How Seeking Transfer Often Fails to Help Define Medically Inappropriate Treatment.

On September 1, 2023, Texas made important revisions to it its decades-old statute granting legal safe harbor immunity to physicians who withhold or withdraw life-sustaining treatment over the objection of critically ill patients' surrogate decision-makers. However, lawmakers left untouched glaring flaws in a key safeguard for patients-the transfer option. The transfer option is ethically important because, when no hospital is willing to accept the patient in transfer, that fact is taken as strong evidence that the surrogates' treatment requests fall outside accepted medical practice. But there are serious shortcomings in how the transfer option is carried out in Texas and many other states, which undermines the ethical usefulness of the process. We identify these shortcomings and recommend revisions to state statutes and professional guidelines to overcome them.

Effect of continuing angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers on the day of surgery on myocardial injury after non-cardiac surgery: A retrospective cohort study.

STUDY OBJECTIVE: To evaluate the effect of continuing of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) prescriptions 24 h before surgery on postoperative myocardial injury and blood pressure in patients undergoing non-cardiac surgery. DESIGN: A single-center, retrospective study. SETTING: Operating room and perioperative care area. PATIENTS: 42,432 patients who had been taking chronic ACEI/ARB underwent non-cardiac surgery from January 2012 to June 2022. INTERVENTIONS: Patients who discontinued ACEI/ARB 24 h before surgery (withheld group, n=31,055) and those who continued ACEI/ARB 24 h before surgery (continued group, n=11,377). MEASUREMENTS: Primary outcome was myocardial injury after non-cardiac surgery (MINS) within 7 days postoperatively. MINS was defined as an elevated postoperative cardiac troponin measurement above the 99th percentile of the upper reference limit with a rise/fall pattern. Perioperative blood pressure and clinical outcomes were secondary outcomes. MAIN RESULTS: Among 42,432 patients, MINS occurred in 2848 patients (6.7%) and was the all-cause of death within 30 days in 122 patients (0.3%). Incidence of MINS was significantly higher in the continued group than the withheld group (847/11,377 [7.4%] vs. 2001/31,055 [6.4%]; OR [95% CI] 1.17 [1.07-1.27]; P<0.001). After 1:1 propensity score matching, 11,373 patients were included in each group. There was still a significant difference for the occurrence of MINS between two groups in matched cohort (7.4% vs. 6.6%, OR [95% CI] 1.14 [1.03-1.26]; P=0.015). Time-average weight of mean arterial pressure <65 mmHg during surgery was significantly higher in the continued group (mean 0.11 vs. 0.09 [95% CI of mean difference] [0.01-0.03]; P<0.001). However, there was no significant difference in other clinical outcomes and mortality. CONCLUSIONS: Withholding ACEI/ARB before surgery was associated with a reduced risk of intraoperative hypotension and postoperative myocardial injury, but it did not affect overall clinical outcomes in patients undergoing non-cardiac surgery.

The Impact of Withdrawing or Withholding of Life-Sustaining Treatment: A Nationwide Case-Control Study Based on Medical Cost Analysis.

This study measured the impact of the Decisions on Life-Sustaining Treatment Act by analyzing medical cost data from the National Health Insurance Service-National Sample Cohort. After identifying the patients who died in 2018 and 2019, the case and control groups were set using the presence of codes for managing the implementation of life-sustaining treatment with propensity score matching. Regarding medical costs, the case group had higher medical costs for all periods before death. The subdivided items of medical costs with significant differences were as follows: consultation, admission, injection, laboratory tests, imaging and radiation therapy, nursing hospital bundled payment, and special equipment. This study is the first analysis carried out to measure the impact of the Decision on Life-Sustaining Treatment Act through a cost analysis and to refute the common expectation that patients who decided to withhold or withdraw life-sustaining treatment would go through fewer unnecessary tests or treatments.

Timing of withdrawal of life-sustaining therapy in traumatic brain injury: exploring indicators of poor prognosis in adult and geriatric populations.

