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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2023:8850666231204305. [PMID: 37822226 DOI: 10.1177/08850666231204305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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Lamb JE, James AJ. Consent for skin biopsy in an unrepresented patient who is incarcerated: The ethical considerations. J Am Acad Dermatol 2023; 89:879-880. [PMID: 35680000 DOI: 10.1016/j.jaad.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/26/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Jordan E Lamb
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alaina J James
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Wendlandt B, Olm-Shipman C, Ceppe A, Hough CL, White DB, Cox CE, Carson SS. Surrogates of Patients With Severe Acute Brain Injury Experience Persistent Anxiety and Depression Over the 6 Months After ICU Admission. J Pain Symptom Manage 2022; 63:e633-e639. [PMID: 35595376 PMCID: PMC9179180 DOI: 10.1016/j.jpainsymman.2022.02.336] [Citation(s) in RCA: 4] [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: 01/10/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Severe Acute Brain Injury (SABI) is neurologically devastating, and surrogates for these patients may struggle with particularly complex decisions due to substantial prognostic uncertainty. OBJECTIVES To compare anxiety and depression symptoms over time between SABI surrogates and non-SABI surrogates for patients requiring prolonged mechanical ventilation (PMV). METHODS We conducted a secondary analysis of the data from a multicenter randomized trial of a decision aid intervention for surrogates of adults experiencing PMV. Eligible patients were enrolled from medical, surgical, trauma, cardiac, and neurologic intensive care units (ICUs). ICU admitting diagnoses were used to identify patients experiencing SABI. We compared anxiety and depression symptoms as measured by the Hospital Anxiety and Depression Scale score 6 months after trial enrollment between surrogates of patients with SABI and surrogates of patients experiencing PMV for other reasons. RESULTS Our analysis included 206 patients, 60 (29%) with SABI and 146 (71%) without SABI, and their primary surrogate decision makers. After adjusting for potential confounders including surrogate demographics, surrogate financial distress, patient severity of illness baseline GCS, and patient health status at 6 months, we found that surrogates of patients experiencing SABI had higher symptoms of anxiety and depression than surrogates of non-SABI patients (adjusted mean difference 3.6, 95% CI 1.2-6.0). CONCLUSION Surrogates of PMV patients with SABI experience persistently elevated anxiety and depression symptoms over 6 months compared to surrogates of PMV patients without SABI. Further work is needed to understand contributors to prolonged distress in this higher risk population.
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Affiliation(s)
- Blair Wendlandt
- Division of Pulmonary Diseases and Critical Care Medicine (B.W., A.C., S.S.C.), University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Casey Olm-Shipman
- Division of Neurocritical Care (C.O.-S.), Departments of Neurology and Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Agathe Ceppe
- Division of Pulmonary Diseases and Critical Care Medicine (B.W., A.C., S.S.C.), University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Catherine L Hough
- Department of Critical Care Medicine (D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Division of Pulmonary, Allergy, and Critical Care Medicine (C.E.C.), Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Christopher E Cox
- Division of Pulmonary and Critical Care (C.L.H.), Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Shannon S Carson
- Division of Pulmonary Diseases and Critical Care Medicine (B.W., A.C., S.S.C.), University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Wendlandt B, Ceppe A, Cox CE, Hanson LC, Nelson JE, Carson SS. The Association between Patient Health Status and Surrogate Decision Maker Post-Traumatic Stress Disorder Symptoms in Chronic Critical Illness. Ann Am Thorac Soc 2021; 18:1868-75. [PMID: 33794122 DOI: 10.1513/AnnalsATS.202010-1300OC] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Surrogate decision-makers of patients with chronic critical illness (CCI) are at high risk for symptoms of post-traumatic stress disorder (PTSD). Whether patient health status after hospital discharge is a risk factor for surrogate PTSD symptoms is not known. Objectives: To determine the association between patient health status 90 days after the onset of CCI and surrogate symptoms of PTSD. Methods: We performed a secondary analysis of the data from a multicenter randomized trial of a communication intervention for adult patients with CCI and their surrogate decision-makers. Results: Surrogate PTSD symptoms were measured at 90 days using the Impact of Events Scale-Revised. For patients who were alive at 90 days, location was used as a marker of health status and included the following categories: 1) home (relatively good health and low acuity), 2) acute rehabilitation (moderate care needs and impairments, generally expected to improve), 3) skilled nursing facility (moderate care needs and impairments, generally not expected to improve significantly or quickly), 4) long-term acute care facility (persistently high acute care needs and functional impairment), and 5) readmission to an acute care hospital (suggesting the highest acuity of illness and care needs of the cohort). Patients who died before 90 days were categorized as deceased. In the analyses, 365 surrogates and 256 patients were included. Among patients, 49% were female, and the mean age was 59 years. Among surrogates, 71% were female, and the mean age was 51 years. A directed acyclic graph was constructed to identify covariates to be included in the model. Compared with symptoms seen among surrogates of patients living at home, heightened PTSD symptoms were seen among surrogates of patients who were readmitted to an acute care hospital (β coefficient, 15.9; 95% confidence interval [CI], 4.5 to 27.3) or had died (β coefficient, 14.8; 95% CI, 8.8 to 20.9) at 90 days. Conclusions: Surrogates of patients with CCI who have died or have been readmitted to an acute care hospital at 90 days experience increased PTSD symptoms as compared with surrogates of patients who are living at home. These patients and surrogates represent a readily identifiable group who may benefit from enhanced emotional support.
