical and legal concern in the three Far East Asian Countries of China, Japan, and Korea. Researchers in the three countries collaboratively conducted a comparative descriptive study with respect to physicians' perspectives concerning end-of-life care decisions. In spite of cultural similarities, each country has its own unique set of social, cultural, and political circumstances. So the content and scope of policies and laws on end-of-life decision reflect the differing views of people based on their social status, moral values, religious beliefs, and economic status.
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Affiliation(s)
- Ji Yeong Ryu
- a Department of Emergency Medicine , Hallym University Medical Center, Kangdong Sacred Heart Hospital , Seoul , Korea
| | - Hyuna Bae
- b School of Law, Ewha Womans University , Seoul , Korea
| | - Hattori Kenji
- c Graduate School of Medicine, Gunma University , Gunma , Japan
| | - Zhai Xiaomei
- d Research Center for Bioethics, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Ivo Kwon
- e School of Medicine, Ewha Womans University , Seoul , Korea
| | - Kyong Jin Ahn
- f Interdisciplinary Program in Bioethics Policy Studies , Ewha Womans University , Seoul , Korea
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Chung GS, Yoon JD, Rasinski KA, Curlin FA. US Physicians' Opinions about Distinctions between Withdrawing and Withholding Life-Sustaining Treatment. J Relig Health 2016; 55:1596-606. [PMID: 26725047 DOI: 10.1007/s10943-015-0171-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Decisions to withhold or withdraw life-sustaining treatment (LST) precede the majority of ICU deaths. Although professional guidelines generally treat the two as ethically equivalent, evidence suggests withdrawing LST is often more psychologically difficult than withholding it. The aim of the experiment was to investigate whether physicians are more supportive of withholding LST than withdrawing it and to assess how physicians' opinions are shaped by their religious characteristics, specialty, and experience caring for dying patients. In 2010, a survey was mailed to 2016 practicing US physicians. Physicians were asked whether physicians should always comply with a competent patient's request to withdraw LST, whether withdrawing LST is more psychologically difficult than withholding it, and whether withdrawing LST is typically more ethically problematic than withholding it. Of 1880 eligible physicians, 1156 responded to the survey (62%); 93% agreed that physicians should always comply with a competent patient's request to withdraw LST. More than half of the physicians reported that they find withdrawing LST more psychologically difficult than withholding it (61%), and that withdrawing LST is typically more ethically problematic (59%). Physician religiosity was associated with finding withdrawal more ethically problematic, but not with finding it more psychologically difficult. Physicians working in an end-of-life specialty and physicians with more experience caring for dying patients were less likely to endorse either a psychological or an ethical distinction between withdrawing and withholding LST. Most US physicians find withdrawing LST not only more psychologically difficult, but also more ethically problematic than withholding such treatment. Physicians' opinions are to some extent shaped by their religious characteristics, specialty, and levels of experience caring for dying patients.
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Affiliation(s)
- Grace S Chung
- MacLean Center for Clinical Medical Ethics, Department of Medicine, The University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - John D Yoon
- MacLean Center for Clinical Medical Ethics, Department of Medicine, The University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | | | - Farr A Curlin
- Trent Center for Bioethics, Humanities and History of Medicine, Duke University, Durham, NC, USA
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Abstract
The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.
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Affiliation(s)
- Mia Svantesson
- Centre for Nursing Science, Orebro University Hospital, Sweden.
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Abstract
This study was an investigation of which distinctive elements would best describe good and bad death, preferences for life-sustaining treatment, and advance directives. The following elements of a good death were identified by surveying 185 acute-care hospital nurses: comfort, not being a burden to the family, a good relationship with family members, a readiness to die, and a belief in perpetuity. Comfort was regarded as the most important. Distinctive elements of a bad death were: persistent vegetative state, sudden death, pain and agony, dying alone, and being a burden to the family. Of the 185 respondents, 90.8% answered that they did not intend to receive life-sustaining treatment if they suffered from a terminal illness without any chance of recovery; 77.8% revealed positive attitudes toward advance directives. Sixty-seven per cent of the respondents stated that they were willing to discuss their own death and dying; the perception of such discussions differed according to the medical condition ( p = 0.001). The elements of a bad death differed significantly depending on the disease state ( p = 0.003) and on economic status ( p = 0.023).