OBJECTIVE: The lack of objective prognostication tools for severe traumatic brain injury (TBI) causes variability in the application of withdrawal of life-saving treatment (WLST). We aimed to determine whether WLST in persons with severe TBI is associated with known indicators of poor prognosis. METHODS: This retrospective descriptive study focused on adult (18-64 years) and geriatric (≥65 years) patients with severe TBI who were admitted between August 1, 2018 and July 31, 2021 at a Level I trauma center and subsequently underwent WLST. The data collected from the Trauma Registry and electronic health records included information regarding demographic characteristics, injury severity, clinical variables, and length of hospital stay and were used to examine the indicators of poor prognosis and WLST. RESULTS: Among the 164 participants with TBI who met the inclusion criteria, 61.0% were geriatric, and 122 (74.4%) patients had 0 or only 1 of the poor prognostic indicators prior to WLST. The non-geriatric group had more indicators of poor prognosis than the geriatric group. Participants with fewer indicators of poor prognosis had a longer length-of-stay. CONCLUSION: In severe TBI cases, standardized prognostication tools can help guide informed WLST decisions, particularly in geriatric patients, improving care consistency.

Parents' participation in collegial meetings to discuss withholding or withdrawing treatment for their newborn: Working to improve information-sharing.

AIM: The role of parents in decision-making concerning their child's end-of-life care is not clearly defined. Their participation is encouraged by ethical reflection, in particular by the CCNE (French National Ethics Advisory Committee), but laws are limited to imposing a duty to provide information to doctors. Decisions are taken at the end of a collegial meeting (CM) intended to better inform the child's referring physician (RP) who is in charge of the final decision following the French law. The aim of this study was to describe the support provided to bereaved families after they had been invited to attend a CM concerning their child, if they so wished. Additional aims were to determine the differences resulting from their acceptance or their refusal to participate as regards their perception of their child's history and as regards their grieving process. MATERIAL AND METHOD: We conducted a retrospective study of all CMs held between November 2016 and May 2021, drawing a distinction between proposals made or not made to parents and their decision to accept or refuse. RESULTS: In total, 49 CMs concerning 46 children were held during the study period. The proposal was not made to the parents in three cases; the parents chose to be present in 28 cases. The psychological follow-up (15/28 parents attending, 10/16 parents absent) illustrated that their presence enabled them to reflect on their child's death after having listened to and understood the reasons why it happened. They did not dispute the team's approach or decisions taken. CONCLUSION: It is possible to include parents in CMs if they so wish. It would appear more beneficial than merely providing them with the information required. Studies must be carried out to ensure potential long-term benefit.

Hospital Policy Variation in Addressing Decisions to Withhold and Withdraw Life-Sustaining Treatment.

BACKGROUND: Sociodemographic disparities in physician decisions to withhold and withdraw life-sustaining treatment exist. Little is known about the content of hospital policies that guide physicians involved in these decisions. RESEARCH QUESTION: What is the prevalence of US hospitals with policies that address withholding and withdrawing life-sustaining treatment; how do these policies approach ethically controversial scenarios; and how do these policies address sociodemographic disparities in decisions to withhold and withdraw life-sustaining treatment? STUDY DESIGN AND METHODS: This national cross-sectional survey assessed the content of hospital policies addressing decisions to withhold or withdraw life-sustaining treatment. We distributed the survey electronically to American Society for Bioethics and Humanities members between July and August 2023 and descriptively analyzed responses. RESULTS: Among 93 respondents from hospitals or hospital systems representing all 50 US states, Puerto Rico, and Washington, DC, 92% had policies addressing decisions to withhold or withdraw life-sustaining treatment. Hospitals varied in their stated guidance, permitting life-sustaining treatment to be withheld or withdrawn in cases of patient or surrogate request (82%), physiologic futility (81%), and potentially inappropriate treatment (64%). Of the 8% of hospitals with policies that addressed patient sociodemographic disparities in decisions to withhold or withdraw life-sustaining treatment, these policies provided opposing recommendations to either exclude sociodemographic factors in decision-making or actively acknowledge and incorporate these factors in decision-making. Only 3% of hospitals had policies that recommended collecting and maintaining information about patients for whom life-sustaining treatment was withheld or withdrawn that could be used to identify disparities in decision-making. INTERPRETATION: Although most surveyed US hospital policies addressed withholding or withdrawing life-sustaining treatment, these policies varied widely in criteria and processes. Surveyed policies also rarely addressed sociodemographic disparities in these decisions.