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Abstract
Objectives: Unbefriended older adults are those who lack the capacity to make medical decisions and do not have a completed advance directive that can guide treatment decisions or a surrogate decision maker. Adult orphans are those who retain medical decision-making capacity but are at risk of becoming unbefriended due to lack of a completed advance health care directive and lack of a surrogate decision maker. In a follow-up to the 2016 American Geriatrics Society (AGS) position statement on unbefriended older adults, we examined clinicians' experiences in caring for unbefriended older adults and adult orphans.Methods: Clinicians recruited through the AGS (N = 122) completed an online survey about their experiences with unbefriended older adults regarding the perceived frequency of contact, clinical concerns, practice strategies, and terminology; and also with adult orphans regarding the perceived frequency of contact, methods of identification, and terminology.Results: Almost all inpatient (95.9%) and outpatient (86.4%) clinicians in this sample encounter unbefriended older adults at least quarterly and 92.2% of outpatient clinicians encounter adult orphans at least quarterly. Concerns about safety (95.9%), medication self-management (90.4%), and advance care planning (86.3%) bring unbefriended older adults to outpatient clinicians' attention "sometimes" to "frequently." Prolonged hospital stays (87.7%) and delays in transitioning to end-of-life care (85.7%) bring unbefriended older adults to inpatient clinicians' attention "sometimes" to "frequently." Clinicians apply a wide range of practice strategies to these populations. Participants suggested alternative terminology to replace "unbefriended" and "adult orphan."Conclusions: This study suggests that unbefriended older adults are frequently encountered in geriatrics practice, both in the inpatient and outpatient settings, and that there is widespread awareness of adult orphans in the outpatient setting. Clinicians' awareness of both groups suggests avenues for intervention and prevention.Clinical Implications: Health care professionals in geriatric settings will likely encounter older adults in need of advocates. Clinicians, attorneys, and policymakers should collaborate to improve early detection and to meet the needs of this vulnerable population.
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Affiliation(s)
- Timothy W Farrell
- Division of Geriatrics, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,VA Salt Lake City Geriatric Research, Education, and Clinical Center, Salt Lake City, UT, USA.,University of Utah Health Interprofessional Education Program, Salt Lake City, UT, USA
| | - Casey Catlin
- Boston VA Research Institute, Inc, Boston, MA, USA
| | - Anna H Chodos
- Division of Geriatrics, UCSF Department of Medicine, San Francisco, CA, USA
| | - Aanand D Naik
- Houston Center for Innovations in Quality, Safety, and Effectiveness (IQuESt) at the Michael DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Eric Widera
- Division of Geriatrics, UCSF Department of Medicine, San Francisco, CA, USA
| | - Jennifer Moye
- VA New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System and Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Rath KA, Tucker KL, Lewis A. Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting. Am J Hosp Palliat Care 2021; 39:79-85. [PMID: 34002621 DOI: 10.1177/10499091211017872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. METHODS Case report and discussion of the associated ethical issues. RESULTS We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. CONCLUSION It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.
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Affiliation(s)
- Kelly A Rath
- Department of Neurocritical Care, Gardner Neuroscience Institute, University of Cincinnati, OH, USA
| | - Kristi L Tucker
- Section on Neurocritical Care, Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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Abstract
Surrogate decision makers (SDMs) are challenged by difficult decisions at the end of life. This becomes more complex in young adult patients when parents are frequently the SDMs. This age group (18 to 39 years old) commonly lacks advanced directives to provide guidance which results in increased moral distress during end of life decisions. Multiple factors help guide medical decision making throughout a patient's disease course and at the end of life. These include personal patient factors and SDM factors. It has been identified that spiritual and community group support is a powerful, but inadequately used resource for these discussions. It can improve patient-SDM-provider communications, decrease psycho-social distress, and avoid unnecessary interventions at the end of life.
