Ethical and Legal Concerns Associated With Withdrawing Mechanical Circulatory Support: A U.S. Perspective.

Hundreds of thousands of Americans have advanced heart failure and experience severe symptoms (e. g., dyspnea) with minimal exertion or at rest despite optimal management. Although heart transplant is an effective treatment for advanced heart failure, the demand for organs far exceeds the supply. Another option for these patients is mechanical circulatory support (MCS) provided by devices such as the ventricular assist device and total artificial heart. MCS alleviates symptoms, prolongs life, and provides a "bridge to transplant" or a decision regarding future management such as "destination therapy," in which the patient receives lifelong MCS. However, a patient receiving MCS, or his/her surrogate decision-maker, may conclude ongoing MCS is burdensome and no longer consistent with the patient's healthcare-related values, goals, and preferences and, as a result, request withdrawal of MCS. Likewise, the patient's clinician and care team may conclude ongoing MCS is medically ineffective and recommend its withdrawal. These scenarios raise ethical and legal concerns. In the U.S., it is ethically and legally permissible to carry out an informed patient's or surrogate's request to withdraw any treatment including life-sustaining treatment (LST) if the intent is to remove a treatment perceived by the patient as burdensome and not to terminate intentionally the patient's life. Under these circumstances, death that follows withdrawal of the LST is due to the underlying disease and not a form of physician-assisted suicide or euthanasia. In this article, frequently encountered ethical and legal concerns regarding requests to withdraw MCS are reviewed: the ethical and legal permissibility of withholding or withdrawing LSTs from patients who no longer want such treatments; what to do if the clinician concludes ongoing LST will not result in achieving clinical goals (i.e., medically ineffective); responding to requests to withdraw LST; the features of patients who undergo withdrawal of MCS; the rationale for advance care planning in patients being considered for, or receiving, MCS; and other related topics. Notably, this article reflects a U.S. perspective.

Computer-Based Patient Bias and Misconduct Training Impact on Reports to Incident Learning System.

OBJECTIVE: To assess the effect of computer-based training (CBT) and leadership communication on incident learning system reports pertaining to institutional policy that targets biased, prejudiced, and racist behaviors of patients and visitors toward health care employees. PATIENTS AND METHODS: Mayo Clinic developed a CBT module and comprehensive communication strategy to educate staff on the Patient and Visitor Conduct Policy. Additional goals were to demonstrate leadership endorsement and support of the policy, teach how to report an incident, and facilitate how policy enforcement might occur. Using descriptive statistics, we compared the reporting data before and after the intervention. RESULTS: Participants were 13,980 employees in 68 clinics and 18 hospitals in the US Midwest. Bias and misconduct incidents entered in the incident reporting system increased 312% (n=140 incidents; preintervention, n=34) in the quarter (ie, 3 months) immediately after intervention. The number of incidents in the next quarter stayed increased (234%; n=114) compared with the preintervention number. Secondary debriefing with employees showed the value of the education and the importance of leadership support at the highest level to facilitate comfort in policy enforcement. CONCLUSION: Institutional policy that targets biased, prejudiced, and racist behaviors of patients toward employees in a health care setting can be augmented with employee education and leadership support to facilitate change. The CBT, paired with a robust communication plan and active leadership endorsement and engagement, resulted in increased reporting of biased, prejudiced, and racist behaviors of patients.

Statutes Governing Default Surrogate Decision Making for Mental Health Treatment.

OBJECTIVE: The authors sought to describe state-to-state variations in the scope of statutory authority granted to default surrogates who decide on mental health treatment for incapacitated patients. METHODS: The authors investigated state statutes delineating the powers of default surrogates to make decisions about mental health treatment. Statutes in all 50 U.S. states and the District of Columbia were identified and analyzed independently by three reviewers. Research was conducted from August 2017 to November 2018 and updated in January 2020. RESULTS: State statutes varied in approaches to default surrogate decision making for mental health treatment. Eight states' statutes delegate broad authority to surrogates, whereas 25 states prohibit surrogates from giving consent for specific therapies. Thirteen states are silent on whether surrogates may make decisions. CONCLUSIONS: Heterogeneity among state statutory laws contributes to complexity of treating patients without decisional capacity. This variability encumbers efforts to support surrogates and clinicians and may contribute to health disparities.

