RESUMEN
The purpose of this paper is to delve into the ethical aspects experienced by the healthcare team when they receive the directive to limit therapeutic effort or a do-not-resuscitate order. From an interpretative, qualitative paradigm with a content analysis approach, a process based on three phases was conducted: pre-analysis in which categories were identified, the projection of the analysis, and inductive analysis. During 2023, interviews were conducted in the clinical setting of a high-complexity hospital in Chile with 56 members of the healthcare teams from critical and emergency units, from which four categories emerged: a) the risk of violating patients' rights by using do-not-resuscitate orders and limiting therapeutic effort; b) the gap in the interpretation of the legal framework addressing the care and attention of patients at the end of life or with terminal illnesses by the healthcare team; c) ethical conflicts in end-of-life care; and d) efficient care versus holistic care in patients with terminal illness. There are significant gaps in bioethics training and aspects of a good death in healthcare teams facing the directive to limit therapeutic effort and not resuscitate. It is suggested to train personnel and work on a consensus guide to address the ethical aspects of a good death.
El propósito de este trabajo es profundizar en los aspectos éticos que experimenta el equipo de salud cuando reciben la indicación de limitar el esfuerzo terapéutico o la orden de no reanimar. Desde un paradigma interpretativo, cualitativo y con un enfoque de análisis de contenido, se realizó un proceso basado en tres fases: preanálisis en el que se identificaron las categorías, la proyección del análisis y el análisis inductivo. Durante 2023, se realizaron entrevistas en el entorno clínico de un hospital de alta complejidad en Chile a 56 miembros de equipos de salud de unidades críticas y urgencias, de las que emergieron cuatro categorías: a) riesgo de vulnerar los derechos de los pacientes al utilizar la orden de no reanimar, y limitación del esfuerzo terapéutico; b) brecha en la interpretación del marco legal que aborda la atención y cuidado de pacientes al final de la vida, o con enfermedades terminales por parte del equipo de salud; c) conflictos éticos de la atención al final de la vida; y d) el cuidado eficiente o el cuidado holístico en pacientes con enfermedad terminal. Existen brechas importantes en la formación en bioética y aspectos del buen morir en los equipos de salud que se enfrentan a la orden de limitar el esfuerzo terapéutico y no reanimar. Se sugiere capacitar al personal, y trabajar una guía de consenso para abordar los aspectos éticos del buen morir.
Asunto(s)
Grupo de Atención al Paciente , Investigación Cualitativa , Órdenes de Resucitación , Cuidado Terminal , Humanos , Chile , Órdenes de Resucitación/ética , Órdenes de Resucitación/legislación & jurisprudencia , Grupo de Atención al Paciente/ética , Cuidado Terminal/ética , Derechos del Paciente/ética , Femenino , Masculino , Actitud del Personal de Salud , Entrevistas como AsuntoRESUMEN
PURPOSE: This study aimed to distinguish and describe the types of perceptions of do not resuscitate (DNR) proxy decisions among families of elderly patients in a long-term care facility. METHODS: This exploratory study applied Q-methodology, which focuses on individual subjectivity. Thirty-four Q-statements were selected from 130 Q-populations formed based on the results of in-depth interviews and literature reviews. The P-samples were 34 families of elderly patients in a long-term care hospital in Busan, Korea. They categorized the Q-statements using a 9-point scale. Using the PC-QUANL program, factor analysis was performed with the P-samples along an axis. RESULTS: The families' perceptions of the DNR proxy decision were categorized into three types. Type I, rational acceptance, valued consensus among family members based on comprehensive support from medical staff. Type II, psychological burden, involved hesitance in making a DNR proxy decision because of negative emotions and psychological conflict. Type III, discreet decisions, valued the patients' right to self-determination and desire for a legitimate proxy decision. Type I included 18 participants, which was the most common type, and types II and III each included eight participants. CONCLUSION: Families' perceptions of DNR proxy decisions vary, requiring tailored care and intervention. We suggest developing and providing interventions that may psychologically support families.
