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1.
Am J Bioeth ; 24(6): 27-33, 2024 Jun.
Article in English | MEDLINE | ID: mdl-38829586

ABSTRACT

The introduction of normothermic regional perfusion (NRP) in controlled donation after circulatory determination of death (cDCDD) protocols is by some regarded as controversial and ethically troublesome. One of the main concerns that opponents have about introducing NRP in cDCDD protocols is that reestablishing circulation will negate the determination of death by circulatory criteria, potentially resuscitating the donor. In this article, I argue that this is not the case. If we take a closer look at the concept of death underlying the circulatory criterion for determination of death, we find that the purpose of the criterion is to show whether the organism as a whole has died. I argue that this purpose is fulfilled by the circulatory criterion in cDCDD protocols, and that applying NRP does not negate the determination of death or resuscitate the donor.


Subject(s)
Death , Tissue and Organ Procurement , Humans , Tissue and Organ Procurement/ethics , Perfusion , Tissue Donors/ethics , Resuscitation/ethics , Blood Circulation
2.
Arch Dis Child Fetal Neonatal Ed ; 106(6): 596-602, 2021 Nov.
Article in English | MEDLINE | ID: mdl-33927001

ABSTRACT

BACKGROUND: Decisions about treatments for extremely preterm infants (EPIs) born in the 'grey zone' of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine. METHODS: The online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents' views based on profession and neonatal unit designation. Further questions explored respondents' conceptual understanding of viability. RESULTS: 336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22+1 and 24+0 weeks' gestation. Registrars/fellows were more likely to select a lower threshold at 22+0 weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22+0 weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be 'viable' if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team. CONCLUSION: Compared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks' gestation.


Subject(s)
Fetal Viability/physiology , Gestational Age , Infant Care , Infant, Extremely Premature , Palliative Care , Resuscitation , Attitude of Health Personnel , Clinical Decision-Making , Female , Health Care Surveys , Humans , Infant Care/ethics , Infant Care/methods , Infant Care/psychology , Infant, Newborn , Intensive Care Units, Neonatal/statistics & numerical data , Male , Neonatologists/statistics & numerical data , Nurses, Neonatal/statistics & numerical data , Palliative Care/ethics , Palliative Care/psychology , Resuscitation/ethics , Resuscitation/methods , Resuscitation/psychology , Resuscitation Orders/ethics , Resuscitation Orders/psychology , United Kingdom/epidemiology
3.
Surgery ; 169(6): 1532-1535, 2021 06.
Article in English | MEDLINE | ID: mdl-33436273

ABSTRACT

BACKGROUND: Trauma patients may present with nonsurvivable injuries, which could be resuscitated for future organ transplantation. Trauma surgeons face an ethical dilemma of deciding whether, when, and how to resuscitate a patient who will not directly benefit from it. As there are no established guidelines to follow, we aimed to describe resuscitation practices for organ transplantation; we hypothesized that resuscitation practices vary regionally. METHOD: Over a 3-month period, we surveyed trauma surgeons practicing in Levels I and II trauma centers within a single state using an instrument to measure resuscitation attitudes and practices for organ preservation. Descriptive statistics were calculated for practice patterns. RESULTS: The survey response rate was 51% (31/60). Many (81%) had experience with resuscitations where the primary goal was to preserve potential for organ transplantation. Many (90%) said they encountered this dilemma at least monthly. All respondents were willing to intubate; most were willing to start vasopressors (94%) and to transfuse blood (84%) (range, 1 unit to >10 units). Of respondents, 29% would resuscitate for ≥24 hours, and 6% would perform a resuscitative thoracotomy. Respect for patients' dying process and future organ quality were the factors most frequently considered very important or important when deciding to stop or forgo resuscitation, followed closely by concerns about excessive resource use. CONCLUSION: Trauma surgeons' regional resuscitation practices vary widely for this patient population. This variation implies a lack of professional consensus regarding initiation and extent of resuscitations in this setting. These data suggest this is a common clinical challenge, which would benefit from further study to determine national variability, areas of equipoise, and features amenable to practice guidelines.


