One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries.

This study examined health professionals' (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)--controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios--BD, uncontrolled DCD and controlled DCD--were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors' loss of circulatory function could be reversed, and raises questions about "death" as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs' discomfort must be further identified and addressed.

"Allow natural death" is not equivalent to " do not resuscitate": a response.

Venneman and colleagues argue that "do not resuscitate" (DNR) is problematic and should be replaced by "allow natural death" (AND). Their argument is flawed. First, while end-of-life discussions should be as positive as possible, they cannot and should not sidestep painful but necessary confrontations with morality. Second, while DNR can indeed be nonspecific and confusing, AND merely replaces one problematic term with another. Finally, the study's results are not generalisable to the populations of physicians and working nurses and certainly do not support the authors' claim that there is a movement to replace DNR with AND.

Should individuals choose their definition of death?

Alireza Bagheri supports a policy on organ procurement where individuals could choose their own definition of death between two or more socially accepted alternatives. First, we claim that such a policy, without any criterion to distinguish accepted from acceptable definitions, easily leads to the slippery slope that Bagheri tries to avoid. Second, we suggest that a public discussion about the circumstances under which the dead donor rule could be violated is more productive of social trust than constantly moving the line between life and death.

Transfer of the hematopoietic stem cell transplant patient to the intensive care unit: does it really matter?

We critically reviewed published English language literature and concluded that from 1998 onward the survival of hematopoietic stem cell transplant (SCT) patients who experienced intensive care unit (ICU) transfer has improved. The factors associated with increased mortality during ICU stay included increased patient age, allogeneic transplant, intubation/mechanical ventilation, multiorgan system failure (MOSF), presumed/documented infection, graft-versus-host disease, and higher APACHE and O-PRISM score at ICU transfer. This encouraging outcome trend reflects evolving advances such as use of recombinant hematopoietic growth factors, use of mobilized blood cells rather than marrow, protective strategies for acute lung injury and early goal-directed therapy for sepsis syndrome. Patient selection bias (which patients were transferred and which were not sent to an ICU) also plays a role in ICU survival rates. New strategies to improve upon SCT patient outcome include use of a scoring system to predict mortality, better therapies for MOSF and integration of ICU components and multispecialist involvement earlier in the clinical course to prevent severe complications such as respiratory failure. SCT recipients comprise a heterogeneous group; to further advance this field, prospective multicenter trials involving larger populations from many centers are needed to reduce the biases of retrospective and single-center reports.

Prosecutors and end-of-life decision making.

OBJECTIVE: To examine personal beliefs and professional behavior of state criminal prosecutors toward end-of-life decisions. DESIGN: Mail survey. SETTING: District attorney offices nationwide. PARTICIPANTS: All prosecuting attorneys who are members of the National District Attorneys Association. A total of 2844 surveys were mailed with 2 follow-up mailings at 6-week intervals; 761 surveys were returned for a response rate of 26.8%. The majority of respondents were white men, Protestant, and served in rural areas. INTERVENTIONS: None. MAIN OUTCOME MEASURES: On the basis of 4 case scenarios, (1) professional behavior as determined by respondents' willingness to prosecute and what criminal charges they would seek; and (2) personal beliefs as determined by whether prosecutors believed the physicians' actions were morally wrong and whether they would want the same action taken if they were in the patient's condition. RESULTS: Most respondents would not seek prosecution in 3 of the 4 cases. In the fourth case, involving physician-assisted suicide, only about one third of the respondents said that they definitely would prosecute. Those who would prosecute would most often seek a charge of criminal homicide. A majority of respondents believed that the physicians' actions were morally correct in each of the 4 cases and would want the same action taken if they were in the patient's position. There was a strong correlation between personal beliefs and professional behaviors. CONCLUSIONS: A large majority of responding prosecutors were unwilling to prosecute physicians in cases that clearly fall within currently accepted legal and professional boundaries. In the case of physician-assisted suicide, results reflected a surprisingly large professional unwillingness to prosecute and an even greater personal acceptance of physician-assisted suicide.

Evaluation of a treatment limitation policy with a specific treatment-limiting order page.

BACKGROUND: Concerns about misinterpretation, misunderstanding, poor communication, and lack of documentation prompted a revision of our hospital's treatment limitation policy. The revised policy was designed to explicate do-not-resuscitate (DNR) orders, structure the use of DNR and other treatment-limiting orders in a logical and standard way, and improve communication. Use of a Specific Treatment-Limiting Order Page (STOP) was required. METHODS: To evaluate the policy's effects, we conducted (1) a prospective cohort study (involving 2733 patients) of treatment limitation practices before and after the new policy and (2) cross-sectional surveys of 58 nurses and 62 physicians. Outcome measures included documented treatment-limiting orders, documented discussions of these decisions, and deaths. Staff opinions about effects on communication and patient care were elicited. RESULTS: Rates of death (5.4% before and 5.6% after the policy; P = .80) and rates of DNR orders (9.3% vs 9.2%, P = .9) did not change. The use of the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly increased the frequency of orders limiting 12 other specific treatments for conditions short of arrest. For example, before the policy, orders prohibited mechanical ventilation in 2% of DNR patients, compared with 66% after the policy (P < .001). Staff reported that the policy improved communication among health professionals, patients, and families. CONCLUSIONS: The treatment limitation policy with the STOP improved documentation and communication of treatment-limiting decisions. On the basis of our results, we offer a STOP for use and evaluation by others.