Parents' experiences of palliative care decision-making in neonatal intensive care units: An interpretative phenomenological analysis.

AIM: This work explores the experiences and meaning attributed by parents who underwent the decision-making process of withholding and/or withdrawing life-sustaining treatment for their newborn. METHODS: Audio-recorded face-to-face interviews were led and analysed using interpretative phenomenological analysis. Eight families (seven mothers and five fathers) whose baby underwent withholding and/or withdrawing of life-sustaining treatment in three neonatal intensive care units from two regions in France were included. RESULTS: The findings reveal two paradoxes within the meaning-making process of parents: role ambivalence and choice ambiguity. We contend that these paradoxes, along with the need to mitigate uncertainty, form protective psychological mechanisms that enable parents to cope with the decision, maintain their parental identity and prevent decisional regret. CONCLUSION: Role ambivalence and choice ambiguity should be considered when shared decision-making in the neonatal intensive care unit. Recognising and addressing these paradoxical beliefs is essential for informing parent support practices and professional recommendations, as well as add to ethical discussions pertaining to parental autonomy and physicians' rapport to uncertainty.

Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study.

OBJECTIVE: Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN: Secondary analysis of multicenter retrospective cohort study. SETTING: Ten PICUs in the United States between 2009 and 2021. PATIENTS: Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS: Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.

End-of-life decision-making in critically ill old patients with and without coronavirus disease 2019.

BACKGROUND: There are few studies on the differences in end-of-life decisions making in critically ill patients with and without coronavirus disease 2019 (COVID-19). This study aimed to investigate the independent factors that predicted the decision to withdraw or withhold life-sustaining treatments (LST) in critically ill patients and if these decisions were based on different variables for critically ill patients with COVID-19 compared to those for critically ill patients with other diagnoses in a Swedish intensive care unit. METHODS: This observational pilot study was performed at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients ≥65 years were included from 1 March 2020 to 30 April 2021. The association between a decision to limit LST and a priori selected variables including sex, age, Simplified Acute Physiology Score 3 (SAPS 3), Clinical Frailty Scale ≥4, Charlson Comorbidity Index, Body Mass Index, living at home, invasive and non-invasive mechanical ventilation was assessed using a univariate and multivariable logistic regression model and presented as odds ratio with corresponding 95% confidence intervals. RESULTS: There were 394 patients included in this study, 131 in the non-COVID-19 group and 263 in the COVID-19 group. For the non-COVID-19 cohort, the univariate analysis demonstrated that age and SAPS 3 were significantly associated with the decision to withdraw or withhold life-sustaining treatments, and this association remained in the multivariable analysis, with odds ratios of 1.10 (1.03-1.19) p = .009 and 1.06 (1.03-1.10) p < .001, respectively. For the COVID-19 cohort, the univariate analysis indicated that age, SAPS 3, and Charlson comorbidity index were significantly associated with the decision to withdraw or withhold life-sustaining treatments. However, in multivariable analysis, only the Charlson comorbidity index remained independently associated with the decision to withdraw or withhold life-sustaining treatments, with an odds ratio of 1.26 (1.07-1.49), p = .006. CONCLUSION: Decisions to withdraw or withhold life-sustaining treatments were based on other variables for the critically ill COVID-19 cohort compared to those for the critically ill non-COVID-19 cohort. Further studies are warranted to forge a common path for ethical end-of-life decision-making in critically ill patients.