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Affiliation(s)
- Nathan Lightfoot
- Department of Neurology, 12231Georgetown University Hospital, Washington, DC, USA
| | - Yordanka Kirkova
- Department of Palliative Care, 12231Georgetown University Hospital, Washington, DC, USA
| | - Stephen Fox
- Department of Medicine, 12231Georgetown University Hospital, Washington, DC, USA
| | - Sheinei Alan
- Department of Medicine, 12231Georgetown University Hospital, Washington, DC, USA
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Ehrman SE, Norton KP, Karol DE, Weaver MS, Lockwood B, Latimer A, Scott E, Jones CA, Macauley R. Top Ten Tips Palliative Care Clinicians Should Know About Medical Decision-Making Capacity Assessment. J Palliat Med 2021; 24:599-604. [PMID: 33595361 DOI: 10.1089/jpm.2021.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Palliative care (PC) clinicians treat seriously ill patients who are at increased risk for compromised decision-making capacity (DMC). These patients face profound and complex questions about which treatments to accept and which to decline. PC clinicians, therefore, have the especially difficult task of performing thorough, fair, and accurate DMC assessments in the face of the complex effects of terminal illness, which may be complicated by fluctuating acute medical conditions, mental illness, or cognitive dysfunction. This study, written by a team of clinicians with expertise in PC, ethics, psychiatry, pediatrics, and geriatrics, aims to provide expert guidance to PC clinicians on best practice for complex DMC assessment.
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Affiliation(s)
- Sarah E Ehrman
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Kavitha P Norton
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - David E Karol
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA.,Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Meaghann S Weaver
- Division of Pediatric Palliative Care, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Bethany Lockwood
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Abigail Latimer
- University of Kentucky College of Social Work, Lexington, Kentucky, USA
| | - Erin Scott
- Division of Palliative Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christopher A Jones
- Department of Medicine and Palliative Care Program, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert Macauley
- Division of Pediatric Palliative Care, Oregon Health and Science University, Portland, Oregon, USA
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Latcha S, Lineberry C, Lendvai N, Tran CA, Matsoukas K, Scharf AE, Voigt LP. "Please Keep Mom Alive One More Day"-Clashing Directives of a Dying Patient and Her Surrogate. J Pain Symptom Manage 2020; 59:1147-1152. [PMID: 32014529 PMCID: PMC7531567 DOI: 10.1016/j.jpainsymman.2020.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/22/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
All medical care providers are legally and ethically bound to respect their patients' wishes. However, as patients lose decision-making capacity and approach end of life, their families or surrogates, who are confronted with grief, fear, self-doubt, and/or uncertainty, may ask physicians to provide treatment that contradicts the patients' previously stated wishes. Our work discusses the legal and ethical issues surrounding such requests and provides guidance for clinicians to ethically and compassionately respond-without compromising their professional and moral obligations to their patients.
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Affiliation(s)
- Sheron Latcha
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Camille Lineberry
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nikoletta Lendvai
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Oncology Clinical Research, Janssen Pharmaceutical Research & Development, Spring House, Pennsylvania, USA
| | - Christine A Tran
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Konstantina Matsoukas
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Information Systems - Medical Library, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy E Scharf
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Louis P Voigt
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Anesthesiology, Pain, and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Lum HD, Brungardt A, Jordan SR, Phimphasone-Brady P, Schilling LM, Lin CT, Kutner JS. Design and Implementation of Patient Portal-Based Advance Care Planning Tools. J Pain Symptom Manage 2019; 57:112-117.e2. [PMID: 30595147 PMCID: PMC6314208 DOI: 10.1016/j.jpainsymman.2018.10.500] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/18/2018] [Accepted: 10/18/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Electronic health record-based portal tools may help patients engage in advance care planning (ACP). We designed and implemented portal-based ACP tools to enable patients to create a medical durable power of attorney (MDPOA). MEASURES MDPOA documentation and System Usability Scale were assessed. INTERVENTION Stakeholder-informed portal-based ACP tools include an electronic MDPOA form, patient educational webpage, online messaging, and patient access to completed advance directives. OUTCOMES A total of 2814 patients used the tools over 15 months. Patients had a mean age 45 years (17-98 years) and 69% were women. Eighty-nine percent completed an MDPOA form, 2% called or sent online messages, and 8% viewed the MDPOA form but did not complete it. The tools were rated highly usable. CONCLUSIONS/LESSONS LEARNED Patients demonstrated willingness to use the portal to complete an MDPOA and rated the new ACP tools as highly usable. Future work will optimize population-based outreach strategies to engage patients in ACP through the portal.
