Fast and slow thinking; and the problem of conflating clinical reasoning and ethical deliberation in acute decision-making.

Expertise in a medical specialty requires countless hours of learning and practice and a combination of neural plasticity and contextual case experience resulting in advanced gestalt clinical reasoning. This holistic thinking assimilates complex segmented information and is advantageous for timely clinical decision-making in the emergency department and paediatric or neonatal intensive care units. However, the same agile reasoning that is essential acutely may be at odds with the slow deliberative thought required for ethical reasoning and weighing the probability of patient morbidity. Recent studies suggest that inadequate ethical decision-making results in increased morbidity for patients and that clinical ethics consultation may reduce the inappropriate use of life-sustaining treatment. Behavioural psychology research suggests there are two systems of thinking - fast and slow - that control our thoughts and therefore our actions. The problem for experienced clinicians is that fast thinking, which is instinctual and reflexive, is particularly vulnerable to experiential biases or assumptions. While it has significant utility for clinical reasoning when timely life and death decisions are crucial, I contend it may simultaneously undermine the deliberative slow thought required for ethical reasoning to determine appropriate therapeutic interventions that reduce future patient morbidity. Whilst health-care providers generally make excellent therapeutic choices leading to good outcomes, a type of substitutive thinking that conflates clinical reasoning and ethical deliberation in acute decision-making may impinge on therapeutic relationships, have adverse effects on patient outcomes and inflict lifelong burdens on some children and their families.

Exploring the vagueness of Religion & Spirituality in complex pediatric decision-making: a qualitative study.

BACKGROUND: Medical advances have led to new challenges in decision-making for parents of seriously ill children. Many parents say religion and spirituality (R&S) influence their decisions, but the mechanism and outcomes of this influence are unknown. Health care providers (HCPs) often feel unprepared to discuss R&S with parents or address conflicts between R&S beliefs and clinical recommendations. Our study sought to illuminate the influence of R&S on parental decision-making and explore how HCPs interact with parents for whom R&S are important. METHODS: A longitudinal, qualitative, descriptive design was used to (1) identify R&S factors affecting parental decision-making, (2) observe changes in R&S themes over time, and (3) learn about HCP perspectives on parental R&S. The study sample included 16 cases featuring children with complex life-threatening conditions. The length of study for each case varied, ranging in duration from 8 to 531 days (median = 380, mean = 324, SD = 174). Data from each case included medical records and sets of interviews conducted at least monthly with mothers (n = 16), fathers (n = 12), and HCPs (n = 108). Thematic analysis was performed on 363 narrative interviews to identify R&S themes and content related to decision-making. RESULTS: Parents from 13 cases reported R&S directly influenced decision-making. Most HCPs were unaware of this influence. Fifteen R&S themes appeared in parent and HCP transcripts. Themes most often associated with decision-making were Hope & Faith, God is in Control, Miracles, and Prayer. Despite instability in the child's condition, these themes remained consistently relevant across the trajectory of illness. R&S influenced decisions about treatment initiation, procedures, and life-sustaining therapy, but the variance in effect of R&S on parents' choices ultimately depended upon other medical & non-medical factors. CONCLUSIONS: Parents consider R&S fundamental to decision-making, but apply R&S concepts in vague ways, suggesting R&S impact how decisions are made more than what decisions are made. Lack of clarity in parental expressions of R&S does not necessarily indicate insincerity or underestimation of the seriousness of the child's prognosis; R&S can be applied to decision-making in both functional and dysfunctional ways. We present three models of how religious and spiritual vagueness functions in parental decision-making and suggest clinical applications.

Debating Medical Utility, Not Futility: Ethical Dilemmas in Treating Critically Ill People Who Use Injection Drugs.

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal.

Problems in Critical Care Nurse-Patient Communication: Examples of Poland and Turkey.