Subject(s)
Practice Patterns, Physicians'/ethics , Resuscitation/ethics , Tissue Donors/ethics , Transplantation/ethics , Traumatology/ethics , Wounds and Injuries/therapy , Adult , Female , Humans , Male , Middle Aged , Practice Patterns, Physicians'/statistics & numerical data , Resuscitation/methods , Surveys and Questionnaires , Tennessee , Trauma Centers/ethics , Trauma Centers/statistics & numerical data , Traumatology/statistics & numerical data
6.
Transplantation ; 104(8): 1542-1552, 2020 08.
Article in English | MEDLINE | ID: mdl-32732830

ABSTRACT

Uncontrolled donation after circulatory death (uDCD) refers to donation from persons who die following an unexpected and unsuccessfully resuscitated cardiac arrest. Despite the large potential for uDCD, programs of this kind only exist in a reduced number of countries with a limited activity. Barriers to uDCD are of a logistical and ethical-legal nature, as well as arising from the lack of confidence in the results of transplants from uDCD donors. The procedure needs to be designed to reduce and limit the impact of the prolonged warm ischemia inherent to the uDCD process, and to deal with the ethical issues that this practice poses: termination of advanced cardiopulmonary resuscitation, extension of advanced cardiopulmonary resuscitation beyond futility for organ preservation, moment to approach families to discuss donation opportunities, criteria for the determination of death, or the use of normothermic regional perfusion for the in situ preservation of organs. Although the incidence of primary nonfunction and delayed graft function is higher with organs obtained from uDCD donors, overall patient and graft survival is acceptable in kidney, liver, and lung transplantation, with a proper selection and management of both donors and recipients. Normothermic regional perfusion has shown to be critical to achieve optimal outcomes in uDCD kidney and liver transplantation. However, the role of ex situ preservation with machine perfusion is still to be elucidated. uDCD is a unique opportunity to improve patient access to transplantation therapies and to offer more patients the chance to donate organs after death, if this is consistent with their wishes and values.


Subject(s)
Donor Selection/methods , Graft Rejection/prevention & control , Heart Arrest/mortality , Organ Preservation/methods , Organ Transplantation/methods , Allografts/supply & distribution , Donor Selection/ethics , Donor Selection/legislation & jurisprudence , Graft Rejection/etiology , Health Services Accessibility , Heart Arrest/therapy , Humans , Organ Transplantation/adverse effects , Organ Transplantation/ethics , Organ Transplantation/legislation & jurisprudence , Perfusion/instrumentation , Perfusion/methods , Resuscitation/ethics , Treatment Outcome , Warm Ischemia/adverse effects
8.
Semin Fetal Neonatal Med ; 24(6): 101029, 2019 12.
Article in English | MEDLINE | ID: mdl-31606328

ABSTRACT

There is very little law-either case law or statutory law - that regulates delivery room decisions about resuscitation of critically ill newborns. Most of the case law that exists is decades old. Thus, physicians cannot look to the law for much guidance about what is permissible or prohibited. Local hospital policies and professional society statements provide some guidance, but they cannot be all-inclusive and encompass all potentially encountered scenarios. Ultimately, the physician, the medical team, and the parents must try to reach a shared decision about the best course of action for each individual infant and each unique family. In this paper, we review some of the case law that may be applicable to such decisions and make recommendations about how decisions should be made.


Subject(s)
Critical Illness , Delivery Rooms , Delivery, Obstetric , Infant, Newborn, Diseases , Physician-Patient Relations/ethics , Resuscitation , Adult , Critical Illness/psychology , Critical Illness/therapy , Decision Making, Shared , Delivery Rooms/ethics , Delivery Rooms/legislation & jurisprudence , Delivery Rooms/organization & administration , Delivery, Obstetric/ethics , Delivery, Obstetric/legislation & jurisprudence , Delivery, Obstetric/psychology , Emergencies/psychology , Female , Humans , Infant, Newborn , Infant, Newborn, Diseases/psychology , Infant, Newborn, Diseases/therapy , Liability, Legal , Obstetric Labor Complications/therapy , Pregnancy , Resuscitation/ethics , Resuscitation/psychology
10.
Emerg Med J ; 36(9): 535-540, 2019 Sep.
Article in English | MEDLINE | ID: mdl-31427472

ABSTRACT

OBJECTIVES: We set out to investigate paramedics' views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA). METHODS: An interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview. RESULTS: Three superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic's willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care. CONCLUSION: A paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials.