Asunto(s)
Toma de Decisiones , Familia/psicología , Órdenes de Resucitación/legislación & jurisprudencia , Adulto , Femenino , Hospitales , Humanos , Entrevistas como Asunto , Cuidados a Largo Plazo , Masculino , Persona de Mediana Edad , Q-Sort , República de CoreaRESUMEN
The COVID-19 Pandemic a stress test for clinical medicine and medical ethics, with a confluence over questions of the proportionality of resuscitation. Drawing upon his experience as a clinical ethicist during the surge in New York City during the Spring of 2020, the author considers how attitudes regarding resuscitation have evolved since the inception of do-not-resuscitate (DNR) orders decades ago. Sharing a personal narrative about a DNR quandry he encountered as a medical intern, the author considers the balance of patient rights versus clinical discretion, warning about the risk of resurgent physician paternalism dressed up in the guise of a public health crisis.
Asunto(s)
COVID-19 , Paternalismo , Derechos del Paciente , Órdenes de Resucitación/ética , Eticistas/historia , Ética Médica/historia , Historia del Siglo XX , Humanos , Inutilidad Médica/ética , New York , Órdenes de Resucitación/legislación & jurisprudenciaRESUMEN
Richard Griffith, Senior Lecturer in Health Law at Swansea University, discusses the lawfulness of instructions to issue bulk do not attempt resuscitation orders during the COVID19 pandemic.
Asunto(s)
Infecciones por Coronavirus/epidemiología , Pandemias , Neumonía Viral/epidemiología , Órdenes de Resucitación/legislación & jurisprudencia , COVID-19 , Humanos , Legislación de Enfermería , Medicina Estatal/legislación & jurisprudencia , Reino Unido/epidemiologíaRESUMEN
Objectives To identify the probability of survival and severe neurodevelopmental impairment (sNDI) at which perinatal physicians would or would not offer or recommend resuscitation at birth for extremely preterm infants. Methods A Delphi process consisting of five rounds was implemented to seek consensus (>80% agreement) amongst British Columbia perinatal physicians. The first-round consisted of neonatal and maternal-fetal-medicine Focus Groups. Rounds two to five surveyed perinatal physicians, building upon previous rounds. Draft guidelines were developed and agreement sought. Results Based on 401 responses across all rounds, consensus was obtained that resuscitation should not be offered if survival probability <5%, not recommended if survival probability 5 to <10%, resuscitation recommended if survival without sNDI probability >70 to 90% and resuscitation standard care if survival without sNDI >90%. Conclusions This physician consensus-based, objective framework for the management of an anticipated extremely preterm infant is a transparent alternative to existing guidelines, minimizing gestational-ageism and allowing for individualized management utilizing up-to-date data. Further input from other key stakeholders will be required prior to guideline implementation.