US medical and surgical society position statements on physician-assisted suicide and euthanasia: a review.

BACKGROUND: An analysis of the position statements of secular US medical and surgical professional societies on physician-assisted suicide (PAS) and euthanasia have not been published recently. Available statements were evaluated for position, content, and sentiment. METHODS: In order to create a comprehensive list of secular medical and surgical societies, the results of a systematic search using Google were cross-referenced with a list of societies that have a seat on the American Medical Association House of Delegates. Societies with position statements were identified. These statements were divided into 5 categories: opposed to PAS and/or euthanasia, studied neutrality, supportive, acknowledgement without statement, and no statement. Linguistic analysis was performed using RapidMinder in order to determine word frequency and sentiment respective to individual statements. To ensure accuracy, only statements with word counts > 100 were analyzed. A 2-tailed independent t test was used to test for variance among sentiment scores of opposing and studied neutrality statements. RESULTS: Of 150 societies, only 12 (8%) have position statements on PAS and euthanasia: 11 for PAS (5 opposing and 4 studied neutrality) and 9 for euthanasia (6 opposing and 2 studied neutrality). Although the most popular words used in opposing and studied neutrality statements are similar, notable exceptions exist (suicide, medicine, and treatment appear frequently in opposing statements, but not in studied neutrality statements, whereas psychologists, law, and individuals appear frequently in studied neutrality statements, but not in opposing statements). Sentiment scores for opposing and studied neutrality statements do not differ (mean, 0.094 vs. 0.104; P = 0.90). CONCLUSIONS: Few US medical and surgical societies have position statements on PAS and euthanasia. Among them, opposing and studied neutrality statements share similar linguistic sentiment. Opposing and studied neutrality statements have clear differences, but share recommendations. Both opposing and studied neutrality statements cite potential risks of PAS legalization and suggest that good palliative care might diminish a patient's desire for PAS.

Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement.

Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons' needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.

Chinese physician perceptions regarding industry support of continuing medical education programs: a cross-sectional survey.

Background: Industry funding in continuing medical education has been extensively studied in the USA. Although continuing medical education is also a requirement for Chinese physicians, little is known about Chinese physician perceptions of industry support in continuing medical education.Objective: We aim to determine perceptions regarding industry support for CME among Chinese physicians at a large CME course, examine potential associations between Chinese physicians' perceptions and their demographic characteristics, and compare Chinese and US physicians' perceptions of industry support for CME.Design: We performed a cross-sectional survey of physicians at a nephrology continuing medical education conference in China. All participants received a previously published, anonymous survey consisting of 4 items, with questions asked in English and Mandarin Chinese. Responses were compared with those of a previous cohort in the USA.Results: The response rate was 24% (128/541). Most respondents were nephrologists (112/126, 89%), women (91/128, 71%), and aged 20 to 40 years (79/127, 62%). Most respondents preferred industry-supported continuing medical education (84/123, 68%) or had no preference (33/123, 27%). More clinicians than clinical researchers supported industry offsetting costs (76.9% vs 58.3%; P = .03). Almost half of participants (58/125, 46%) stated that industry-supported continuing medical education was biased in support of industry. Compared with US physicians, Chinese physicians were more likely to believe, or had no opinion, that industry-supported courses were biased (67.2% vs 47.0%; P < .001).Conclusions: Chinese continuing medical education participants preferred industry-sponsored continuing medical education and were strongly in favor of industry offsetting costs, but almost half believed that such education was biased in favor of supporting companies. Concern for bias was higher among Chinese than US physicians. Given participants' concerns, further study examining industry bias in Chinese continuing medical education is recommended.Abbreviations: CME: Continuing medical education; US: USA.

Utilization of Palliative Care for Cardiogenic Shock Complicating Acute Myocardial Infarction: A 15-Year National Perspective on Trends, Disparities, Predictors, and Outcomes.

