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1.
J Clin Ethics ; 31(2): 111-125, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32585654

RESUMO

INTRODUCTION: In highly developed countries, as many as 16 percent of children are physically abused each year. Traumatic brain injury (TBI) is the most common injury in non-accidental trauma (NAT) and is responsible for 80 percent of fatal NAT cases, with most deaths occurring in children younger than three years old. Cases of abusers who refuse withdrawal of life-sustaining medical treatment (LSMT) to avoid criminal charges have previously been reported. Therefore, we hypothesized that NAT is associated with a lower risk for withdrawal LSMT in pediatric TBI. METHODS: The pediatric Trauma Quality Improvement Program database was analyzed (2014 to 2016) for patients aged 16 and younger with TBI and Glasgow Coma Scale (GCS) of 8 and lower on admission. Patients with a head Abbreviated Injury Scale (AIS) of 2 or less or who died within 48 hours were excluded. A multivariable logistic regression model was used for analysis. RESULTS: Of 2,209 TBI patients, 92 (4.2 percent) had withdrawal of LSMT. Compared to those without withdrawal of LMST, those with LMST had statistically similar median age (three years of age versus seven years) and a higher rate of NAT (33.7 percent versus 13.5 percent). The most common specified perpetrator was a father/stepfather/male partner (70 percent). After adjusting for covariates, factors associated with higher risk for withdrawal of LSMT included age of less than three years (OR 2.38, CI 1.34-4.23) and NAT (OR 1.86, CI 1.02-3.41). CONCLUSION: NAT is associated with increased risk for withdrawal of LSMT in pediatric TBI. Age of less than three years is similarly associated with a higher risk for withdrawal of LSMT. Future research in this population is needed to determine what other factors predict withdrawal of LSMT and what resources, such as social workers and/or ethics consults, are utilized.


Assuntos
Lesões Encefálicas Traumáticas , Lesões Encefálicas , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Adolescente , Criança , Pré-Escolar , Escala de Coma de Glasgow , Humanos , Cuidados para Prolongar a Vida/ética , Masculino , Estudos Retrospectivos , Suspensão de Tratamento/ética
4.
J Trauma Acute Care Surg ; 89(1): 160-166, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32218021

RESUMO

BACKGROUND: Although several trauma centers have developed direct to operating room (DOR) trauma resuscitation programs, there is little published data on optimal patient selection, practices, and outcomes. We sought to analyze triage criteria and interventions associated with optimal DOR outcomes and resource utilization. METHODS: Retrospective review of all adult DOR resuscitations for a 6-year period was performed. Triage criteria were analyzed individually and grouped into categories: mechanism, physiology, anatomy/injury, or other. The best univariate and multivariate predictors of requiring lifesaving interventions (LSIs) or emergent surgery (ES) were analyzed. Actual and predicted mortality were compared for all patients and for predefined time-sensitive subgroups. RESULTS: There were 628 DOR patients (5% of all admissions) identified; the majority were male (79%), penetrating mechanism (70%), severely injured (40% ISS >15), and 17% died. Half of patients required LSI and 23% required ES, with significantly greater need for ES and lower need for LSI after penetrating versus blunt injury (p < 0.01). Although injury mechanism criteria triggered most DOR cases and best predicted need for ES, the physiology and anatomy/injury criteria were associated with greater need for LSI and mortality. Observed mortality was significantly lower than predicted mortality with DOR for several key subgroups. Triage schemes for both ES and LSI could be simplified to four to six independent predictors by regression analysis. CONCLUSION: The DOR program identified severely injured trauma patients at increased risk for requiring LSI and/or ES. Different triage variable categories drive the need for ES versus LSI and could be simplified or optimized based on local needs or preferences. Direct to operating room was associated with better than expected survival among specific time-sensitive subgroups. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.


