Trial of Therapy on Trial: Inconsistent Thresholds for Discussing Withdrawal of Life-Sustaining Therapies in the Neonatal Intensive Care Unit.

OBJECTIVE: This study aimed to establish the degree of variability in thresholds for discussing withdrawal of life-sustaining therapies (WLST) in periviable infants among neonatal intensive care unit (NICU) personnel. STUDY DESIGN: A vignette-style survey was administered to NICU personnel at two urban NICUs assessing likelihood of discussing WLST or support for discussing WLST (on a scale from 1, not at all likely/supportive to 10, extremely likely/supportive) in 10 clinical scenarios. RESULTS: Response rates ranged by clinical role from 26 to 89%. Participant responses ranged from 1 to 10 in 5 out of 10 vignettes for NICU attendings, and 9 out of 10 vignettes for bedside nurses. Lower gestational age (22-23 vs. 24-25 weeks) was associated with increased likelihood to discuss WLST in some but not all scenarios. CONCLUSION: NICU personnel have widely variable criteria for discussing WLST which threatens the informed consent process surrounding resuscitation decisions in a "trial of therapy" framework. KEY POINTS: · NICU personnel have variable criteria for WLST.. · Parents have little say in whether WLST is offered.. · Disclosure of variable criteria is not routine..

To tell or not to tell: attitudes of transplant surgeons and transplant nephrologists regarding the disclosure of recipient information to living kidney donors.

BACKGROUND: Organ Procurement and Transplantation Network policy regarding "Living Donation Informed Consent Requirements" only requires general disclosure of candidate health information to prospective living kidney donors. We examined attitudes of transplant surgeons and transplant nephrologists regarding greater disclosure. METHODS: Web-based and mailed surveys to explore attitudes about disclosing potential recipient health information, health-associated behaviors, and lifestyle choices to living donors. RESULTS: Of 397 potential participants, 111 eligible participants (28%) fully or partially responded. Respondents were split between surgeons (42%) and nephrologists (58%). While 72% believed that general disclosure did not require explicit permission, 88% believed that disclosure of specific recipient information did. Many would disclose more information if legally permissible. Over 65% thought disclosure of recipient information should not depend on the donor-recipient relationship. Virtually all supported disclosing expected one- and five-yr graft survival and anticipated deceased donor wait-time. Sixty-six percent supported disclosing non-compliance or difficulty taking medications. Support was divided for disclosure of HIV (52%), hepatitis (49%), smoking (53%), illicit drugs (50%), alcohol (49%), and psychiatric history (44%). CONCLUSIONS: While virtually all respondents support disclosing recipient information directly relevant to graft and patient survival to prospective living donors, they are divided about sharing other recipient health, health behavior, and/or lifestyle information.

Unconscious semantic processing of polysemous words is not automatic.

Semantic processing of visually presented words can be identified both on behavioral and neurophysiological evidence. One of the major discoveries of the last decades is the demonstration that these signatures of semantic processing, initially observed for consciously perceived words, can also be detected for masked words inaccessible to conscious reports. In this context, the distinction between conscious and unconscious verbal semantic processing constitutes a challenging scientific issue. A prominent view considered that while conscious representations are subject to executive control, unconscious ones would operate automatically in a modular way, independent from control and top-down influences. Recent findings challenged this view by revealing that endogenous attention and task-setting can have a strong influence on unconscious processing. However, one of the major arguments supporting the automaticity of unconscious semantic processing still stands, stemming from a seminal observation reported by Marcel in 1980 about polysemous words. In the present study we reexamined this evidence. We present a combination of behavioral and event-related-potentials (ERPs) results that refute this view by showing that the current conscious semantic context has a major and similar influence on the semantic processing of both visible and masked polysemous words. In a classical lexical decision task, a polysemous word was preceded by a word which defined the current semantic context. Crucially, this context was associated with only one of the two meanings of the polysemous word, and was followed by a word/pseudo-word target. Behavioral and electrophysiological evidence of semantic priming of target words by masked polysemous words was strongly dependent on the conscious context. Moreover, we describe a new type of influence related to the response-code used to answer for target words in the lexical decision task: unconscious semantic priming constrained by the conscious context was present both in behavior and ERPs exclusively when right-handed subjects were instructed to respond to words with their right hand. The strong and respective influences of conscious context and response-code on semantic processing of masked polysemous words demonstrate that unconscious verbal semantic representations are not automatic.

Disclosing Health and Health Behavior Information between Living Donors and Their Recipients.

BACKGROUND AND OBJECTIVES: Living donor guidelines-both national and international-either do not address or are vague about what information can be shared between prospective living donors and transplant candidates, as well as when to make such disclosures and who should make them. This study explored the attitudes of donors and recipients regarding how much information they believe should be shared. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Two Email invitations were sent by the National Kidney Foundation (national headquarters) to its Email listservs, inviting members to participate in an online survey to assess the attitudes of kidney transplant stakeholders regarding the disclosure of health and health risk behavior information. RESULTS: From approximately 4200 unique Email addresses, 392 (9.3%) respondents completed part or all of the survey. The analyses were limited to the 236 respondents who self-identified as either donors (potential and actual, n=160) or recipients (candidates and actual, n=76). Overall, 79% (186 of 234) of respondents supported disclosure of general recipient health information that would affect post-transplant outcome to donors, and 88% (207 of 235) supported disclosure of general donor health information to recipients. Recipients and donors were also supportive of sharing donor and recipient information, particularly information relevant to graft and patient survival. There is some reticence, however, about sharing social information. The closer the relationship, the more information they are willing to share. Both donors and recipients wanted the transplant team involved in the information disclosure. Over three quarters of donors (79%) and recipients (78%) did not think the recipient had a right to know why a donor was excluded from donating. CONCLUSIONS: Both donors and recipients want a significant amount of health information to be disclosed. The opinions of other stakeholders need to be surveyed to determine whether a revision of current policies and practices is warranted.