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Affiliation(s)
- Hillary D Lum
- Rocky Mountain Regional VA Geriatric Research Education and Clinical Center, Denver, Colorado, USA; Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Adreanne Brungardt
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sarah R Jordan
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Phoutdavone Phimphasone-Brady
- Department of Family Medicine, Adult and Child Consortium for Health Outcomes and Delivery Science (ACCORDS), University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lisa M Schilling
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Data Science to Patient Value Program, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Chen-Tan Lin
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA; Data Science to Patient Value Program, University of Colorado School of Medicine, Aurora, Colorado, USA
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Su SH, Wu LM. [The Intentions Affecting the Medical Decision-Making Behavior of Surrogate Decision Makers of Critically Ill Patients and Related Factors]. Hu Li Za Zhi 2018; 65:32-42. [PMID: 29564855 DOI: 10.6224/jn.201804_65(2).06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The severity of diseases and high mortality rates that typify the intensive care unit often make it difficult for surrogate decision makers to make decisions for critically ill patients regarding whether to continue medical treatments or to accept palliative care. PURPOSE To explore the behavioral intentions that underlie the medical decisions of surrogate decision makers of critically ill patients and the related factors. METHODS A cross-sectional, correlation study design was used. A total of 193 surrogate decision makers from six ICUs in a medical center in southern Taiwan were enrolled as participants. Three structured questionnaires were used, including a demographic datasheet, the Family Relationship Scale, and the Behavioral Intention of Medical Decisions Scale. RESULTS Significantly positive correlations were found between the behavioral intentions underlying medical decisions and the following variables: the relationship of the participant to the patient (Eta = .343, p = .020), the age of the patient (r = .295, p < .01), and whether the patient had signed a currently valid advance healthcare directive (Eta = .223, p = .002). Furthermore, a significantly negative correlation was found between these intentions and length of stay in the ICU (r = -.263, p < .01). Patient age, whether the patient had signed a currently valid advance healthcare directive, and length of stay in the ICU were all predictive factors for the behavioral intentions underlying the medical decisions of the surrogate decision makers, explaining 13.9% of the total variance. CONCLUSIONS / IMPLICATIONS FOR PRACTICE In assessing the behavioral intentions underlying the medical decisions of surrogate decision makers, health providers should consider the relationship between critical patients and their surrogate decision makers, patient age, the length of ICU stay, and whether the patient has a pre-signed advance healthcare directive in order to maximize the effectiveness of medical care provided to critically ill patients.
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Affiliation(s)
- Szu-Huei Su
- MSN, RN, Instructor, Department of Nursing, Chang Jung Christian University, Taiwan, ROC
| | - Li-Min Wu
- PhD, RN, Associate Professor, School of Nursing, College of Nursing, Kaohsiung Medical University, Taiwan, ROC.
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Burns KE, Prats CJ, Maione M, Lanceta M, Zubrinich C, Jeffs L, Smith OM; Canadian Critical Care Trials Group. The Experience of Surrogate Decision Makers on Being Approached for Consent for Patient Participation in Research. A Multicenter Study. Ann Am Thorac Soc 2017; 14:238-45. [PMID: 27849142 DOI: 10.1513/AnnalsATS.201606-425OC] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Recruitment in critical care research differs from other contexts in important ways: patients lack decision-making capacity, uncertainty exists regarding patient prognosis, and critical illnesses are often associated with appreciable morbidity and mortality. OBJECTIVES We aimed to describe the experiences of surrogate decision makers (SDMs) in being approached for consent for critically ill patients to participate in research. METHODS A multicenter, qualitative study involving semistructured interviews with 26 SDMs, who provided or declined surrogate consent for research participation, at 5 Canadian centers nested within a multicenter observational study of research recruitment practices. Transcripts were reviewed by three qualitative researchers, and data were analyzed using grounded theory and a narrative critical analysis. MEASUREMENTS AND MAIN RESULTS SDMs were guided by an overarching desire for the patient to live. Surrogate research decision-making involved three sequential stages: (1) being approached; (2) reflecting on participation; and (3) making a decision. In stage 1, SDMs identified factors (their expectations, how they were approached, the attributes of the person approaching, and study risks and benefits) that characterized their consent encounter and affirmed a preference to be approached in person. If SDMs perceived the risk of participation to be too high or felt patients may not benefit from participation, they did not contemplate further. In stage 2, SDMs who knew the patient's wishes or had a deeper understanding of research prioritized the patient's wishes and the perceived benefits of participation. Without this information, SDMs prioritized obtaining more and better care for the patient, considered what was in their mutual best interests, and valued healthcare professional's knowledge. Trust in healthcare professionals was essential to proceeding further. In stage 3, SDMs considered six factors in rendering decisions. CONCLUSIONS SDMs engaged in three sequential stages and considered six factors in making surrogate decisions for research participation. Surrogates' assessments of the risks and benefits of participation and their trust in healthcare professionals were critical factors in research decision-making. By conceptualizing surrogate decision-making for research in stages, future research can develop and test procedures to enhance the surrogate research decision-making process.