Assuntos
Salas Cirúrgicas , Seleção de Pacientes , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Cuidados para Prolongar a Vida , Masculino , Oregon , Sistema de Registros , Estudos Retrospectivos , Tempo para o Tratamento , Centros de Traumatologia , Triagem , Ferimentos e Lesões/mortalidade
6.
Medicina (B Aires) ; 80(1): 48-53, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32044741

RESUMO

Patient relatives often request withdrawal of life support, especially artificial nutrition and hydration, in cases of permanent vegetative or minimally conscious state, and resort to court in case of disagreement. Two recent cases of withdrawal authorized by the courts concerned, one from abroad and one from Argentina, have been controversial. Although it may appear inhuman to stop feeding and hydrating such patients, to continue it only prolongs a state of irreversible biological subsistence. Families tend to increasingly accept withdrawal if the patient status remains unchanged. However, concern persists regarding the suffering that patients may undergo from onset of withdrawal till death, even though such suffering is little conceivable in the absence of cortical function and conscience content. While doctors and the layman consider ethical to withdraw life support, a nonnegligible proportion of doctors consider that vegetative state patients, even more minimally conscious state patients, do experience hunger, thirst and pain. In some countries, like the United Kingdom, strict withdrawal criteria were proposed, together with pharmacological treatment schemes for the distress arising during the withdrawal period, even though its benefit is controversial. In Argentina, two scientific societies have publicly advocated withdrawal, but not issued formal guidelines. In any case, both "dignified death" Law 26.742 and the Civil Code consent withdrawal of life support, if accompanied by appropriate relief of clinical symptoms indicating suffering.


Assuntos
Cuidados para Prolongar a Vida/legislação & jurisprudência , Estado Vegetativo Persistente , Direito a Morrer/legislação & jurisprudência , Suspensão de Tratamento/legislação & jurisprudência , Argentina , Humanos
7.
Ann Emerg Med ; 75(5): 559-567, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31983499

RESUMO

STUDY OBJECTIVE: Out-of-hospital naloxone has been championed as a lifesaving solution during the opioid epidemic. However, the long-term outcomes of out-of-hospital naloxone recipients are unknown. The objectives of this study are to describe the 1-year mortality of presumed opioid overdose victims identified by receiving out-of-hospital naloxone and to determine which patient factors are associated with subsequent mortality. METHODS: This was a regional retrospective cohort study of out-of-hospital records from 7 North Carolina counties from January 1, 2015 to February 28, 2017. Patients who received out-of-hospital naloxone were included. Out-of-hospital providers subjectively assessed patients for improvement after administering naloxone. Naloxone recipients were cross-referenced with the North Carolina death index to examine mortality at days 0, 1, 30, and 365. Naloxone recipient mortality was compared with the age-adjusted, at-large population's mortality rate in 2017. Generalized estimating equations and Cox proportional hazards models were used to assess for mortality-associated factors. RESULTS: Of 3,085 out-of-hospital naloxone encounters, 72.7% of patients (n=2,244) improved, whereas 27.3% (n=841) had no improvement with naloxone. At day 365, 12.0% (n=269) of the improved subgroup, 22.6% (n=190) of the no improvement subgroup, and 14.9% (n=459) of the whole population were dead. Naloxone recipients who improved were 13.2 times (95% confidence interval 13.0 to 13.3) more likely to be dead at 1 year than a member of the general populace after age adjusting of the at-large population to match this study population. Older age and being black were associated with 1-year mortality, whereas sex and multiple overdoses were not. CONCLUSION: Opioid overdose identified by receiving out-of-hospital naloxone with clinical improvement carries a 13-fold increase in mortality compared to the general population. This suggests that this is a high-risk population that deserves attention from public health officials, policymakers, and health care providers in regard to the development of long-term solutions.