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Affiliation(s)
- Shinmi Kim
- Department of Nursing, Woosuk University, Chonbuk, South Korea.
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Abstract
Kahneman and Tversky's (1979) Prospect theory was tested as a model of preferences for prolonging life under various hypothetical health statuses. A sample of 384 elderly people living in congregate housing (263 healthy, 131 frail) indicated how long (if at all) they would want to live under each of nine hypothetical health conditions (e.g., limited to bed or chair in a nursing home). Prospect theory, a decision model which takes into account the individual's point of reference, would predict that frail people would view prospective poorer health conditions as more tolerable and express preferences to live longer in worse health than would currently healthy people. In separate analyses of covariance, we evaluated preferences for continued life under four conditions of functional ability, four conditions of cognitive impairment, and three pain conditions—each as a function of participant's current health status (frail vs. healthy). The predicted interaction between frailty and declining prospective health status was obtained. Frail participants expressed preferences for longer life under more compromised health conditions than did healthy participants. The results imply that such preferences are malleable, changing as health deteriorates. They also help explain disparities between proxy decision-makers' and patients' own preferences as expressed in advance directives.
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Affiliation(s)
- Laraine Winter
- Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Ayeh DD, Tak HJ, Yoon JD, Curlin FA. U.S. Physicians' Opinions About Accommodating Religiously Based Requests for Continued Life-Sustaining Treatment. J Pain Symptom Manage 2016; 51:971-8. [PMID: 27039013 DOI: 10.1016/j.jpainsymman.2015.12.337] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 06/03/2015] [Revised: 12/19/2015] [Accepted: 12/24/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Families of critically ill patients occasionally request that physicians continue life-sustaining treatment (LST), sometimes giving religious reasons. OBJECTIVES To examine whether U.S. physicians are more likely to accommodate requests for LST that are based on religious reasons. METHODS In 2010, we surveyed 1156 practicing U.S. physicians from specialties likely to care for adult patients with advanced illness. The questionnaire included two randomized experimental vignettes: one where a family asked that LST be continued for a patient that met brain death criteria and a second where the son of an elderly patient with cancer insists on continuing LST. In both, we experimentally varied the reasons that the family member gave to justify the request, to see if physicians are more likely to accommodate a request based on a religious requirement or hope for a miracle, compared to no mention of either. For physicians' religious characteristics, we assessed their religious affiliation and level of religiosity. RESULTS For the patient meeting brain death criteria, physicians were more likely to accommodate the request to continue LST when the family mentioned their Orthodox Jewish community (85% vs. 70%, P < 0.001). For the patient with metastatic cancer, physicians were more likely to accommodate the request when the son said his religious faith does not permit discontinuing LST (65% vs. 46%, P < 0.001), but not when he said he expected divine healing (50% vs. 46%). CONCLUSION Physicians appear more willing to accommodate requests to continue LST when those requests are based on particular religious communities or traditions, but not when based on expectations of divine healing.
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Affiliation(s)
| | - Hyo Jung Tak
- Department of Health Services Research and Administration, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John D Yoon
- Department of Medicine and MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Farr A Curlin
- Trent Center for Bioethics, Humanities & History of Medicine, Duke University, Durham, North Carolina, USA.