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Bern-Klug M, Byram EA. Older Adults More Likely to Discuss Advance Care Plans With an Attorney Than With a Physician. Gerontol Geriatr Med 2017; 3:2333721417741978. [PMID: 29201947 PMCID: PMC5697586 DOI: 10.1177/2333721417741978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/12/2017] [Accepted: 09/29/2017] [Indexed: 11/17/2022] Open
Abstract
Adults are encouraged to discuss their end-of-life health care preferences so that their wishes will be known and hopefully honored. The purpose of this study was to determine with whom older adults had communicated their future health care wishes and the extent to which respondents themselves were serving as a surrogate decision maker. Results from the cross-sectional online survey with 294 persons aged 50 and older reveal that among the married, over 80% had a discussion with their spouse and among those with an adult child, close to two thirds (64%) had. Over a third had discussed preferences with an attorney and 23% with a physician. Close to half were currently serving as a surrogate decision maker or had been asked to and had signed papers to formalize their role. 18% did not think that they were a surrogate but were not sure. More education is needed to emphasize the importance of advance care planning with a medical professional, especially for patients with advanced chronic illness. More education and research about the role of surrogate medical decision makers is called for.
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Sinha S, Belcher C, Torke A, Howard J, Caccamo M, Slaven JE, Gradus-Pizlo I. Development of a Protocol for Successful Palliative Care Consultation in Population of Patients Receiving Mechanical Circulatory Support. J Pain Symptom Manage 2017; 54:583-588. [PMID: 28716615 DOI: 10.1016/j.jpainsymman.2017.07.021] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 06/27/2017] [Accepted: 07/07/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND In 2014, Joint Commission recommended palliative care (PC) engagement in ventricular assist device (VAD) implantation as destination therapy. Limited information is available on established PC protocols in the mechanical circulatory support (MCS) population. MEASURES The goals of our PC consultation were to document advance care planning (ACP) discussions and designate a surrogate decision maker (SDM) before MCS implantation. A retrospective analysis compared the frequency of PC consults, ACP discussion, and SDM before and after protocol implementation. INTERVENTION A protocol was developed to conduct interdisciplinary PC consultations for the MCS population. OUTCOMES The percentage of PC consults placed before MCS implantation increased from 11 (17.2%) before protocol to 56 (96.6%) after protocol (P < 0.0001) and documented SDM increased from 26 (40.6%) before protocol to 57 (98.3%) after protocol (P < 0.0001). CONCLUSIONS Close PC/cardiology collaboration can substantially improve ACP discussions and SDM documentation in the MCS population. This multidisciplinary protocol facilitates successful PC consultations.
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Affiliation(s)
- Shilpee Sinha
- Indiana University (IU) School of Medicine, Indianapolis, Indiana; IU Health Physicians, Indianapolis, Indiana.