Continued Treatment With Tirzepatide for Maintenance of Weight Reduction in Adults With Obesity: The SURMOUNT-4 Randomized Clinical Trial.

Importance: The effect of continued treatment with tirzepatide on maintaining initial weight reduction is unknown. Objective: To assess the effect of tirzepatide, with diet and physical activity, on the maintenance of weight reduction. Design, Setting, and Participants: This phase 3, randomized withdrawal clinical trial conducted at 70 sites in 4 countries with a 36-week, open-label tirzepatide lead-in period followed by a 52-week, double-blind, placebo-controlled period included adults with a body mass index greater than or equal to 30 or greater than or equal to 27 and a weight-related complication, excluding diabetes. Interventions: Participants (n = 783) enrolled in an open-label lead-in period received once-weekly subcutaneous maximum tolerated dose (10 or 15 mg) of tirzepatide for 36 weeks. At week 36, a total of 670 participants were randomized (1:1) to continue receiving tirzepatide (n = 335) or switch to placebo (n = 335) for 52 weeks. Main Outcomes and Measures: The primary end point was the mean percent change in weight from week 36 (randomization) to week 88. Key secondary end points included the proportion of participants at week 88 who maintained at least 80% of the weight loss during the lead-in period. Results: Participants (n = 670; mean age, 48 years; 473 [71%] women; mean weight, 107.3 kg) who completed the 36-week lead-in period experienced a mean weight reduction of 20.9%. The mean percent weight change from week 36 to week 88 was -5.5% with tirzepatide vs 14.0% with placebo (difference, -19.4% [95% CI, -21.2% to -17.7%]; P < .001). Overall, 300 participants (89.5%) receiving tirzepatide at 88 weeks maintained at least 80% of the weight loss during the lead-in period compared with 16.6% receiving placebo (P < .001). The overall mean weight reduction from week 0 to 88 was 25.3% for tirzepatide and 9.9% for placebo. The most common adverse events were mostly mild to moderate gastrointestinal events, which occurred more commonly with tirzepatide vs placebo. Conclusions and Relevance: In participants with obesity or overweight, withdrawing tirzepatide led to substantial regain of lost weight, whereas continued treatment maintained and augmented initial weight reduction. Trial Registration: ClinicalTrials.gov Identifier: NCT04660643.

Analysis of microbiological tests in patients withholding or withdrawing life-sustaining treatment at the end stage of life in 2 Korean hospitals.

OBJECTIVE: We evaluated the adequacy of microbiological tests in patients withholding or withdrawing life-sustaining treatment (WLST) at the end stage of life. SETTING: The study was conducted at 2 tertiary-care referral hospitals in Daegu, Republic of Korea. DESIGN: Retrospective cross-sectional study. METHODS: Demographic findings, clinical and epidemiological characteristics, statistics of microbiological tests, and microbial species isolated from patients within 2 weeks before death were collected in 2 tertiary-care referral hospitals from January to December 2018. We also reviewed the antimicrobial treatment that was given within 3 days of microbiological testing in patients on WLST. RESULTS: Of the 1,187 hospitalized patients included, 905 patients (76.2%) had WLST. The number of tests per 1,000 patient days was higher after WLST than before WLST (242.0 vs 202.4). Among the category of microbiological tests, blood cultures were performed most frequently, and their numbers per 1,000 patient days before and after WLST were 95.9 and 99.0, respectively. The positive rates of blood culture before and after WLST were 17.2% and 18.0%, respectively. Candida spp. were the most common microbiological species in sputum (17.4%) and urine (48.2%), and Acinetobacter spp. were the most common in blood culture (17.3%). After WLST determination, 70.5% of microbiological tests did not lead to a change in antibiotic use. CONCLUSIONS: Many unnecessary microbiological tests are being performed in patients with WLST within 2 weeks of death. Microbiological testing should be performed carefully and in accordance with the patient's treatment goals.