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Tang ST, Wen FH, Liu LN, Chiang MC, Lee SCK, Chou MC, Feng WL, Lin YC, Liu IP, Kuo YH, Chi SC, Lee KC. A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society. J Pain Symptom Manage 2016; 51:907-915.e2. [PMID: 26921491 DOI: 10.1016/j.jpainsymman.2015.12.326] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/20/2015] [Accepted: 12/24/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Temporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible. OBJECTIVES To identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients. METHODS Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. RESULTS Five distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%-18.6%), and favoring nutritional support but rejecting (37.1%-37.5%) or uncertain about other treatments (8.0%-10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time. CONCLUSION Family caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University School of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, New Taipei City, Taiwan, Republic of China
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Shiuyu C K Lee
- School of Nursing, National Taipei University of Nursing and Health Science, Taipei City, Taiwan, Republic of China
| | - Man Chun Chou
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Wei-Lien Feng
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan, Republic of China
| | - Yu-Chuan Lin
- Department of Nursing, Tzu Chi University, Hualien City, Taiwan, Republic of China
| | - I-Ping Liu
- Chi-Mei Hospital, Chi Ali, Taiwan, Republic of China
| | - Ya-Hui Kuo
- Chia-Yi Christian Hospital, Chiayi City, Taiwan, Republic of China
| | - Shu Ching Chi
- Department of Nursing, E-Da Hospital and I-Shou University, Kaohsiung City, Taiwan, Republic of China
| | - Kwo C Lee
- School of Nursing, China Medical University, Taichung, Taiwan, Republic of China; Department of Nursing, China Medical University Hospital, Taichung, Taiwan, Republic of China
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Maiser S, Kabir A, Sabsevitz D, Peltier W. Locked-In Syndrome: Case Report and Discussion of Decisional Capacity. J Pain Symptom Manage 2016; 51:789-793. [PMID: 26674610 DOI: 10.1016/j.jpainsymman.2015.10.021] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/26/2015] [Accepted: 10/28/2015] [Indexed: 12/14/2022]
Abstract
Locked-in syndrome (LIS) is a rare neurologic disorder rendering an individual quadriplegic and anarthric with preserved self-awareness and normal if not near-normal cognition. A lesion to the ventral pons causes the classic form of LIS, and patients can typically interact with their environment with eye/eyelid movements. LIS patients may live for years with preserved quality of life (QoL) and cognitive function, but with severe disability. However, medical providers and family often underestimate the patient's QoL, and choose less aggressive care. Prompt assessment of decisionality in LIS patients is challenging, but it must be done to allow these patients to participate in their care. We present the case of a 54-year-old man with LIS. The medical team recommended comfort measures, but the family advocated involving the patient in goals of care discussions. The patient was determined to be decisional during the acute hospitalization, and he elected for life-prolonging care. This case emphasizes the importance of unbiased shared decision making, but also the importance of utilizing a practical framework to assess the decision-making capacity in these patients. We provide a suggested approach to determining decision-making capacity in similar cases or conditions.
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Affiliation(s)
- Samuel Maiser
- Palliative Care Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Departments of Neurology and Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA.
| | - Ashish Kabir
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David Sabsevitz
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Wendy Peltier
- Palliative Care Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Tang ST, Wen FH, Hsieh CH, Chou WC, Chang WC, Chen JS, Chiang MC. Preferences for Life-Sustaining Treatments and Associations With Accurate Prognostic Awareness and Depressive Symptoms in Terminally Ill Cancer Patients' Last Year of Life. J Pain Symptom Manage 2016; 51:41-51.e1. [PMID: 26386187 DOI: 10.1016/j.jpainsymman.2015.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 06/22/2015] [Revised: 08/20/2015] [Accepted: 09/03/2015] [Indexed: 11/23/2022]
Abstract
CONTEXT The stability of life-sustaining treatment (LST) preferences at end of life (EOL) has been established. However, few studies have assessed preferences more than two times. Furthermore, associations of LST preferences with modifiable variables of accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms have been investigated in cross-sectional studies only. OBJECTIVES To explore longitudinal changes in LST preferences and their associations with accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms in terminally ill cancer patients' last year. METHODS LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, intubation, and mechanical ventilation) were measured approximately every two weeks. Changes in LST preferences and their associations with independent variables were examined by hierarchical generalized linear modeling with logistic regression. RESULTS Participants (n = 249) predominantly rejected cardiopulmonary resuscitation, ICU care, intubation, and mechanical ventilation at EOL without significant changes as death approached. Patients with inaccurate prognostic awareness were significantly more likely than those with accurate understanding to prefer ICU care, intubation, and mechanical ventilation than to reject these LSTs. Patients with more severe depressive symptoms were less likely to prefer ICU care and to be undecided about wanting ICU care and mechanical ventilation than to reject such LSTs. LST preferences were not associated with physician-patient EOL care discussions, which were rare in our sample. CONCLUSION LST preferences are stable in cancer patients' last year. Facilitating accurate prognostic awareness and providing adequate psychological support may counteract the increasing trend for aggressive EOL care and minimize emotional distress during EOL care decisions.