Asunto(s)
Recien Nacido Extremadamente Prematuro , Inutilidad Médica , Nacimiento Prematuro/epidemiología , Órdenes de Resucitación , Colombia Británica/epidemiología , Técnica Delphi , Femenino , Viabilidad Fetal , Edad Gestacional , Humanos , Lactante , Muerte del Lactante/etiología , Mortalidad Infantil , Recién Nacido , Inutilidad Médica/ética , Inutilidad Médica/legislación & jurisprudencia , Inutilidad Médica/psicología , Mortalidad , Guías de Práctica Clínica como Asunto , Embarazo , Órdenes de Resucitación/ética , Órdenes de Resucitación/legislación & jurisprudencia , Órdenes de Resucitación/psicologíaRESUMEN
BACKGROUND: On-line tutorials are being increasingly used in medical education, including in teaching housestaff skills regarding end of life care. Recently an on-line tutorial incorporating interactive clinical vignettes and communication skills was used to prepare housestaff at Johns Hopkins Hospital to use the Maryland Orders for Life Sustaining Treatment (MOLST) form, which documents patient preferences regarding end of life care. 40% of housestaff who viewed the module felt less than comfortable discussing choices on the MOLST with patients. We sought to understand factors beyond knowledge that contributed to housestaff discomfort in MOLST discussions despite successfully completing an on-line tutorial. METHODS: We conducted semi-structured telephone interviews with 18 housestaff who completed the on-line MOLST training module. Housestaff participants demonstrated good knowledge of legal and regulatory issues related to the MOLST compared to their peers, but reported feeling less than comfortable discussing the MOLST with patients. Transcripts of interviews were coded using thematic analysis to describe barriers to using the MOLST and suggestions for improving housestaff education about end of life care discussions. RESULTS: Qualitative analysis showed three major factors contributing to lack of housestaff comfort completing the MOLST form: [1] physician barriers to completion of the MOLST, [2] perceived patient barriers to completion of the MOLST, and [3] design characteristics of the MOLST form. Housestaff recommended a number of adaptations for improvement, including in-person training to improve their skills conducting conversations regarding end of life preferences with patients. CONCLUSIONS: Some housestaff who scored highly on knowledge tests after completing a formal on-line curriculum on the MOLST form reported barriers to using a mandated form despite receiving training. On-line modules may be insufficient for teaching communication skills to housestaff. Additional training opportunities including in-person training mechanisms should be incorporated into housestaff communication skills training related to end of life care.
Asunto(s)
Directivas Anticipadas/psicología , Reanimación Cardiopulmonar/psicología , Conocimientos, Actitudes y Práctica en Salud , Médicos/psicología , Órdenes de Resucitación/psicología , Adulto , Directivas Anticipadas/legislación & jurisprudencia , Femenino , Hospitales Universitarios/estadística & datos numéricos , Humanos , Masculino , Maryland , Relaciones Médico-Paciente , Órdenes de Resucitación/legislación & jurisprudencia , Encuestas y CuestionariosRESUMEN
BACKGROUND: The advancements in neonatal critical care have not only improved the outcomes of extreme prematurity but also prolonged the process of death in terminally ill neonates. This study analyzed the characteristics of neonates who died at a single tertiary center in Taiwan. The utilization of neonatal hospice care before and after the legalization of life-sustaining treatment (LST) withdrawal in Taiwan in 2013 was also compared. METHODS: This study enrolled the neonatal mortality cases in the Taipei Veterans General Hospital during January 2008 to December 2017 through chart review. Data on birth history, primary diagnosis, complications, and death circumstances were recorded and analyzed. RESULTS: In total, 105 neonatal deaths were analyzed. The circumstances of death were as follows: 22 (21%) cases of full LST and cardiopulmonary resuscitation (CPR) performed until death; 63 (60%) cases of LST initiated but no more CPR after do-not-resuscitate (DNR) consents signed; 8 (7.6%) cases of LST withdrawn; 4 (3.8%) cases of DNR signed without LST initiation; 3 (2.9%) cases of CPR not performed, although no DNR signed; and 5 (4.8%) cases of discharge against medical advice under critical condition. The incidence of written DNR consents (57.9% in 2008-2009 vs 93.8% in 2016-2017; p = 0.02) showed an increasing trend. Regarding the incidence of comorbidities, renal failure rate was higher in the DNR group than in the non-DNR group (p = 0.002). CONCLUSION: There was an increasing trend for written DNR consent and the utilization of neonatal hospice care. Renal failure, as a comorbidity, was significantly associated with the written DNR consent in the neonates. Further studies to evaluate the factors associated with neonatal hospice care utilization are suggested.
Asunto(s)
Cuidados Paliativos al Final de la Vida , Órdenes de Resucitación/legislación & jurisprudencia , Femenino , Humanos , Recién Nacido , Masculino , Estudios Retrospectivos , Taiwán , Centros de Atención TerciariaRESUMEN
Richard Griffith, Senior Lecturer in Health Law at Swansea University, set out the steps nurses must take to ensure that a DNACPR notice is lawful.