Assuntos
Analgésicos Opioides/envenenamento , Overdose de Drogas/tratamento farmacológico , Serviços Médicos de Emergência , Mortalidade/tendências , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Adolescente , Adulto , Criança , Pré-Escolar , Overdose de Drogas/mortalidade , Feminino , Humanos , Lactente , Recém-Nascido , Cuidados para Prolongar a Vida/métodos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Adulto Jovem
10.
Am J Hosp Palliat Care ; 37(1): 19-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31122034

RESUMO

BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is an effective advance care planning tool. However, barriers to implementation persist. In the United States, POLST program development occurs at the state-level. Substantial differences between states has left POLST implementation largely unstandardized. No peer-reviewed studies to date have evaluated state-based POLST program development over time. OBJECTIVE: To assess and learn from the successes and barriers in state-based POLST program development over time to improve the reach of POLST or similar programs across the United States. DESIGN: An exploratory, prospective cohort study that utilized semistructured telephone interviews was conducted over a 3-year period (2012-2015). Stakeholder representatives from state POLST coalitions (n = 14) were repeatedly queried on time-relevant successes, barriers, and innovations during POLST program development with levels of legislative and medical barriers rated 1 to 10. Interviews were transcribed and analyzed using techniques grounded in qualitative theory. RESULTS: All coalition representatives reported continuous POLST expansion with improved outreach and community partnerships. Significant barriers to expansion included difficulty in securing funding for training and infrastructure, lack of statewide metric systems to adequately assess expansion, lack of provider support, and legislative concerns. Medical barriers (mean [standard deviation]: 5.0 [0.2]) were rated higher than legislative (3.0 [0.6]; P < .001). CONCLUSION: POLST programs continue to grow, but not without barriers. Based on the experiences of developing coalitions, we were able to identify strategies to expand POLST programs and overcome barriers. Ultimately the "lessons learned" in this study can serve as a guide to improve the reach of POLST or similar programs.


Assuntos
Planejamento Antecipado de Cuidados/organização & administração , Cuidados para Prolongar a Vida/organização & administração , Assistência Terminal/organização & administração , Planejamento Antecipado de Cuidados/economia , Planejamento Antecipado de Cuidados/legislação & jurisprudência , Atitude do Pessoal de Saúde , Humanos , Capacitação em Serviço/organização & administração , Entrevistas como Assunto , Cuidados para Prolongar a Vida/economia , Cuidados para Prolongar a Vida/legislação & jurisprudência , Estudos Longitudinais , Estudos Prospectivos , Assistência Terminal/normas , Estados Unidos
11.
BMC Med Educ ; 19(1): 452, 2019 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-31801502

RESUMO

BACKGROUND: Proper basic life support (BLS) is key in improving the survival of out-of-hospital cardiac arrest. BLS skills deteriorate in three to 6 months after training. One method to improve skill retention may be using the "testing effect" to test skills at the end of a BLS course. The aim of our study was to investigate whether either testing or the timing of such testing after BLS training have any influence on skill retention. METHODS: This was a post-test only, partial coverage, prospective quasi-experimental study designed to evaluate a BLS training course among 464 fifth year medical students at Semmelweis University in the first semester of 2013/2014. Groups were systematically but non-randomly assigned to either a control group that took no exam or one of two experimental groups that took an exam (N = 179, NoExam group; N = 165, EndExam group - exam at the end of the BLS training; N = 120, 3mExam group - exam 3 months after the BLS training). The ability to perform ten prescribed essential BLS steps was evaluated during a skill retention assessment 2 months after the course in the NoExam, 2 months after the course (and the exam) in the EndExam and 5 months after the course (2 months after the exam) in the 3mExam group to measure skill retention and the effect of our intervention. Scores were calculated for each BLS step, and also summed up as a total score. We used Kruskal-Wallis test to assess differences in skill retention. RESULTS: Overall, NoExam and EndExam groups showed similar skill retention. The mean total score (and many of the sub-scores) of students was significantly higher in the 3mExam group compared to both the NoExam and the EndExam groups, and there was no difference in the total score (and many of the sub-scores) of the latter two groups. The 3mExam group had less variability in total scores (and many of the sub-scores) than the other two groups. CONCLUSION: Our study provides evidence that testing these skills 3 months after BLS training may be more effective than either testing immediately at the end of the course or no testing at all.