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Affiliation(s)
- Siew Tzuh Tang
- School of Nursing, Chang Gung University, Taoyuan, Taiwan.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Cheng Chang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jen-Shi Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Prischmann J. Life and death in Alzheimer's disease. Minn Med 2016; 99:20-21. [PMID: 26897890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Lattie EG, Asvat Y, Shivpuri S, Gerhart J, O'Mahony S, Duberstein P, Hoerger M. Associations Between Personality and End-of-Life Care Preferences Among Men With Prostate Cancer: A Clustering Approach. J Pain Symptom Manage 2016; 51:52-9. [PMID: 26344553 PMCID: PMC4698197 DOI: 10.1016/j.jpainsymman.2015.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 03/16/2015] [Revised: 08/13/2015] [Accepted: 08/21/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Increased focus on patient-centered care models has contributed to greater emphasis on improving quality of life at the end of life through personalized medicine. However, little is known about individual-level factors impacting end-of-life care preferences. OBJECTIVES To examine whether the five-factor model of personality explains variation in preferences for end-of-life care in men with prostate cancer. METHODS Two hundred twelve men with a prostate cancer diagnosis (mean age = 62 years) completed a measure of the five-factor model of personality--spanning the personality dimensions of neuroticism, agreeableness, extraversion, openness, and conscientiousness--and reported on end-of-life care preferences. Cluster analyses were used to partition the sample into groups with similar care preferences. Analyses of variance and Chi-square tests were used to evaluate differences in care preferences among the groups. RESULTS Cluster analyses revealed three groups of participants: "comfort-oriented patients," "service-accepting patients," and "service-reluctant patients." Most (67%) were comfort oriented, preferring palliative care and opposing life support services. A subset of patients were service accepting (17%), preferring both palliative care and life support, or were service reluctant (16%), preferring neither. Service-reluctant patients endorsed significantly higher levels of neuroticism (emotional instability and negativity) than comfort-oriented patients. Comfort-oriented patients endorsed significantly higher levels of agreeableness than service-accepting patients and service-reluctant patients. CONCLUSION Findings suggest that personality traits are associated with specific health care preferences. Individuals high on neuroticism are likely to report reluctance toward all forms of end-of-life care and may benefit from in-depth information about the process and likely outcomes of receiving life support and palliative care services.
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Affiliation(s)
- Emily G Lattie
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Yasmin Asvat
- Siteman Cancer Center, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Smriti Shivpuri
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - James Gerhart
- Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Sean O'Mahony
- Department of Palliative Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Paul Duberstein
- Departments of Psychiatry and Family Medicine, University of Rochester, Rochester, New York, USA
| | - Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Tulane University, New Orleans, Louisiana, USA
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Abstract
This qualitative study explored perspectives toward a good or bad death among 21 older homeless adults residing in transitional housing. Using grounded theory approach, the themes for a good death were (a) dying peacefully; (b) not suffering; (c) experiencing spiritual connection; and (d) making amends with significant others. Themes for a bad death were (a) experiencing death by accident or violence; (b) prolonging life with life supports; (c) becoming dependent while entering a dying trajectory; and (d) dying alone. Healthcare professionals need to develop approaches for end-of-life care grounded in understanding unique needs of older homeless adults.