| | | | - Alexia Torke
- Indiana University (IU) School of Medicine, Indianapolis, Indiana; IU Health Physicians, Indianapolis, Indiana; IU Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, Indiana; IU Division of General Internal Medicine and Geriatrics, Indianapolis, Indiana; Fairbanks Center for Medical Ethics, IU Health, Indianapolis, Indiana; Daniel F. Evans Center for Spiritual and Religious Values in Healthcare, IU Health, Indianapolis, Indiana
| | | | - Marco Caccamo
- Indiana University (IU) School of Medicine, Indianapolis, Indiana; IU Health Physicians, Indianapolis, Indiana
| | - James E Slaven
- IU Department of Biostatistics, Indianapolis, Indiana, USA
| | - Irmina Gradus-Pizlo
- Indiana University (IU) School of Medicine, Indianapolis, Indiana; IU Health Physicians, Indianapolis, Indiana
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15
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Fetherstonhaugh D, McAuliffe L, Shanley C, Bauer M, Beattie E. "Did I make the right decision?": The difficult and unpredictable journey of being a surrogate decision maker for a person living with dementia. Dementia (London) 2017; 18:1601-1614. [PMID: 28766384 DOI: 10.1177/1471301217721862] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many people living with dementia eventually lose the capacity to make their own decisions and will rely on another person – a surrogate decision maker – to make decisions on their behalf. It is important – especially with the increasing prevalence of dementia – that the role of surrogate decision maker is understood and supported. This qualitative study explored the experiences of 34 surrogate decision makers of persons living with dementia in Australia. Face-to-face and telephone interviews were conducted over six months in 2014. Five themes were identified: becoming the only – or main – surrogate decision maker; growing into the role of surrogate decision maker; dealing with the stress of making decisions; having to challenge healthcare professionals; and getting support – or not – from family members. An overarching construct tying the themes together is the description of the participants’ experience as being on a difficult and unpredictable journey. Healthcare professionals can provide support by acting as empathic guides on this journey.
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Affiliation(s)
| | | | - Christopher Shanley
- Western Sydney University, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia
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16
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Trees AR, Ohs JE, Murray MC. Family Communication about End-of-Life Decisions and the Enactment of the Decision-Maker Role. Behav Sci (Basel) 2017; 7:E36. [PMID: 28590407 DOI: 10.3390/bs7020036] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/12/2017] [Accepted: 06/02/2017] [Indexed: 11/18/2022] Open
Abstract
End-of-life (EOL) decisions in families are complex and emotional sites of family interaction necessitating family members coordinate roles in the EOL decision-making process. How family members in the United States enact the decision-maker role in EOL decision situations was examined through in-depth interviews with 22 individuals who participated in EOL decision-making for a family member. A number of themes emerged from the data with regard to the enactment of the decision-maker role. Families varied in how decision makers enacted the role in relation to collective family input, with consulting, informing and collaborating as different patterns of behavior. Formal family roles along with gender- and age-based roles shaped who took on the decision-maker role. Additionally, both family members and medical professionals facilitated or undermined the decision-maker’s role enactment. Understanding the structure and enactment of the decision-maker role in family interaction provides insight into how individuals and/or family members perform the decision-making role within a cultural context that values autonomy and self-determination in combination with collective family action in EOL decision-making.
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17
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Farrell TW, Widera E, Rosenberg L, Rubin CD, Naik AD, Braun U, Torke A, Li I, Vitale C, Shega J. AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults. J Am Geriatr Soc 2016; 65:14-15. [PMID: 27874181 DOI: 10.1111/jgs.14586] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate to assist in the medical decision-making process. Given the vulnerable nature of this population, clinicians, health care teams, ethics committees and other stakeholders working with unbefriended older adults must be diligent when formulating treatment decisions on their behalf. The process of arriving at a treatment decision for an unbefriended older adult should be conducted according to standards of procedural fairness and include capacity assessment, a search for potentially unidentified surrogate decision makers (including non-traditional surrogates) and a team-based effort to ascertain the unbefriended older adult's preferences by synthesizing all available evidence. A concerted national effort is needed to help reduce the significant state-to-state variability in legal approaches to unbefriended patients. Proactive efforts are also needed to identify older adults, including "adult orphans," at risk for becoming unbefriended and to develop alternative approaches to medical decision making for unbefriended older adults. This document updates the 1996 AGS position statement on unbefriended older adults.