Subject(s)
Attitude of Health Personnel , Clinical Trials as Topic/ethics , Emergency Medical Technicians/psychology , Out-of-Hospital Cardiac Arrest/drug therapy , Adult , Ambulances/ethics , Emotions , Epinephrine/administration & dosage , Female , Humans , Male , Middle Aged , Morals , Patient Selection/ethics , Placebos/administration & dosage , Qualitative Research , Refusal to Participate/ethics , Refusal to Participate/psychology , Resuscitation/ethics , Resuscitation/methods , United Kingdom
11.
J Palliat Med ; 22(7): 870-872, 2019 Jul.
Article in English | MEDLINE | ID: mdl-30702373

ABSTRACT

Requests for hastened death and suicidal ideation may be more prevalent in populations approaching the end of life. Often these wishes and thoughts occur in the context of concurrent psychiatric disorders and emotional suffering. We discuss the case of a veteran with terminal lung cancer and comorbid psychiatric illness who attempted suicide while under the care of an inpatient interdisciplinary hospice team and describe our team's response to this suicide attempt. We review risk factors for suicidality at end of life, challenges of distinguishing desire for hastened death from suicidality, and the ethics of resuscitation of a dying patient after a suicide attempt.


Subject(s)
Lung Neoplasms/psychology , Lung Neoplasms/therapy , Resuscitation/ethics , Suicide, Attempted , Terminally Ill , Veterans/psychology , Aged , Attitude to Death , Fatal Outcome , Humans , Male
12.
Med Health Care Philos ; 22(3): 475-486, 2019 Sep.
Article in English | MEDLINE | ID: mdl-30671733

ABSTRACT

The aim of this paper is to analyze an Intensive Care Unit case that required ethics consultation at a University Hospital in Northern Italy. After the case was resolved, a retrospective ethical analysis was performed by four clinical ethicists who work in different healthcare contexts (Italy, the United States, and Switzerland). Each ethicist used a different method to analyze the case; the four general approaches provide insight into how these ethicists conduct ethics consultations at their respective hospitals. Concluding remarks examine the similarities and differences among the various approaches and offer a reflection concerning the possibility of a shared resolution to the case. The authors' efforts to come to a tentative consensus may serve as an example for professionals working in medical contexts that reflect an increasing pluralism of values. This article aims to respond to some of these concerns by illustrating how different methods in clinical ethics would be used when considering a real case. The goal is not to establish the best model (if there is one) on a theoretical level, but to learn from actual practice in order to see if there are common elements in the different methods, and to validate their pertinence to clinical ethics consultation.


Subject(s)
Decision Making , Ethics Consultation , Intensive Care Units/ethics , Acute Disease/therapy , Cervical Vertebrae/injuries , Craniocerebral Trauma/therapy , Cultural Diversity , Family , Fractures, Bone/therapy , Humans , Male , Medical Futility/ethics , Middle Aged , Morals , Patient Preference , Quality of Life , Resuscitation/ethics , Spinal Cord Injuries/therapy , Treatment Refusal/ethics
13.
Heart Lung ; 48(4): 268-272, 2019.
Article in English | MEDLINE | ID: mdl-30448022

ABSTRACT

INTRODUCTION: Family presence during resuscitation (FPDR), remains inconsistently implemented by emergency personnel. The benefits for family members is well documented, providing opportunities for family to say goodbye, facilitates closure and enables family to provide emotional support to the patient. The aim of this study was to explore the experiences and attitudes of emergency personnel towards FPDR immediately post resuscitation events. METHOD: A descriptive qualitative design was used to explore the experiences of emergency personnel with FPDR. Data was collected from single rural and metropolitan emergency departments in the state of Victoria, Australia. The participants consisted of nurses and doctors who took active roles during resuscitation events. Following transcription of the audiotaped interviews Creswell's (2003) six step analysis process was employed. RESULT: A total of 29 interviews of key personnel, following 6 paediatric and 18 adult resuscitation events. Interviews were conducted over a period of two weeks in each venue. The data was organised into six themes following analysis including: care coordinators inconsistently called, gate keepers to implementation, effective communication strategies helping to deliver bad news, life experience generates confidence, allocation of family support person, and family members roles dependent on age of patient. CONCLUSION: FPDR is common practice in paediatric events however remains inconsistently implemented during adult resuscitations. A designated family support person is essential to successful implementation of FPDR and should be incorporated in to the allocation of the resuscitation team roles during both adult and paediatric resuscitation events. Education and training is important for clinicians to learn essential communication skills, building practice confidence, which is required to successfully implement FPDR.