The aim of this study was to determine the problems related to nurse-patient communication in the intensive care unit (ICU), with a focus on differences between Poland and Turkey. A descriptive survey design was used. The study was conducted in Surgical ICU, Lwowska Hospital in Poland and ICU, Training and Research Hospital in Turkey. Fifty critical care nurses in Poland and 52 critical care nurses in Turkey were included in the study. Patient data were collected using a questionnaire that was prepared by the researchers. In this study, 46% and 42.3% of the nurses reported they had communication problems with patients in Poland and Turkey, respectively. It was also found that the nurses in Poland mostly used therapeutic touch for non-verbal communication (80%), whereas the nurses in Turkey used facial expression (90.4%). Critical care nurses in both countries experienced similar difficulties in patient communication. It is recommended that the patient to nurse ratio in ICUs be planned according to the intensive care standards.

Integración de los principios de cuidados paliativos en cuidados intensivos / Integration of the principles of palliative care in intensive care medicine

En la literatura científica se constata un reciente interés por integrar los principios de la medicina paliativa en el trabajo cotidiano de la unidad de cuidados intensivos (UCI). El artículo revisa este planteamiento con la idea de fondo de que su aplicación pueda aportar luz en la resolución de ciertos problemas éticos presentes. Los pacientes con procesos avanzados y en situación de final de vida ingresados en cuidados intensivos se encuentran con un nivel de sufrimiento y vulnerabilidad que sólo una atención comprensiva y holística puede dar un alivio adecuado. Sin embargo, la realidad clínica del cuidado de estos pacientes en UCI, por el momento, está lejana a ese ideal. La mejora de la atención clínica en este sentido, especialmente en el fallecimiento, es el punto de interés que nos ocupa. Avanzar en este aspecto es complejo pero se hace necesario un esfuerzo. La propuesta es recurrir a la medicina paliativa como modelo de referencia en los cuidados del final de vida y en la atención holística, e introducir sus principios de tratamiento en la UCI. El objetivo del artículo es exponer una estrategia práctica para llevarlo a cabo y que pueda ser útil en la mejora de la atención clínica y ética de los pacientes

Recent scientific literature has shown a growing interest to integrate palliative medicine principles into the daily workflow in the intensive care unit (ICU). This article reviews this trend with the goal that its application might provide more understanding in the resolution of some current ethical issues. Patients with an advanced disease process and at the end of life who are admitted in the intensive care unit are in such a profound level of suffering and vulnerability that only an holistic and comprehensive approach can provide adequate relief to them. Nevertheless, the reality of the clinical care of these patients in the ICU is far beyond that ideal. Our primary end point is the improvement in the clinical care provided, especially when the patient is dying. It is indeed very complex to make progress in this field, but an effort has to be made. The project is to turn to palliative medicine as a role model for end of life care and as an holistic approach, and introduce palliative medicine principles in the ICU. The goal of this article is to reveal a practical approach to accomplish this, and make it functional in order to improve our patients' clinical and ethical care

Nurses' Perceptions of Futile Care: A Qualitative Study.

Health care professionals believe that futile care must not be provided; however, there is no clear agreement over the definition and the manifestations of futile care. The aim of this study was to explore Iranian nurses' perceptions of futile care. In this qualitative exploratory study, the conventional content analysis approach was used for collecting and analyzing the study data. Three main themes were extracted from the data: nonfutility of care: care tantamount with outcome; sense of burnout; and subjectivity and relativity of medical futility concept.

Ethical issues and palliative care in the cardiovascular intensive care unit.

Medical advances over the past 50 years have helped countless patients with advanced cardiac disease or who are critically ill in the intensive care unit (ICU), but have added to the ethical complexity of the care provided by clinicians, particularly at the end of life. Palliative care has the primary aim of improving symptom burden, quality of life, and the congruence of the medical plan with a patient's goals of care. This article explores ethical issues encountered in the cardiac ICU, discusses key analyses of these issues, and addresses how palliative care might assist medical teams in approaching these challenges.

Integration of palliative care in chronic critical illness management.