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Affiliation(s)
- Eunjeong Ko
- a School of Social Work, San Diego State University , San Diego , California , USA
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34
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McCarthy M. Massachusetts requires doctors to inform patients about end of life options. BMJ 2014; 349:g7817. [PMID: 25547658 DOI: 10.1136/bmj.g7817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
The privileging of the substituted judgment standard as the gold standard for surrogate decision making in law and bioethics has constrained the research agenda in end-of-life decision making. The empirical literature is inundated with a plethora of "Newlywed Game" designs, in which potential patients and potential surrogates respond to hypothetical scenarios to see how often they "get it right." The preoccupation with determining the capacity of surrogates to accurately reproduce the judgments of another makes a number of assumptions that blind scholars to the variables central to understanding how surrogates actually make medical decisions on behalf of another. These assumptions include that patient preferences are knowable, surrogates have adequate and accurate information, time stands still, patients get the surrogates they want, patients want and surrogates utilize substituted judgment criteria, and surrogates are disinterested. This article examines these assumptions and considers the challenges of designing research that makes them problematic.
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Brom L, Pasman HRW, Widdershoven GAM, van der Vorst MJDL, Reijneveld JC, Postma TJ, Onwuteaka-Philipsen BD. Patients' preferences for participation in treatment decision-making at the end of life: qualitative interviews with advanced cancer patients. PLoS One 2014; 9:e100435. [PMID: 24964036 PMCID: PMC4070976 DOI: 10.1371/journal.pone.0100435] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/28/2014] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Patients are often encouraged to participate in treatment decision-making. Most studies on this subject focus on choosing between different curative treatment types. In the last phase of life treatment decisions differ as they often put more emphasis on weighing quantity against quality of life, such as whether or not to start treatment aimed at life prolongation but with the possibility of side effects. This study aimed to obtain insight into cancer patients' preferences and the reasons for patients' preferred role in treatment decision-making at the end of life. METHODS 28 advanced cancer patients were included at the start of their first line treatment. In-depth interviews were held prior to upcoming treatment decisions whether or not to start a life prolonging treatment. The Control Preference Scale was used to start discussing the extent and type of influence patients wanted to have concerning upcoming treatment decision-making. Interviews were audio taped and transcribed. RESULTS All patients wanted their physician to participate in the treatment decision-making process. The extent to which patients themselves preferred to participate seemed to depend on how patients saw their own role or assessed their own capabilities for participating in treatment decision-making. Patients foresaw a shift in the preferred level of participation to a more active role depending in the later phase of illness when life prolongation would become more limited and quality of life would become more important. CONCLUSION Patients vary in how much involvement they would like to have in upcoming treatment decision-making. Individual patients' preferences may change in the course of the illness, with a shift to more active participation in the later phases. Communication about patients' expectations, wishes and preferences for participation in upcoming treatment decisions is of great importance. An approach in which these topics are openly discussed would be beneficial.
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Affiliation(s)
- Linda Brom
- Department of Public and Occupational Health, EMGO Institute for Health and care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | - H. Roeline W. Pasman
- Department of Public and Occupational Health, EMGO Institute for Health and care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Guy A. M. Widdershoven
- Department of Medical Humanities, EMGO Institute for Health and care research, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Jaap C. Reijneveld
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Tjeerd J. Postma
- Department of Neurology, VU University Medical Center, Amsterdam, The Netherlands
| | - Bregje D. Onwuteaka-Philipsen
- Department of Public and Occupational Health, EMGO Institute for Health and care research, Expertise Center for Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
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Lüthi U. [Out of the blue]. Krankenpfl Soins Infirm 2014; 107:1. [PMID: 24683786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Wolenberg KM, Yoon JD, Rasinski KA, Curlin FA. Religion and United States physicians' opinions and self-predicted practices concerning artificial nutrition and hydration. J Relig Health 2013; 52:1051-1065. [PMID: 23754580 DOI: 10.1007/s10943-013-9740-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This study surveyed 1,156 practicing US physicians to examine the relationship between physicians' religious characteristics and their approaches to artificial nutrition and hydration (ANH). Forty percent of physicians believed that unless a patient is imminently dying, the patient should always receive nutrition and fluids; 75 % believed that it is ethically permissible for doctors to withdraw ANH. The least religious physicians were less likely to oppose withholding or withdrawing ANH. Compared to non-evangelical Protestant physicians, Jews and Muslims were significantly more likely to oppose withholding ANH, and Muslims were significantly more likely to oppose withdrawing ANH.