Asunto(s)
Legislación de Enfermería , Órdenes de Resucitación/legislación & jurisprudencia , Reanimación Cardiopulmonar/enfermería , Humanos , Inutilidad Médica/legislación & jurisprudencia , Competencia Mental/legislación & jurisprudencia , Relaciones Enfermero-Paciente , Política Organizacional , Medicina Estatal/organización & administración , Reino UnidoRESUMEN
PURPOSE OF REVIEW: Tattoos and medallions are examples of nonstandard do-not-resuscitate (DNR) orders that some people use to convey end-of-life wishes. These DNR orders are neither universally accepted nor understood for reasons discussed within this manuscript. RECENT FINDINGS: Studies show both providers and patients confuse the meaning and implication of DNR orders. In the United States, out-of-hospital DNR orders are legislated at the state level. Most states standardized out-of-hospital DNR orders so caregivers can immediately recognize and accept the order and act on its behalf. These out-of-hospital orders are complicated by the need to be printed on paper that does not always accompany the individual. Oregon created an online system whereby individuals recorded their end-of-life wishes that medical personnel can access with an Internet connection. This system improved communication of end-of-life wishes in patients who selected comfort care only. SUMMARY: To improve conveyance of an individual's wishes for end-of-life care, the authors discuss nationwide adoption of Oregon's online registry where a person's account could comprehensively document end-of-life wishes, be universally available in all healthcare institutions, and be searchable by common patient identifiers. Facial recognition software could identify unconscious patients who present without identification.
Asunto(s)
Directivas Anticipadas/legislación & jurisprudencia , Órdenes de Resucitación/legislación & jurisprudencia , Cuidado Terminal/legislación & jurisprudencia , Reconocimiento Facial , Humanos , Internet/legislación & jurisprudencia , Sistemas en Línea/legislación & jurisprudencia , Programas Informáticos , Inconsciencia , Estados UnidosRESUMEN
BACKGROUND: Guidelines for cardiopulmonary resuscitation (CPR) recommend using the universal termination-of-resuscitation (TOR) rule to identify out-of-hospital cardiac arrest (OHCA) patients eligible for field termination of resuscitation, thus avoiding medically futile transportation to the hospital. However, in Japan, emergency medical services (EMS) personnel are forbidden from terminating CPR in the field and transport almost all patients with OHCA to hospitals. We aimed to develop and validate a novel TOR rule to identify patients eligible for field termination of CPR. METHODS: We analyzed 540,478 patients with OHCA from 2011 to 2015 using a Japanese registry. Main outcome measures were specificity and positive predictive value (PPV) of the newly developed TOR rule in predicting 1-month mortality after OHCA. RESULTS: Recursive partitioning analysis in the development group (n=434,208) showed that EMS personnel could consider TOR if patients with OHCA met all of the following five criteria: (1) initial asystole, (2) arrest unwitnessed by a bystander, (3) age ≥81 years, (4) no bystander-administered CPR or automated external defibrillator use before EMS arrival, and (5) no return of spontaneous circulation after EMS-initiated CPR for 14min. For patients meeting these criteria, specificity and PPV for predicting 1-month mortality were 99.2% [95% confidence interval (CI), 99.0-99.3%] and 99.7% (95% CI, 99.6-99.7%), respectively, for the development group and were 99.5% (95% CI, 99.3-99.7%) and 99.8% (95% CI, 99.7-99.9%), respectively, for the validation group. Implementation of this novel rule would reduce patient transports to hospitals by 10.6% in the development group and 10.4% in the validation group. CONCLUSIONS: Having both high specificity and PPV of >99% for predicting 1-month mortality, our developed TOR rule may be applied in the field for Japanese patients with OHCA who meet all five criteria. Prospective validation studies and establishment of prehospital EMS protocol are required before implementing this rule.