Palliative care is an essential component of comprehensive care for all patients with chronic critical illness, including those receiving restorative or life-sustaining therapies. Core elements include alleviation of symptom distress, communication about care goals, alignment of treatment with the patient's values and preferences, transitional planning, and family support. Here we address strategies for assessment and management of symptoms, including pain, dyspnea, and depression, and for assisting patients to communicate while endotracheally intubated. We also discuss approaches to optimize communication among clinicians, patients, and families about care goals. Challenges for supporting families and planning for transitions between care settings are identified, while the value of interdisciplinary input is emphasized. We review "consultative" and "integrative" models for integrating palliative care and restorative critical care. Finally, we highlight key ethical issues that arise in the care of chronically critically ill patients and their families.

Systems biology in critical-care nursing.

Systems biology applies advances in technology and new fields of study including genomics, transcriptomics, proteomics, and metabolomics to the development of new treatments and approaches of care for the critically ill and injured patient. An understanding of systems biology enhances a nurse's ability to implement evidence-based practice and to educate patients and families on novel testing and therapies. Systems biology is an integrated and holistic view of humans in relationship with the environment. Biomarkers are used to measure the presence and severity of disease and are rapidly expanding in systems biology endeavors. A systems biology approach using predictive, preventive, and participatory involvement is being utilized in a plethora of conditions of critical illness and injury including sepsis, cancer, pulmonary disease, and traumatic injuries.

Progress in ethical decision making in the care of the dying.

Practitioners in critical care have made a significant progress in caring for dying patients in critical care by taking advantage of the suggestions from their professional groups. Progress has been made in responding to and controlling patients' pain. Major initiatives from the Joint Commission and the American Pain Society have helped direct this improvement. Palliative care consultations as well as ethics consultations have improved symptom control in the critically ill. Issues of consent have been problematic for dying patients in critical care especially in the area of discontinuing therapies. But, better policies related to advance directives have been developed to ensure good care. Spiritual care has received more attention, and now chaplains are recognized by the Society for Critical Care Medicine as integral to the critical care team. The American Association of Critical-Care Nurses has been a leader in improving end-of-life issues and continues to spearhead many projects to improve end-of-life care.

Pain management within the palliative and end-of-life care experience in the ICU.

In the ICU where critically ill patients receive aggressive life-sustaining interventions, suffering is common and death can be expected in up to 20% of patients. High-quality pain management is a part of optimal therapy and requires knowledge and skill in pharmacologic, behavioral, social, and communication strategies grounded in the holistic palliative care approach. This contemporary review article focuses on pain management within comprehensive palliative and end-of-life care. These key points emerge from the transdisciplinary review: (1) all ICU patients experience opportunities for discomfort and suffering regardless of prognosis or goals, thus palliative therapy is a requisite approach for every patient, of which pain management is a principal component; (2) for those dying in the ICU, an explicit shift in management to comfort-oriented care is often warranted and may be the most beneficial treatment the health-care team can offer; (3) communication and cultural sensitivity with the patient-family unit is a principal approach for optimizing palliative and pain management as part of comprehensive ICU care; (4) ethical and legal misconceptions about the escalation of opiates and other palliative therapies should not be barriers to appropriate care, provided the intention of treatment is alleviation of pain and suffering; (5) standardized instruments, performance measurement, and care delivery aids are effective strategies for decreasing variability and improving palliative care in the complex ICU setting; and (6) comprehensive palliative care should addresses family and caregiver stress associated with caring for critically ill patients and anticipated suffering and loss.

Medical futility: a paradigm as old as Hippocrates.

Medical futility is a concept commonly used to describe medical therapy that has no known or anticipated immediate or long-term benefit for a patient. The concept of futility has existed since the time of Hippocrates and has become the predominant dilemma for many end-of-life situations. Today, clinicians grapple with ethical conflicts and concepts in their daily practice. Many healthcare providers use the concept of medical futility when they are talking with patients and families who are in a quandary about their loved one's care. This article provides an overview of medical futility.