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Affiliation(s)
- Kelly M Wolenberg
- Vanderbilt University School of Medicine, 215 Light Hall, Nashville, TN, 37232, USA,
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Schubart JR, Levi BH, Dellasega C, Whitehead M, Green MJ. Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning. J Psychosoc Nurs Ment Health Serv 2013; 52:38-44. [PMID: 24200911 DOI: 10.3928/02793695-20131028-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 08/07/2013] [Indexed: 11/20/2022]
Abstract
This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.
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Rish JA. Inaugural address of the president, 146th session, 2013-14, POLST. J Miss State Med Assoc 2013; 54:293. [PMID: 24498711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Bransford C. DollyBelle: a patient's final gift. Minn Med 2013; 96:60. [PMID: 23437588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Affiliation(s)
- Dae Seog Heo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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43
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Abstract
UNLABELLED As the community of physicians and nurses dedicated to the care of critically ill children has gained ever more well-developed skill sets, the decision to either continue or forego life-sustaining measures has become less time-sensitive. As a result, there is greater opportunity for careful consideration and discussion. The core principle in making decisions about whether to continue or forego life-sustaining measures is the best interests of the child. However, there are many clinical situations wherein factors other than the child's best interests may influence treatment decisions. The present report seeks to examine the notion that in the arena of paediatric critical care medicine, the decision-making process regarding life-sustaining measures may place insufficient priority upon the child's best interests. We examine actual, de-identified clinical situations, encountered in the critical care arena in two categories: (i) cases that challenge the imperative to act in the child's best interests, and (ii) cases that compromise the ability of parents and caregivers to use child-centred, best-interests approaches to decision-making. Clarity surrounding the implications of a clinical decision for the patient is essential. Decisions that are not focused squarely on the child's best interests may compromise the delivery of optimally ethical end-of-life care. CONCLUSION The cases and analysis may benefit parents and caregivers as they struggle with the difficult ethical issues that accompany decisions to continue or forego life-sustaining measures in children.
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Affiliation(s)
- David N Cornfield
- Center of Excellence in Pulmonary Biology, Division of Pediatric Pulmonary, Allergy and Critical Care Medicine, Department of Pediatrics, Stanford University Medical School, Stanford, CA, USA.
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Affiliation(s)
- John Lantos
- Center for Practical Bioethics, Kansas City, MO, USA
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45
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Abstract
Although more is known about how individuals within families make decisions and manage more discrete issues when a family member is dying, less is known about how families as a unit manage after the sudden death of a family member. The article discusses an investigation that was conducted to better understand how families respond to the life-threatening illness or injury and eventual death of a family member. The purpose of the study was to define Family Management Styles (FMSs) and determine distinctive characteristics of each FMS used by families after the death of a family member who had life-sustaining therapy withdrawn as a result of an unexpected, life-threatening illness or injury. Interviews are conducted with 8 families (22 family members) 1 to 2 years after the death of their family members. A modified typology of FMSs based on a directed analysis that was then inductively modified includes: progressing, accommodating, maintaining, struggling, and floundering. Understanding FMSs and how FMSs may change over time, reflecting the changing focus of family work, will further aid in the development of family-focused interventions as well as develop FMSs within the context of end of life.