Asunto(s)
Reanimación Cardiopulmonar/métodos , Reglas de Decisión Clínica , Servicios Médicos de Urgencia/métodos , Paro Cardíaco Extrahospitalario/terapia , Anciano , Reanimación Cardiopulmonar/normas , Servicios Médicos de Urgencia/normas , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Sistema de Registros , Órdenes de Resucitación/legislación & jurisprudencia , Sensibilidad y EspecificidadRESUMEN
OBJECTIVES: The 2014 Court of Appeals decision with respect to Tracey vs Cambridge University Hospital ('the Tracey judgement') changed the requirements for discussing Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions with patients. This study is a retrospective case note review aiming to identify any changes in practice around discussing DNACPR decisions in hospices following the judgement. METHODS: 150 case notes from 2013 (before the Tracey judgement) were compared with 150 case notes from 2015 (following the Tracey judgement). These notes came from five hospices in the West Midlands. The notes were analysed to determine if the judgement resulted in changes to how frequently DNACPR decisions were discussed with patients and their families, as well as whether there were any changes in the documentation of reasons for not discussing such decisions. RESULTS: Discussions with patients around DNACPR decisions increased from 31% to 60% and with relatives from 29% to 59% following the Tracey judgement. Prior to the judgement the most frequently documented reason for not discussing was to avoid distress (23%), whereas after judgement it was patients lacking capacity to engage in such a discussion (40%). There was a lack of consistency and clarity in defining the concept of 'physical or psychological harm'. CONCLUSIONS: Although DNACPR decisions are being discussed more frequently with patients and families following the Tracey judgement, clarity on what constitutes 'physical or psychological harm' caused by these discussions is still required. Future research must examine whether the judgement is delaying or preventing DNACPR decisions being made.
Asunto(s)
Planificación Anticipada de Atención/legislación & jurisprudencia , Toma de Decisiones , Cuidados Paliativos al Final de la Vida/legislación & jurisprudencia , Cuidados Paliativos al Final de la Vida/psicología , Órdenes de Resucitación/legislación & jurisprudencia , Adulto , Anciano , Femenino , Hospitales para Enfermos Terminales , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVE: To compare 2011 and 2017 documentation of resuscitation decisions in older patients, including the frequency and clarity of documentation. METHODS: The clinical case notes of 130 patients aged 70 years and over were examined to identify how resuscitation decisions are discussed and documented at a major teaching hospital. Results were compared to 2011 data. RESULTS: The proportion of patients with a documented order significantly increased, from 34 to 63%, with a concurrent increased number of patients identified as Not For Cardiopulmonary Resuscitation (Not for CPR). The standardised documentation has also improved rates of documented discussion, legibility and identification of the involved doctor. CONCLUSION: The Resuscitation Plan 7-Step Pathway has markedly improved the frequency of documented discussion, the rate of recorded Not For CPR status and clarity of documentation. There is scope for improvement as this policy is embraced across South Australia.
Asunto(s)
Directivas Anticipadas/legislación & jurisprudencia , Documentación , Control de Formularios y Registros/legislación & jurisprudencia , Formularios como Asunto , Órdenes de Resucitación/legislación & jurisprudencia , Cuidado Terminal/legislación & jurisprudencia , Anciano , Anciano de 80 o más Años , Documentación/normas , Femenino , Control de Formularios y Registros/normas , Hospitales de Enseñanza/legislación & jurisprudencia , Humanos , Masculino , Autonomía Personal , Formulación de Políticas , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Estudios Retrospectivos , Australia del Sur , Cuidado Terminal/normas , Factores de TiempoRESUMEN
Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.