Background This study sought to evaluate the 15-year national utilization, trends, predictors, disparities, and outcomes of palliative care services (PCS) use in cardiogenic shock complicating acute myocardial infarction. Methods and Results A retrospective cohort from January 1, 2000 through December 31, 2014 was analyzed using the National Inpatient Sample database. Administrative codes for acute myocardial infarction-cardiogenic shock and PCS were used to identify eligible admissions. The primary outcomes were the frequency, utilization trends, and predictors of PCS. Secondary outcomes included in-hospital mortality and resources utilization. Multivariable regression and propensity-matching analyses were used to control for confounding. In this 15-year period, there were 444 253 acute myocardial infarction-cardiogenic shock admissions, of which 4.5% received PCS. The cohort receiving PCS was older, of white race, female sex, and with higher comorbidity and acute organ failure. The PCS cohort received fewer cardiac procedures, but more noncardiac organ support therapies. Older age, female sex, white race, higher comorbidity, higher socioeconomic status, admission to a larger hospital, and admission after 2008 were independent predictors of PCS use. Use of PCS was independently associated with higher in-hospital mortality (odds ratio 6.59 [95% CI 6.37-6.83]; P<0.001). The cohort with PCS use had >2-fold higher in-hospital mortality, 12-fold higher use of do-not-resuscitate status, lesser in-hospital resource utilization, and fewer discharges to home. Similar findings were observed in the propensity-matched cohort. Conclusions PCS use in patients with acute myocardial infarction-cardiogenic shock is low, though there is a trend towards increased adoption. There are significant patient and hospital-specific disparities in the utilization of PCS.

Decisions to Withdraw Extracorporeal Membrane Oxygenation Support: Patient Characteristics and Ethical Considerations.

OBJECTIVE: To describe the prevalence and context of decisions to withdraw extracorporeal membrane oxygenation (ECMO), with an ethical analysis of issues raised by this technology. PATIENTS AND METHODS: We retrospectively reviewed medical records of adults treated with ECMO at Mayo Clinic in Rochester, Minnesota, from January 1, 2010, through December 31, 2014, from whom ECMO was withdrawn and who died within 24 hours of ECMO separation. RESULTS: Of 235 ECMO-supported patients, we identified 62 (26%) for whom withdrawal of ECMO was requested. Of these 62 patients, the indication for ECMO initiation was bridge to transplant for 8 patients (13%), bridge to mechanical circulatory support for 3 (5%), and bridge to decision for 51 (82%). All the patients were supported with other life-sustaining treatments. No patient had decisional capacity; for all the patients, consensus to withdraw ECMO was jointly reached by clinicians and surrogates. Eighteen patients (29%) had a do-not-resuscitate order at the time of death. CONCLUSION: For most patients who underwent treatment withdrawal eventually, ECMO had been initiated as a bridge to decision rather than having an established liberation strategy, such as transplant or mechanical circulatory support. It is argued that ethically, withdrawal of treatment is sometimes better after the prognosis becomes clear, rather than withholding treatment under conditions of uncertainty. This rationale provides the best explanation for the behavior observed among clinicians and surrogates of ECMO-supported patients. The role of do-not-resuscitate orders requires clarification for patients receiving continuous resuscitative therapy.

Crucial conversations about weight management with healthcare providers: patients' perspectives and experiences.