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Affiliation(s)
- Timothy W Farrell
- University of Utah School of Medicine, Salt Lake City, UT.,VA Salt Lake City Geriatric Research, Education, and Clinical Center, Salt Lake City, UT
| | - Eric Widera
- University of California San Francisco, San Francisco, CA.,San Francisco VA Medical Center, San Francisco, CA
| | | | - Craig D Rubin
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Aanand D Naik
- Baylor College of Medicine, Houston, TX.,Michael E. DeBakey VA Medical Center, Houston, TX
| | - Ursula Braun
- Baylor College of Medicine, Houston, TX.,Michael E. DeBakey VA Medical Center, Houston, TX
| | | | - Ina Li
- Christiana Care Health System, Wilmington, DE
| | - Caroline Vitale
- University of Michigan, Ann Arbor, MI.,VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Joseph Shega
- VITAS Hospice Care Healthcare, Gotha, FL.,University of Central Florida, Gotha, FL
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18
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Huff NG, Nadig N, Ford DW, Cox CE. Therapeutic Alliance between the Caregivers of Critical Illness Survivors and Intensive Care Unit Clinicians. Ann Am Thorac Soc 2015; 12:1646-53. [PMID: 26452172 DOI: 10.1513/AnnalsATS.201507-408OC] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
RATIONALE Therapeutic alliance is a novel measure of the multifaceted caregiver-clinician relationship and a promising intervention target for improving patient-centered outcomes. However, therapeutic alliance has not been studied in an intensive care unit (ICU) setting. OBJECTIVES To explore the relationships among caregiver-reported therapeutic alliance and psychological distress as well as patient, caregiver, and ICU clinician factors. METHODS In this cross-sectional study, we enrolled consecutive patient caregivers of mechanically ventilated patients discharged from all ICUs at Duke University and the Medical University of South Carolina Hospitals between December 2013 and August 2014. MEASUREMENTS AND MAIN RESULTS Caregivers completed an in-person, hospital-based interview that included measures of therapeutic alliance with the ICU physicians (Human Connection Scale) as well as patient centeredness of care; symptoms of depression, anxiety, and post-traumatic stress; decisional conflict; and quality of communication. We performed a multivariate regression to characterize associations between Human Connection Scale scores and key variables. A total of 56 caregivers were included in these exploratory analyses. Patients were largely disabled (47%) and Medicare insured (53%). Caregivers were highly educated and generally had high therapeutic alliance (median, 55; interquartile range, 48-58) with the ICU clinicians. Therapeutic alliance was strongly correlated with patient centeredness (r = 0.78) and poorly correlated with psychological distress (r < 0.2). Stepwise multivariate modeling revealed that higher therapeutic alliance was associated with fewer baseline patient comorbidities as well as caregiver report of greater trust in the ICU team, better quality of communication, and less decisional conflict (all P < 0.012). CONCLUSIONS Therapeutic alliance encompasses measures of trust, communication, and cooperation, which are intuitive to forming a good working relationship. Therapeutic alliance among ICU caregivers is strongly associated with both modifiable and nonmodifiable factors. Our exploratory study highlights new intervention targets that may inform strategies for improving the quality of the caregiver-clinician interaction.
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19
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Song MK, Ward SE, Fine JP, Hanson LC, Lin FC, Hladik GA, Hamilton JB, Bridgman JC. Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates. Am J Kidney Dis 2015; 66:813-22. [PMID: 26141307 DOI: 10.1053/j.ajkd.2015.05.018] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/21/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Few trials have examined long-term outcomes of advance care planning (ACP) interventions. We examined the efficacy of an ACP intervention on preparation for end-of-life decision making for dialysis patients and surrogates and for surrogates' bereavement outcomes. STUDY DESIGN A randomized trial compared an ACP intervention (Sharing Patient's Illness Representations to Increase Trust [SPIRIT]) to usual care alone, with blinded outcome assessments. SETTING & PARTICIPANTS 420 participants (210 dyads of prevalent dialysis patients and their surrogates) from 20 dialysis centers. INTERVENTION Every dyad received usual care. Those randomly assigned to SPIRIT had an in-depth ACP discussion at the center and a follow-up session at home 2 weeks later. OUTCOMES & MEASUREMENTS PRIMARY OUTCOMES preparation for end-of-life decision making, assessed for 12 months, included dyad congruence on goals of care at end of life, patient decisional conflict, surrogate decision-making confidence, and a composite of congruence and surrogate decision-making confidence. SECONDARY OUTCOMES bereavement outcomes, assessed for 6 months, included anxiety, depression, and posttraumatic distress symptoms completed by surrogates after patient death. RESULTS PRIMARY OUTCOMES adjusting for time and baseline values, dyad congruence (OR, 1.89; 95% CI, 1.1-3.3), surrogate decision-making confidence (β=0.13; 95% CI, 0.01-0.24), and the composite (OR, 1.82; 95% CI, 1.0-3.2) were better in SPIRIT than controls, but patient decisional conflict did not differ between groups (β=-0.01; 95% CI, -0.12 to 0.10). SECONDARY OUTCOMES 45 patients died during the study. Surrogates in SPIRIT had less anxiety (β=-1.13; 95% CI, -2.23 to -0.03), depression (β=-2.54; 95% CI, -4.34 to -0.74), and posttraumatic distress (β=-5.75; 95% CI, -10.9 to -0.64) than controls. LIMITATIONS Study was conducted in a single US region. CONCLUSIONS SPIRIT was associated with improvements in dyad preparation for end-of-life decision making and surrogate bereavement outcomes.