Asunto(s)
Cuidados para Prolongación de la Vida , Prioridad del Paciente , Órdenes de Resucitación , Directivas Anticipadas/legislación & jurisprudencia , Directivas Anticipadas/psicología , Servicio de Urgencia en Hospital , Control de Formularios y Registros/métodos , Humanos , Cuidados para Prolongación de la Vida/legislación & jurisprudencia , Cuidados para Prolongación de la Vida/psicología , Prioridad del Paciente/legislación & jurisprudencia , Prioridad del Paciente/psicología , Relaciones Médico-Paciente , Órdenes de Resucitación/legislación & jurisprudencia , Órdenes de Resucitación/psicologíaRESUMEN
BACKGROUND AND PURPOSE: Advanced care planning documents, such as the Physician Orders for Life-Sustaining Treatment (POLST), require authorized medical provider signatures; only recently have nurse practitioners (NPs) been authorized to sign these forms. Recent legislation in West Virginia (WV) granting NPs signatory authority on POLST forms and the creation of a statewide registry provides an opportunity to examine the completion rates. The aim of this study was to investigate how recent legislation allowing NPs signatory authority for POLST forms has affected POLST completion. METHODS: Data were obtained from the WV statewide registry of POST forms completed by all authorized personnel. Forms submitted by NPs were compared with those completed by physicians on patient demographics, setting, resuscitation status, level of medical intervention, and errors. Variables were cross-tabulated by provider type to determine whether and how NP POST completion differed from that of physicians. CONCLUSIONS: Forty-five NPs submitted 430 POST forms to the WV registry, which constituted 14.4% of the POST forms received. Ten NPs in community and hospital specialist palliative care teams submitted more than two thirds of these 430 forms. Nurse practitioner-completed POST forms were more likely to order do not resuscitate and comfort measures than POST forms ordered by physicians (both p < .001) and to be without errors (p < .001). IMPLICATIONS FOR PRACTICE: Nurse practitioners practicing in specialist palliative care roles in communities and hospitals have embraced the use of POST and followed through on complete and accurate completion of the forms. With this signatory authority, primary and specialist NPs have the potential to improve end-of-life care.
Asunto(s)
Enfermeras Practicantes/tendencias , Rol de la Enfermera/psicología , Cuidados Paliativos/métodos , Planificación Anticipada de Atención/legislación & jurisprudencia , Planificación Anticipada de Atención/tendencias , Distribución de Chi-Cuadrado , Humanos , Enfermeras Practicantes/psicología , Enfermeras Practicantes/normas , Cuidados Paliativos/legislación & jurisprudencia , Sistema de Registros/estadística & datos numéricos , Órdenes de Resucitación/legislación & jurisprudencia , West VirginiaRESUMEN
A Do Not Attempt Resuscitation notice (DNACPR) is an important mechanism for avoiding inappropriate CRP attempts, and protects district nurses and others from allegations of ill treatment or wilful neglect. The DNACPR notice must be discussed with the patient or their relatives, before placed on file ( Tracey v Cambridge Uni Hospital NHS Foundation Trust and others [2014] ; Winspear v City Hospitals Sunderland NHSFT [2015] ). In this article Richard Griffith set out the steps district nurses must take to ensure that a DNACPR notice is lawful.
Asunto(s)
Participación del Paciente/legislación & jurisprudencia , Atención Primaria de Salud , Órdenes de Resucitación/legislación & jurisprudencia , Toma de Decisiones Clínicas , Enfermería en Salud Comunitaria , Humanos , Inutilidad Médica/legislación & jurisprudencia , Reino UnidoRESUMEN
BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is used across the country to document the treatment preferences of seriously ill or frail patients as medical orders. The National POLST Paradigm Task Force maintains consensus-based standards for POLST programs and uses these to determine whether a state POLST program is developing, endorsed, or mature. OBJECTIVES: To evaluate state program form adherence to national standards. DESIGN: Document review. MEASUREMENTS: Forms from endorsed/mature (n = 21) and developing (n = 23) states were compared with national standards to assess adherence to required and optional form elements. RESULTS: Required elements were present on 84% of endorsed/mature state POLST forms and 73% of the developing state POLST forms. Compliance with required elements in endorsed states ranged from 50% to 100%. Three endorsed/mature states (14%) had forms that met all of the required elements fully and 14 (67%) had forms that met the all of the elements fully or partially. CONCLUSIONS: There is variability in adherence to required and optional standards as well as challenges in interpreting and applying existing standards. Although there may be legal and logistical barriers to the existence of a national POLST form, standardization remains an important goal to support patient-centered care.