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Affiliation(s)
- Debra L Wiegand
- University of Maryland School of Nursing, Baltimore, MD 21201, USA.
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Curran V, Fleet L, Greene M. An exploratory study of factors influencing resuscitation skills retention and performance among health providers. J Contin Educ Health Prof 2012; 32:126-33. [PMID: 22733640 DOI: 10.1002/chp.21135] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Resuscitation and life support skills training comprises a significant proportion of continuing education programming for health professionals. The purpose of this study was to explore the perceptions and attitudes of certified resuscitation providers toward the retention of resuscitation skills, regular skills updating, and methods for enhancing retention. METHODS A mixed-methods, explanatory study design was undertaken utilizing focus groups and an online survey-questionnaire of rural and urban health care providers. RESULTS Rural providers reported less experience with real codes and lower abilities across a variety of resuscitation areas. Mock codes, practice with an instructor and a team, self-practice with a mannequin, and e-learning were popular methods for skills updating. Aspects of team performance that were felt to influence resuscitation performance included: discrepancies in skill levels, lack of communication, and team leaders not up to date on their skills. Confidence in resuscitation abilities was greatest after one had recently practiced or participated in an update or an effective debriefing session. Lowest confidence was reported when team members did not work well together, there was no clear leader of the resuscitation code, or if team members did not communicate. DISCUSSION The study findings highlight the importance of access to update methods for improving providers' confidence and abilities, and the need for emphasis on teamwork training in resuscitation. An eclectic approach combining methods may be the best strategy for addressing the needs of health professionals across various clinical departments and geographic locales.
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Affiliation(s)
- Vernon Curran
- Faculty of Medicine, Memorial University of Newfoundland, Canada.
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Führer M, Jox RJ, Borasio GD. [Treatment decisions for severely ill children and adolescents]. MMW Fortschr Med 2011; 153:35-38. [PMID: 21950186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Monika Führer
- Koordinationsstelle Kinderpalliativmedizin, Dr. von Haunersches Kinderspital und Interdisziplinäres Zentrum für Palliativmedizin, Ludwig-Maximilians-Universität München.
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Busch J, Rodogno R. Life support and euthanasia, a perspective on Shaw's new perspective. J Med Ethics 2011; 37:81-125. [PMID: 21030476 DOI: 10.1136/jme.2010.037275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
It has recently been suggested by Shaw (2007) that the distinction between voluntary active euthanasia, such as giving a patient a lethal overdose with the intention of ending that patient's life, and voluntary passive euthanasia, such as removing a patient from a ventilator, is much less obvious than is commonly acknowledged in the literature. This is argued by suggesting a new perspective that more accurately reflects the moral features of end-of-life situations. The argument is simply that if we consider the body of a mentally competent patient who wants to die, a kind of 'unwarranted' life support, then the distinction collapses. We argue that all Shaw has provided is a perspective that makes the conclusion that there is little distinction between voluntary active euthanasia and voluntary passive euthanasia only seemingly more palatable. In doing so he has yet to convince us that this perspective is superior to other perspectives and thus more accurately reflects the moral features of the situations pertaining to this issue.
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Affiliation(s)
- Jacob Busch
- Department of Philosophy, University of Aarhus, Denmark.