Subject(s)
Attitude of Health Personnel , Emergency Service, Hospital , Family/psychology , Physicians/psychology , Professional-Family Relations/ethics , Qualitative Research , Resuscitation/ethics , Adult , Female , Humans , Male , Middle Aged , Resuscitation/psychology , Surveys and Questionnaires , Victoria
14.
Hastings Cent Rep ; 48 Suppl 4: S33-S35, 2018 Nov.
Article in English | MEDLINE | ID: mdl-30584855

ABSTRACT

Uncontrolled donation after circulatory death, which occurs when an individual has experienced unexpected cardiac arrest, usually not in a hospital, generates both excitement and concern. On the one hand, uDCD programs have the capacity to significantly increase organ donation rates, with good transplant outcomes-mainly for kidneys, but also for livers and lungs. On the other hand, uDCD raises a number of ethical challenges. In this essay, we focus on an issue that is central to all uDCD protocols: When should we cease resuscitation and shift to organ preservation? Do current uDCD protocols prematurely consider as potential donors patients who could still have some chances of meaningful survival? Can the best interest of patients be fostered once they are considered and treated as potential donors?


Subject(s)
Death , Life Support Care , Resuscitation , Tissue and Organ Harvesting , Tissue and Organ Procurement , Clinical Decision-Making , Heart Arrest/diagnosis , Heart Arrest/therapy , Humans , Life Support Care/legislation & jurisprudence , Life Support Care/methods , Resuscitation/ethics , Resuscitation/methods , Resuscitation Orders , Tissue and Organ Harvesting/ethics , Tissue and Organ Harvesting/legislation & jurisprudence , Tissue and Organ Harvesting/methods , Tissue and Organ Procurement/ethics , Tissue and Organ Procurement/methods
16.
J Emerg Med ; 55(1): 141-142, 2018 07.
Article in English | MEDLINE | ID: mdl-29776701

ABSTRACT

BACKGROUND: Critically ill or injured emergency department or prehospital patients who lack decision-making capacity sometimes present with a non-standard advance directive, such as a "Do Not Resuscitate" tattoo or medallion. Emergency clinicians must immediately address the question of whether to withhold treatment based on what may or may not be a valid patient directive. DISCUSSION: Advance directives have been standardized for a good reason. Emergency department or prehospital healthcare providers must be able to immediately interpret and act on them without needing a legal interpretation. When faced with non-standard directives, physicians can follow them, ignore them, or simply use them as an additional piece of information about the individual's wishes for some situations at one point in his or her life. Absent the patient's input or that of aknowledgeable surrogate, both the patient's initial reasons for their non-standard directive and his or her present wishes concerning resuscitation cannot be independently known. Therefore, healthcare providers must initiate treatment while they buy time, attempt to return the patient to lucidity, and search for probative information regarding their current wishes concerning medical treatment. Without such additional information, the moral weight will always favor initiating treatment, since withholding treatment is often irreversible and any treatment instituted can later be withdrawn.


Subject(s)
Advance Directives/trends , Decision Making , Resuscitation/ethics , Advance Directives/ethics , Emergency Medicine/methods , Emergency Medicine/trends , Emergency Service, Hospital/organization & administration , Humans , Resuscitation/trends , Tattooing/adverse effects , Tattooing/trends
17.
J Relig Health ; 57(3): 1183-1195, 2018 Jun.
Article in English | MEDLINE | ID: mdl-29569111

ABSTRACT

Spirituality is becoming of increasing importance in the international healthcare context. While patients' spirituality or faith is often overlooked, there is a growing awareness that understanding, addressing and supporting patients' spiritual and faith needs can influence healthcare outcomes. This review aims to illuminate this role and highlight healthcare chaplains' potential in relation to the provision of pastoral support for families during and after patient resuscitation, and the dearth of interdisciplinary education in this field. A rapid structured review was undertaken using four databases-PubMed, CINAHL, PsycINFO and ATLA. Primary research studies published during the 10-year period 2007-2017 written in English addressing the chaplain's role or perceived role in resuscitation were included. An initial search using key terms yielded 18 relevant citations. This reduced to 11 once duplicates were removed. Ultimately five relevant primary research studies were included in the final analysis. This review found few studies that directly explored the topic. Certainly many view the chaplain as a key member of the resuscitation team, although this role has not been fully explored. Chaplains likely have a key role in supporting families during decisions about 'not for resuscitation' and in supporting families during and after resuscitation procedures. Chaplains are key personnel, already employed in many healthcare organisations, who are in a pivotal position to contribute to future developments of spiritual and pastoral care provision and support. Their role at the end of life, despite well described and supported, has received little empirical support. There is an emerging role for chaplains in healthcare ethics, supporting end-of-life decisions and supporting family witnessed resuscitation where relevant. Their role needs to be more clearly understood by medical staff, and chaplain's input into undergraduate medical education programmes is becoming vital.