Assuntos
Avaliação Educacional , Cuidados para Prolongar a Vida , Retenção Psicológica , Estudantes de Medicina , Reanimação Cardiopulmonar/educação , Competência Clínica , Feminino , Humanos , Hungria , Masculino , Estudos Prospectivos
12.
Semin Respir Crit Care Med ; 40(6): 842-856, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31887769

RESUMO

Cystic fibrosis (CF) remains the most common indication for lung transplantation in children and the third most common in adults and has the highest median survival posttransplant for all pretransplant diagnoses. Criteria for transplant in patients with CF vary widely among transplant centers and early referral to multiple centers may be needed to maximize opportunities for lung transplantation. Comorbidities unique to CF such as resistant and atypical pathogens like Burkholderia and Mycobacterium abscessus, and cirrhosis require special consideration for lung transplantation but should not be considered as absolute contraindications. For those patients who are listed for lung transplantation, mechanical support with extracorporeal membrane oxygenation and mechanical ventilation can be efficacious as bridges to lung transplantation in experienced centers with adequate resources. Liver and pancreas transplantations are also acceptable options for end-organ disease related to CF and can provide improvements in both quantity and quality of life.


Assuntos
Fibrose Cística/cirurgia , Transplante de Pulmão , Adulto , Infecções por Burkholderia/cirurgia , Criança , Comorbidade , Fibrose Cística/complicações , Fibrose Cística/microbiologia , Fibrose Cística/mortalidade , Humanos , Cuidados para Prolongar a Vida , Cirrose Hepática/cirurgia , Transplante de Fígado , Infecções por Mycobacterium não Tuberculosas/cirurgia , Transplante de Pâncreas , Encaminhamento e Consulta , Fatores de Risco , Listas de Espera
13.
Yale J Biol Med ; 92(4): 781-791, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31866795

RESUMO

Current efforts to legalize medical aid-in-dying in this country follow a half century of remarkable legal developments regarding when, how, and on whose terms to intervene to prevent death and extend life in critically and terminally ill patients. The starting point-which I call the first stage along the path-was the creation in the two decades following World War II of powerful means of keeping very ill, and typically unconscious, patients alive. The second stage began in the late 1960s as physicians (and then others in society) began to grapple with the consequences of maintaining such patients on life-support indefinitely. Over five decades, judicial decisions, followed by implementing statutes and regulations, transformed legal rights and medical practices. Are the current developments-which center on legalizing medical aid-in-dying-a third stage along the same path, or do the striking differences between the issues raised about life-sustaining treatment and euthanasia suggest that they are separate? What lessons might those proceeding along the aid-in-dying path take from the development of the other path, and if the two paths are still distinct today, might they merge in the future?


Assuntos
Cuidados para Prolongar a Vida/legislação & jurisprudência , Políticas , Suicídio Assistido/legislação & jurisprudência , Humanos , Autonomia Pessoal
14.
BMC Med Ethics ; 20(1): 91, 2019 12 30.
Artigo em Inglês | MEDLINE | ID: mdl-31884958