Variation in the use of do-not-resuscitate orders in patients with stroke.

OBJECTIVES: To identify sociodemographic and clinical characteristics associated with the use of do-not-resuscitate (DNR) orders in hospitalized patients with stroke. To examine whether the use of DNR orders varies across hospitals. METHODS: This observational cohort study used data collected for 13337 consecutive eligible patients with a primary diagnosis of stroke. These patients were discharged in 1991 through 1994 from 30 hospitals in a large metropolitan area. Study data were abstracted from patients' hospital records using standard forms. Admission severity of illness was measured using a validated multivariable model. Sociodemographic and clinical factors independently associated with the use of DNR orders were identified using stepwise logistic regression. RESULTS: Do-not-resuscitate orders were written for 2898 patients (22%). Patient characteristics independently (P < .01) associated with increased use of DNR orders included increasing age (odds ratio [OR], 1.06 per year); admission from a skilled nursing facility (OR, 2.44) or through the emergency department (OR, 1.49); cancer (OR, 2.73), intracerebral hemorrhage (OR, 2.12), coma (OR, 7.47), or lethargy or stupor on admission neurological assessment (OR, 3.38); and increasing admission severity (OR; 1.29 per decile). In contrast, African American race was associated with lower use of DNR orders (OR, 0.54). Although substantial variation in the use of DNR orders was observed across hospitals, with rates ranging from 12% to 32%, adjusting for the above patient characteristics eliminated much of this variation, including differences between major teaching and other hospitals and between hospitals with and without religious affiliations. CONCLUSIONS: In our community-based analysis of patients with stroke, the use of DNR orders was common and was strongly related to several patient characteristics. These factors explained much of the variation across hospitals. While our analysis did not account for differences in patient preferences for treatment, the differences we observed in the use of DNR orders across sociodemographic groups are suggestive of variations in care and may have important implications for the cost and quality of hospital care.

Depression, competence, and the right to refuse lifesaving medical treatment.

OBJECTIVE: The authors explore the possibility that psychiatrists inappropriately extend their views on suicide by the medically well to refusal of lifesaving treatment by the seriously medically ill. METHOD: The legal and bioethics literature on competence to refuse lifesaving treatment and the possible impact of depression on this refusal is reviewed. RESULTS: Over the past 20 years, the burden of proof concerning the mental competence of seriously medically ill patients who refuse lifesaving treatment has shifted to the persons who seek to override these refusals. However, in psychiatry a patient's desire to die is generally considered to be evidence of an impaired capacity to make decisions about lifesaving treatment. This contrast between ethical traditions is brought into clinical focus during the evaluation and treatment of medically ill patients with depression who refuse lifesaving treatment. The clinical evaluation of the effect of depression on a patient's capacity to make medical decisions is difficult for several reasons: 1) depression is easily seen as a "reasonable" response to serious medical illness, 2) depression produces more subtle distortions of decision making than delirium or psychosis (i.e., preserving the understanding of medical facts while impairing the appreciation of their personal importance), and 3) a diagnosis of major depression is neither necessary nor sufficient for determining that the patient's medical decision making is impaired. CONCLUSIONS: Depression can be diagnosed and treated in patients with serious medical illness. But after optimizing medical and psychiatric treatment and determining that the patient is competent to make medical decisions, it may be appropriate to honor the patient's desire to die.

Medical futility.

Recent discussions about futility have been useful in elucidating health professionals' responsibility to communicate, to establish trust, and to collaborate with patients and families about end-of-life decisions. They have highlighted the often impersonal and fragmented care that patients receive in today's large medical centers. Futility also has been a stalking horse for the much more important and problematic issue of rationing. The latter must be discussed on its own merits, however painful that may be.

Patient autonomy, informed consent, and the reality of critical care.

The realities of serious illness and critical care environments often complicate our efforts to evaluate treatment refusal according to the doctrine of informed consent. However, health professionals must strive to use informed consent as the ultimate standard for both treatment and nontreatment decisions, by making continual efforts to communicate with patients, share information, and enhance their sense of autonomy and control.

The dead donor rule: should we stretch it, bend it, or abandon it?

The dead donor rule--that persons must be dead before their organs are taken--is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse.

Do-not-resuscitate orders: no longer secret, but still a problem.

Over the past decade, public discussion has focused on the ethics of issuing Do-Not-Resuscitate Orders, and the failure of many hospitals to acknowledge their actions openly. Recent efforts on the part of some hospitals to establish formal DNR guidelines that are prudent, fair, and humane, are a helpful beginning, though they cannot account for all the vagaries of illness and human communication. But concerns about DNR should not divert us from looking closely and rigorously at other, more common treatment/nontreatment decisions in the critical care setting.

Bureaucratizing suicide.

Although helpful in many ways, the Guidelines for Assessing Mental Capacity and Impaired Judgment fall short in 3 areas. First, the term capacity is poorly defined and explicated. Second, the inevitable role of the evaluator's own values is given short shrift. Finally, the Guidelines rely too heavily on lists and formal test without guidance about what is most important. This failure threatens to further burden dying patients with unwanted and unnecessary bureaucratic intrusion.