PURPOSE: To elicit patient experiences of weight management discussions with providers and provide recommendations for future weight-related discussions. METHODS: 1000 patients who recently saw their provider for non-weight specific appointments were mailed measures of demographics, self-reported height and weight, activity level, adherence, perceptions of and recommendations for weight-related discussions, and internalized weight bias. This study was primarily descriptive and utilized a mixed method design including collection of quantitative and qualitative data. RESULTS: 242 patients responded (24 % response rate); 32.4 % overweight (N = 72), 41.9 % obese (N = 93). 47 % of overweight and 71 % of obese patients recalled that their provider discussed weight; 92 % were motivated to follow recommendations and 89 % felt confident doing so. Most patients (75 %) would like their provider to be "very direct/straightforward" when discussing weight, and 52 % would be "not at all offended" if they were diagnosed as "overweight/obese." Most patients (63 %) reported being "extremely comfortable" discussing weight with providers. Patients with higher BMI had higher levels of internalized weight bias (p < .001) and wanted their provider to "discuss weight sensitively" (p < .05). CONCLUSION: This study suggests that patients have important preferences that providers should be mindful of when discussing weight. While these discussions can be challenging, most patients report that they would be comfortable having these conversations directly and most would have enhanced motivation and confidence following these conversations. Communicating about weight is needed and desired by patients; doing so sensitively with those at higher weight is essential.

Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper.

Calls to legalize physician-assisted suicide have increased and public interest in the subject has grown in recent years despite ethical prohibitions. Many people have concerns about how they will die and the emphasis by medicine and society on intervention and cure has sometimes come at the expense of good end-of-life care. Some have advocated strongly, on the basis of autonomy, that physician-assisted suicide should be a legal option at the end of life. As a proponent of patient-centered care, the American College of Physicians (ACP) is attentive to all voices, including those who speak of the desire to control when and how life will end. However, the ACP believes that the ethical arguments against legalizing physician-assisted suicide remain the most compelling. On the basis of substantive ethics, clinical practice, policy, and other concerns articulated in this position paper, the ACP does not support legalization of physician-assisted suicide. It is problematic given the nature of the patient-physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession's role in society. Furthermore, the principles at stake in this debate also underlie medicine's responsibilities regarding other issues and the physician's duties to provide care based on clinical judgment, evidence, and ethics. Society's focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care. The ACP remains committed to improving care for patients throughout and at the end of life.

Ethical Analysis of Withdrawing Total Artificial Heart Support.

OBJECTIVES: To describe the characteristics of patients who undergo withdrawal of total artificial heart support and to explore the ethical aspects of withdrawing this life-sustaining treatment. PATIENTS AND METHODS: We retrospectively reviewed the medical records of all adult recipients of a total artificial heart at Mayo Clinic from the program's inception in 2007 through June 30, 2015. Management of other life-sustaining therapies, approach to end-of-life decision making, engagement of ethics and palliative care consultation, and causes of death were analyzed. RESULTS: Of 47 total artificial heart recipients, 14 patients or their surrogates (30%) requested withdrawal of total artificial heart support. No request was denied by treatment teams. All 14 patients were supported with at least 1 other life-sustaining therapy. Only 1 patient was able to participate in decision making. CONCLUSION: It is widely held to be ethically permissible to withdraw a life-sustaining treatment when the treatment no longer meets the patient's health care-related goals (ie, the burdens outweigh the benefits). These data suggest that some patients, surrogates, physicians, and other care providers believe that this principle extends to the withdrawal of total artificial heart support.

The Organ Transplant Imperative.

More than 120,000 US patients were listed for solid organ transplants in 2016. Although data are scarce, we suspect that many of these patients will die while awaiting transplant and without engaging in goals-of-care discussions with their physicians. The challenges of addressing goals of care in patients with malignancy, end-stage renal disease, and heart failure have been studied. However, there is sparse literature on addressing goals of care throughout the dynamic process of transplant assessment and listing. We propose the concept of an organ transplant imperative, which is the perceived obligation by patients and health care providers to proceed with organ transplant and to avoid advance care planning and triggered goals-of-care discussions, even in situations in which patients' clinical trajectories have worsened, resulting in poor quality of life and low likelihood of meaningful survival. We situate this concept within the paradigms of clinical inertia and the treatment and technological imperatives. We illustrate this concept by describing a patient with end-stage liver disease (ESLD) who was hoping for a liver transplant, who was caught between the conflicting perspectives of specialist and primary care physicians, and who died of complications of ESLD without experiencing the benefits of advance care planning. Greater awareness of the transplant imperative should generate a shared understanding among specialists, generalists, and patients and will provide opportunities for more formalized involvement of palliative medicine experts in the care of transplant patients.