RESUMO

BACKGROUND: In the ruling in Y [2018], the UK Supreme Court has confirmed that there is no general requirement for the courts in England and Wales to authorise the withdrawal of clinically assisted nutrition and hydration from patients with prolonged disorders of consciousness. The perceived requirement, which originated in a court ruling in 1993, encompassed those in the vegetative state and those in the minimally conscious state. The ruling in Y confirms that the court may still be approached to decide difficult or contested cases, but there is otherwise no routine requirement that the judges be approached. MAIN BODY: There is much to welcome in this ruling, particularly as it means that these decisions for these patients are no longer (unusually) singled out for a judicial decision, with all the financial and emotional costs that court proceedings can entail. However, there is also a risk that the ruling might have unwelcome consequences. First, there is the possibility that patients might die too soon, particularly if doctors should now adopt the courts' previous reasoning, which has suggested that patients in the vegetative state lack interests, so treatment may - perhaps must - be withdrawn. Secondly, there is the converse possibility that patients might live too long, since empirical research suggests that - whether intentionally or not - patients' families, clinicians, and the health system appear to promote treatment-by-default. CONCLUSION: Rather than adopt general positions, which may be contestable and potentially risky, this article argues, on a pluralistic basis, that the individual patient should be the focus of any decision made in his or her 'best interests'. The existing legal framework in England and Wales, which is provided by the Mental Capacity Act 2005, already points in this direction, although more efforts may be needed to ensure that those involved in making these decisions are suitably educated and supported. Fortunately, new guidance from the British Medical Association could help clinicians and families to make decisions in the future, which are appropriate for the incapacitated individual patient in question.


Assuntos
Estado de Consciência , Dissidências e Disputas , Estado Vegetativo Persistente , Suspensão de Tratamento/ética , Suspensão de Tratamento/legislação & jurisprudência , Dissidências e Disputas/legislação & jurisprudência , Humanos , Cuidados para Prolongar a Vida , Reino Unido
15.
J Law Health ; 33(1): 79-106, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31841618

RESUMO

Alfie Evans was a terminally ill British child whose parents, clinging to hope, were desperately trying to save his life. Hospital authorities disagreed and petitioned the court to enjoin the parents from removing him and taking him elsewhere for treatment. The court stepped in and compelled the hospital to discontinue life support and claimed that further treatment was not in the child's best interest. This note discusses the heartbreaking stories of Alfie and two other children whose parents' medical decisions on their behalf were overridden by the court. It argues that courts should never decide that death is in a child's best interest and compel parents to withdraw life support from their children. Such a decision is outside the scope of the judiciary. Furthermore, it argues that even in those instances when the court may or must intervene, a new framework is necessary because the current framework used by the court to determine the best interest of the child ignores fundamental realities of child psychology. Too often, as a result of the court's mistaken framework, the court illegitimately trespasses into the parental domain. By adopting a new framework, the court will intervene only when actual abuse or neglect is suspected. In all other cases, judicial restraint will be practiced and the court will show greater deference to the parents' wishes.


Assuntos
Tomada de Decisões , Dissidências e Disputas , Função Jurisdicional , Pais , Adolescente , Adulto , Terapias Complementares/ética , Terapias Complementares/legislação & jurisprudência , Ética Institucional , Ética Médica , Feminino , Humanos , Identificação Psicológica , Lactente , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/legislação & jurisprudência , Masculino , Obrigações Morais , Autonomia Pessoal , Autonomia Profissional
16.
BMC Health Serv Res ; 19(1): 865, 2019 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752855

RESUMO

BACKGROUND: Basic Life Support (BLS) is the recognition of sudden cardiac arrest and activation of the emergency response system, followed by resuscitation, and rapid defibrillation. According to WHO, Pakistan has one of the highest mortality rates from accidental deaths therefore assessment and comparison of BLS knowledge in health professionals is crucial. We thereby aim to assess and compare the knowledge of BLS in doctors, dentists and nurses. METHODS: A multi-centric cross-sectional survey was conducted in Karachi at different institutions belonging to the private as well as government sector from January to March 2018. We used a structured questionnaire which was adapted from pretested questionnaires that have been used previously in similar studies. Descriptive statistics were analyzed using SPSS v22.0, where adequate knowledge was taken as a score of at least 50%. P < 0.05 was considered as significant. Logistic regression was used to identify the factors affecting the knowledge regarding BLS in health care professionals. RESULTS: The responders consisted of 140 doctors, nurses and dentists each. Only one individual (dentist) received a full score of 100%. In total, 58.3% of the population had inadequate knowledge. Average scores of doctors, dentists and nurses were 53.5, 43.3 and 38.4% respectively. Doctors, participants with prior training in BLS and those with 6 to 10 years after graduation were found to be a significant predictor of adequate knowledge, on multivariate analysis. CONCLUSION: Even though knowledge of BLS in doctors is better than that of dentists and nurses, overall knowledge of health care professionals is extremely poor. Present study highlights the need for a structured training of BLS for health care workers.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde , Cuidados para Prolongar a Vida , Adulto , Cidades , Estudos Transversais , Odontólogos/estatística & dados numéricos , Feminino , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros/estatística & dados numéricos , Paquistão , Médicos/estatística & dados numéricos , Adulto Jovem
17.
PLoS One ; 14(11): e0225303, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31756229

