Physician Family Conflict Following Cardiac Arrest: A Qualitative Study.

Comatose survivors of cardiac arrest may die following withdrawal of life-sustaining therapy (WLST) due to poor neurologic prognosis. Family members, acting as surrogate decision makers, are frequently asked to decide whether the patient should continue to receive ongoing life-sustaining therapy such as mechanical ventilation in this context of risk of death following removal. Sometimes, physicians and family members disagree about what is in the patient's best interest, and this conflict causes distress for both families and medical personnel.This article examines themes recorded in the medical records of 24 cardiac arrest patients at Columbia University Medical Center (CUMC) whose families chose to pursue continued life support despite physician recommendations for withdrawal. In documented conversations between patients' families and their providers, the most prominent themes included faith in miracles, the inappropriateness of "playing God," the value of more time with the patient, and differences in how providers and family members perceived the patient's status.

When Imaging Data Contradict a Patient's Self-report, How Should Clinicians Proceed?

Following a case in which a patient's self-report contradicts imaging data, this commentary considers how patient-clinician communication, including an assessment of and accommodations for maximizing health literacy and shared decision making, can elucidate a patient's values and preferences. Patients' perceptions of how much input they have in making their health decisions influences the patient-clinician therapeutic alliance and outcomes and can support patients' physical and emotional well-being.

Ethical Framework to Guide Decisions of Treatment Over Objection.

BACKGROUND: Whether to proceed with a medical intervention over the objection of a patient who lacks capacity is a common problem facing practitioners. Despite this, there is a notable gap in the literature describing how to proceed in such situations in an ethically rigorous and consistent fashion. We elaborate on the practical application of the 2018 Rubin and Prager 7-question algorithm for ethics consultations about treatment over objection and we describe the impact of each of the 7 questions. STUDY DESIGN: We retrospectively review a series of consultations at Columbia University Irving Medical Center between April 2017 and May 2020 for treatment over objection in adult patients determined to lack capacity. Outcomes about the final ethics recommendation and the assessment of each of the 7 questions are reported. The statistical analysis was designed to determine which of the 7 questions in the algorithm were most predictive of the final ethics recommendation. RESULTS: In our series, there was an ethics recommendation to proceed over the objection of a patient in 63% of consultations. Although all 7 questions were considered to be important to the ethical analysis of a patient's situation, the presence of logistical barriers to treatment and the imminence of harm to a patient without treatment emerged as the most significant drivers of the recommendation of whether to proceed over objection or not. CONCLUSIONS: Cases of treatment over objection in a patient lacking capacity are frequently encountered problems that require a careful balance of patient autonomy and a physician's duty of beneficence. The application of the Rubin and Prager 7-question algorithm reliably guides a care team through such a complex ethical dilemma.

Clinical Ethics Consultations during the COVID-19 Pandemic Surge at a New York City Medical Center.

The COVID-19 pandemic swept through New York City swiftly and with devastating effect. The crisis put enormous pressure on all hospital services, including the clinical ethics consultation team. This report describes the recent experience of the ethics consultants and Columbia University Irving Medical Center during the COVID-19 surge and compares the case load and characteristics to the corresponding period in 2019. By reporting this experience, we hope to supplement the growing body of COVID-19 scientific literature and provide details of the human toll the virus took on our hospitals and communities. We also aim to highlight the role of the clinical ethics consultant as well as areas of policy and law that may need to be addressed in order to be better prepared for a future public health crisis.

Characterization, Categorization, and 5-Year Mortality of Medicine High Utilizer Inpatients.

BACKGROUND: Patients who are frequently admitted to Medicine inpatient services comprise a distinct subset of readmitted patients about whom not much is known. OBJECTIVE: We sought to characterize this group including mortality rates, with the goal of better understanding this population. DESIGN: Observational study of frequently hospitalized patients defined as 4 or more admissions over a 6-month period, with hospitalization defined as nonelective admission to the hospital. SETTING: Single large academic medical center. PATIENTS: Adult inpatients on general medicine and medicine subspecialty services. MEASUREMENTS: The number of nonelective medicine hospitalizations, age, clinical conditions and comorbidities, calculation of an age-adjusted Charlson Comorbidity Index (CCI), outpatient and emergency department visits, length of stay, costs of hospitalization, and mortality over a 5-year period. Descriptive statistics were used to characterize variables of interest. RESULTS: We identified 153 patients with a total of 781 nonelective hospitalizations, totaling greater than 4000 hospital days and with charges of approximately US$9 million during the 6 months. Nearly all had insurance coverage and good outpatient follow-up (median of 7 appointments over the 6-month study period). Only 14% of those admissions qualified for observation status. Over 40% of patients had comorbid mental health disease or chronic narcotic dependence. Twenty-nine percent of patients died within 1 year; 50% were dead within 5 years. Age-adjusted CCI scores ranged annually from 3.00 to 3.58 among surviving patients versus 4.31 to 6.60 among deceased patients. CONCLUSIONS: These findings point to distinct groups of patients who are frequently hospitalized, and therefore would benefit from tailored management strategies: Those with progression of end-stage disease comprised one-third of the group and targeting that subset with palliative care referrals could help decrease readmission rates. Those with recurrent exacerbations of a chronic medical condition could be managed through telemanagement programs. Those with exacerbations of chronic pain could be addressed through collaboration with pain management specialists. Individualized care management plans may be useful for all, especially the latter two groups. Based on differences between survivors and deceased patients, an age-adjusted CCI score of 4 or 5 could be valuable sensitive or specific cutoffs, respectively, for predicting those who would benefit most from palliative care consultation regarding end-of-life goals and management.