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Affiliation(s)
- Mi-Kyung Song
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sandra E Ward
- School of Nursing, University of Wisconsin-Madison, Madison, WI
| | - Jason P Fine
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Laura C Hanson
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Feng-Chang Lin
- School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Jessica C Bridgman
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC
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20
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Bolcic-Jankovic D, Clarridge BR, LeBlanc JL, Mahmood RS, Roman AM, Freeman BD. Exploring determinants of surrogate decision-maker confidence: an example from the ICU. J Empir Res Hum Res Ethics 2014; 9:76-85. [PMID: 25747298 DOI: 10.1177/1556264614545036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article is an exploratory data analysis of the determinants of confidence in a surrogate decision maker who has been asked to permit an intensive care unit (ICU) patient's participation in genetic research. We pursue the difference between surrogates' and patients' confidence that the surrogate can accurately represent the patient's wishes. The article also explores whether greater confidence leads to greater agreement between patients and surrogates. Our data come from a survey conducted in three hospital ICUs. We interviewed 445 surrogates and 214 patients. The only thing that influences patients' confidence in their surrogate's decision is whether they had prior discussions with him or her; however, there are more influences operating on the surrogate's self-confidence. More confident surrogates are more likely to match their patients' wishes. Patients are more likely to agree to research participation than their surrogates would allow. The surrogates whose response did not match as closely were less trusting of the hospital staff, were less likely to allow patient participation if there were no direct benefits to the patient, had given less thought about the way genetic research is conducted, and were much less likely to have a person in their life who they would trust to make decisions for them if they were incapacitated.
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Affiliation(s)
| | - Brian R Clarridge
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
| | - Jessica L LeBlanc
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
| | - Rumel S Mahmood
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
| | - Anthony M Roman
- Center for Survey Research, University of Massachusetts, Boston, MA, USA
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21
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Brush DR, Rasinski KA, Hall JB, Alexander GC. Recommendations to limit life support: a national survey of critical care physicians. Am J Respir Crit Care Med 2012; 186:633-9. [PMID: 22837382 PMCID: PMC3480524 DOI: 10.1164/rccm.201202-0354oc] [Citation(s) in RCA: 23] [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] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 07/14/2012] [Indexed: 11/16/2022] Open
Abstract
RATIONALE There is debate about whether physicians should routinely provide patient surrogates with recommendations about limiting life support. OBJECTIVES To explore physicians' self-reported practices and attitudes. METHODS A cross-sectional, stratified survey of 1,000 randomly selected US critical care physicians was mailed. We included a vignette to experimentally examine how surrogate desire for a recommendation and physician agreement with the surrogate modified whether physicians would provide a recommendation. MEASUREMENTS AND MAIN RESULTS Proportion of respondents reporting they routinely provide surrogates with a recommendation and how responses varied based on vignette characteristics. A total of 608 (66%) of 922 eligible physicians participated. Approximately one (22%) in five reported always providing surrogates with a recommendation, whereas 1 (11%) in 10 reported rarely or never doing so. Almost all respondents reported comfort making recommendations (92%) and viewed them as appropriate (93%). Most also viewed recommendations as a critical care physician's duty (87%) and did not view them as unduly influential (80%). Approximately two-fifths (41%) believed recommendations were only appropriate if sought by surrogates. In response to the vignettes, nearly all respondents (91%) provided a recommendation when the surrogate requested a recommendation and the physician agreed with the surrogate's likely decision. Physicians were less likely to provide an unwanted recommendation, both when physicians agreed (29%) and disagreed with the surrogate's likely decision (44%). CONCLUSIONS There is substantial variation among physicians' self-reported use of recommendations to surrogates of critically ill adults. Surrogates' desires for recommendations and physicians' agreement with surrogates' likely decisions may have important influence on whether recommendations are provided.
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Affiliation(s)
- David R Brush
- Johns Hopkins School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
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22
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Howe E. Informed consent, participation in research, and the Alzheimer's patient. Innov Clin Neurosci 2012; 9:47-51. [PMID: 22808449 PMCID: PMC3398682] [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] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Patients with Alzheimer's disease may want to participate in research on Alzheimer's disease, but their participation involves exceptional considerations. Plans should be made for determining these patients' cognitive capacity on a regular basis; for example, throughout a study, cognitive capacity may decline, making it necessary for a patient's pre-designated surrogate decision maker to become more involved. Patients with Alzheimer's disease may also choose to designate someone other than their primary caregiver to be their surrogate decision maker. This article discusses these and other core ethical issues.
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Affiliation(s)
- Edmund Howe
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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