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Reinke LF, Slatore CG, Udris EM, Moss BR, Johnson EA, Au DH. The association of depression and preferences for life-sustaining treatments in veterans with chronic obstructive pulmonary disease. J Pain Symptom Manage 2011; 41:402-11. [PMID: 21145201 DOI: 10.1016/j.jpainsymman.2010.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 05/08/2010] [Accepted: 05/11/2010] [Indexed: 11/20/2022]
Abstract
CONTEXT Depressive symptoms are common among patients with chronic obstructive pulmonary disease (COPD) and may modify patients' preferences for life-sustaining therapy. Examining the relationship between patient preferences for life-sustaining treatments and depressive symptoms is important for clinicians engaging in end-of-life care discussions. OBJECTIVES To assess whether a history of depression or active depressive symptoms is associated with preferences for life-sustaining therapies among veterans with COPD. METHODS This was a cross-sectional study of 376 veterans who participated in a randomized trial to improve the occurrence and quality of end-of-life communication between providers and patients. Depressive symptoms were assessed by self-reported history and the Mental Health Index-5 survey. Preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) were assessed using standardized instruments. Multivariate logistic regression was conducted to adjust for potential confounding factors. RESULTS Participants were older men with severe COPD. A substantial proportion of participants noted that they would want MV (64.2%) or CPR (77.8%). Depressive history and active symptoms were not associated with preferences for MV and CPR either before or after adjusting for confounding variables. CONCLUSION Depressive history and active symptoms among veterans with severe COPD were not associated with their decisions for life-sustaining treatments. Clinicians caring for patients with COPD should understand the importance of assessing and treating patients with depressive symptoms, yet recognize that depressive symptoms may not be predictive of a patient declining life-sustaining treatments.
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Affiliation(s)
- Lynn F Reinke
- Health Services Research and Development, Seattle, Washington, USA.
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Moro TT, Kavanaugh K, Savage TA, Reyes MR, Kimura RE, Bhat R. Parent decision making for life support for extremely premature infants: from the prenatal through end-of-life period. J Perinat Neonatal Nurs 2011; 25:52-60. [PMID: 21311270 PMCID: PMC3085847 DOI: 10.1097/jpn.0b013e31820377e5] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Most deaths of extremely premature infants occur in the perinatal period. Yet, little is known about how parents make life support decisions in such a short period of time. In the paper, how parents make life support decisions for extremely premature infants from the prenatal period through death from the perspectives of parents, nurses, and physicians is described. Five cases, comprised of five mothers, four neonatologists, three nurses, and one neonatal nurse practitioner, are drawn from a larger collective case study. Prenatal, postnatal and end-of-life interviews were conducted, and medical record data were obtained. In an analysis by two research team members, mothers were found to exhibit these characteristics: desire for and actual involvement in life support decisions, weighing pain, suffering and hope in decision making, and wanting everything done for their infants. All mothers received decision making help and support from partners and family, but relationships with providers were also important. Finally, external resources impacted parental decision making in several of the cases. By understanding what factors contribute to parents' decision making, providers may be better equipped to prepare and assist parents when making life support decisions for their extremely premature infants.
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Affiliation(s)
- Teresa T. Moro
- Project Director, University of Illinois at Chicago, Department of Women, Children, and Family Health Science (MC802), College of Nursing, 845 S. Damen Avenue, Room 843, Chicago, IL 60612-7350, Phone: (312) 355-0210, Fax: (312) 996-8871
| | - Karen Kavanaugh
- Professor, University of Illinois at Chicago, Department of Women, Children, and Family Health Science (MC802), College of Nursing, 845 S. Damen Avenue, Room 848, Chicago, IL 60612-7350, Phone: (312) 996-6828
| | - Teresa A. Savage
- University of Illinois at Chicago, Research Assistant Professor, Department of Women, Children, and Family Health Science (MC802), College of Nursing, 845 S. Damen Avenue, Room 843, Chicago, IL 60612-7350, Phone: (312) 355-0210
| | - Maria R. Reyes
- Rush University Medical Center, Perinatal / Women's HC Nurse Practitioner, Clinical Coordinator, Rush Fetal & Neonatal Medicine Program, 407 Pro Building, Office: (312)942-9823, Fax:(312) 942-9198
| | - Robert E. Kimura
- Rush University Medical Center, Director of the Section of Neonatology and Department of Pediatrics, Rush University Medical Center, 1653 West Congress Parkway, ste. 622 Murdoch, Chicago, IL 60612-3833, Office: (312) 942-6640
| | - Rama Bhat
- University of Illinois Medical Center, Professor Emeritus of Pediatrics, University of Illinois at Medical Center, Chicago, IL-60612
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