Subject(s)
Chaplaincy Service, Hospital/organization & administration , Clergy , Pastoral Care/methods , Resuscitation , Spirituality , Adult , Delivery of Health Care , Humans , Resuscitation/ethics , Resuscitation/psychology
18.
Arch Dis Child Fetal Neonatal Ed ; 103(3): F280-F284, 2018 May.
Article in English | MEDLINE | ID: mdl-29353257

ABSTRACT

Neonatal resuscitation is provided to approximately 3% of neonates. Adequate ventilation is often the key to successful resuscitation, but this can be difficult to provide. There is increasing evidence that inappropriate respiratory support can have severe consequences. Several neonatal intensive care units have recorded and reviewed neonatal resuscitation procedures for quality assessment, education and research; however, ethical dilemmas sometimes make it difficult to implement this review process. We reviewed the literature on the development of recording and reviewing neonatal resuscitation and have summarised the ethical concerns involved. Recording and reviewing vital physiological parameters and video imaging of neonatal resuscitation in the delivery room is a valuable tool for quality assurance, education and research. Furthermore, it can improve the quality of neonatal resuscitation provided. We observed that ethical dilemmas arise as the review process is operating in several domains of healthcare that all have their specific moral framework with requirements and conditions on issues such as consent, privacy and data storage. These moral requirements and conditions vary due to local circumstances. Further research on the ethical aspects of recording and reviewing is desirable before wider implementation of this technique can be recommended.


Subject(s)
Ethics, Medical , Intensive Care Units, Neonatal/ethics , Quality Assurance, Health Care/ethics , Resuscitation/ethics , Video Recording/ethics , Humans , Infant, Newborn , Infant, Premature , Intensive Care Units, Neonatal/standards
19.
Acta Paediatr ; 107(2): 223-226, 2018 Feb.
Article in English | MEDLINE | ID: mdl-28921688

ABSTRACT

AIM: We aimed to evaluate mortality and short-term neonatal morbidity of babies born ≤500 g cared for in the Northern Neonatal Network over a 15-year period. METHOD: Using regional databases, we identified all live-born babies ≥22 weeks gestation and ≤500 g, in North East England and North Cumbria from 1998 to 2012. We quantified major neonatal morbidities and survival to one year. RESULTS: We identified 104 live-born babies ≥22 weeks gestation and ≤500 g (birth prevalence 0.22/1000), of which 49 were admitted for intensive care. Overall one-year survival was 11%, but survival for those receiving intensive care was 22%. There was significant short-term neonatal morbidity in survivors, in particular retinopathy of prematurity and chronic lung disease. CONCLUSION: Survival of babies born weighing ≤500 g in this cohort remains poor despite advances in neonatal care, with considerable short-term neonatal morbidity in survivors. This could be due to a combination of attitudes and a rather conservative approach towards resuscitation and intensive care, and the intrinsic nature of these tiny babies.


Subject(s)
Infant, Extremely Low Birth Weight , Infant, Extremely Premature , Infant, Premature, Diseases/mortality , Intensive Care, Neonatal , England/epidemiology , Female , Gestational Age , Humans , Infant, Newborn , Infant, Premature, Diseases/epidemiology , Intensive Care Units, Neonatal , Male , Resuscitation/ethics
20.
Isr Med Assoc J ; 19(9): 586-589, 2017 09.
Article in English | MEDLINE | ID: mdl-28971647

ABSTRACT

BACKGROUND: Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus. OBJECTIVES: To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized. METHODS: Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother's vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother. RESULTS: We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered. CONCLUSIONS: The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible.


Subject(s)
Cesarean Section/ethics , Emergency Medicine/ethics , Evidence-Based Medicine/ethics , Heart Arrest/therapy , Judaism , Pregnancy Complications, Cardiovascular/therapy , Resuscitation/ethics , Female , Humans , Mothers , Pregnancy
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