RESUMO

PURPOSE: There have been few studies on the limitation of Life Supporting Care (LSC) and Withdrawal of LSC in Intermediate Care Units (IMCUs). We report the prevalence of LSC limited patients in a medico-surgical IMCU over a six-month period, examining the description, outcomes, and patterns of LSC Limitations and Withdrawal of LSC. METHODS: Single center, retrospective observational study in an IMCU of a 500-bed general hospital. RESULTS: Our study of 404 patients, reported 79 (19.5%, 95%CI: [16.0-23.7]%) being admitted with LSC limitations in the IMCU. This group of LSC limited patients presented with higher chronic and acute severity scores. The most common admission diagnosis of LSC limited patients was acute respiratory failure (51%). Non-invasive ventilation (NIV) was frequently used within this population (39%). Hospital mortality for LSC limited patients was high (53%) and associated with age (OR = 1.07, 95%CI: [1.01-1.13)]), SOFA score (OR 1.29, 95%CI: [1.01-1.64]), and hypoxemic respiratory failure (OR 7.2, 95%CI: [1.27-40.9]). Withdrawal of LSC occurred in 19.5% of cases, often accompanied with terminal sedation with or without NIV removal (43.8%). CONCLUSIONS: Patients with limitation of LSC are frequently admitted into IMCU. Hospital mortality rate was high and associated with age, acute organ failures, and hypoxemic respiratory failure. Life support withdrawal includes palliative sedation with or without NIV discontinuation.


Assuntos
Ventilação não Invasiva/estatística & dados numéricos , Insuficiência Respiratória/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Instituições para Cuidados Intermediários , Cuidados para Prolongar a Vida , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos
20.
Afr Health Sci ; 19(2): 2252-2262, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31656511

RESUMO

Background: Provision of up-to-date information and skills training related to basic life support practices is very important for nursing students' professional development and practitioner and education related roles. Objective: The purpose of the study was to examine the effectiveness of basic life support training on knowledge and practices among nursing students. Methods: A non-randomized quasi-experimental design (One group pre-test-post-test) was used in this study. The study was conducted in the laboratory of an undergraduate nursing school. The sample consisted of a convenience sample of 1st-year students enrolled in the undergraduate nursing class. The study sample consisted of 65 nursing students. Basic life support training included both theoretical and practical components. The students' knowledge and practices were assessed before basic life support training. Data were collected using the knowledge assessment questionnaire. The practical skills for basic life support were observed and assessed using a checklist. The pre- and post-assessment practice scores were compared. Results: After basic life support training, level of knowledge and practical skill scores were higher compared to pre-training scores (t= -12.442, p=0.000; t= -22.899, p=0.000). There was a significant and moderate association between the adult basic life support Knowledge Form scores and the adult basic life support practice assessment form scores obtained after the training (r = 0.39, p<0.01). Conclusion: The study showed that basic life support training improved knowledge and skills related to basic life support practices in nursing students. Periodic basic life support training is very important for competency in this area among nursing students.


Assuntos
Bacharelado em Enfermagem , Avaliação Educacional , Conhecimentos, Atitudes e Prática em Saúde , Cuidados para Prolongar a Vida , Adolescente , Adulto , Feminino , Humanos , Masculino , Turquia
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