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1.
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
3.
BMJ Case Rep ; 12(9)2019 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-31570361

RESUMO

A 28-year-old woman suffered a traffic accident resulting in severe head injuries with deleterious prognosis. Diagnostics further revealed a hitherto unknown pregnancy, at suspected week 9. Based on the patient's wish to donate organs, brain death protocol confirmed irreversible loss of brain function. Yet, vital pregnancy rendered organ transplantation impossible. Multiple ethical and legal issues arose, from invalidation of established legal care after brain death to the delivery of a healthy child after trauma and long-term critical care. After medicolegal and ethical counselling, pregnancy was sustained, and the goal of organ donation postponed. Critical care focused on foetal homeostasis. At 30+4 weeks, a viable girl was born via assisted vaginal delivery. Postpartal organ donation resulted in heart, kidney and pancreas transplantation. The case emphasises the medical, legal and ethical challenges to combine two apparently diametrical goals: the successful full-term pregnancy and the fulfilment of a patient's wish to donate organs.


Assuntos
Morte Encefálica , Viabilidade Fetal/fisiologia , Cuidados para Prolongar a Vida/ética , Doadores Vivos/ética , Mães , Defesa do Paciente/ética , Cuidado Pré-Natal/ética , Obtenção de Tecidos e Órgãos/ética , Adulto , Diretivas Antecipadas , Aconselhamento , Cuidados Críticos , Feminino , Humanos , Cuidados para Prolongar a Vida/métodos , Direitos do Paciente/ética , Gravidez , Resultado da Gravidez , Cuidado Pré-Natal/métodos
5.
World Neurosurg ; 131: e508-e513, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31398522

RESUMO

BACKGROUND: Poor-grade subarachnoid hemorrhage (SAH) has been associated with a high case fatality, either in the acute phase or in the later stages. The exact causes of death in these patients are unknown. METHODS: We performed a retrospective study of all consecutive patients with SAH with World Federation of Neurosurgical Societies grade IV or V on admission from 2009 to 2013 at 2 tertiary referral centers in Amsterdam, the Netherlands, and Toronto, Ontario, Canada, who had died during their hospital stay. RESULTS: Of 357 patients, 152 (43%) had died. Of these 152 patients, 87 (24%) had not undergone aneurysm treatment. The median interval to death was 3 days (interquartile range, 1-12 days) after initial hemorrhage. The major cause of death in both centers was withdrawal of life support (107 patients [71%]; 74 of 94 [79%] in Amsterdam and 33 of 58 [58%] in Toronto; P < 0.01), followed by brain death in 23 (15%; 16 of 58 [28%] in Amsterdam vs. 7 of 94 [7%] in Toronto; P < 0.01). The remaining causes of death represented <15%. CONCLUSIONS: The decision to withdraw life support was the major reason for death of patients with poor-grade SAH for an overwhelming majority of the patients. The exact reasons for withdrawal of life support, other than cultural and referral differences, were undetermined. Insight into the reasons of death should be prospectively studied to improve the care and clinical outcomes of patients with poor-grade SAH.


Assuntos
Morte Encefálica , Eutanásia Passiva , Cuidados para Prolongar a Vida , Hemorragia Subaracnóidea/mortalidade , Causas de Morte , Feminino , Parada Cardíaca/mortalidade , Humanos , Hipertensão Intracraniana/mortalidade , Masculino , Isquemia Mesentérica/mortalidade , Pessoa de Meia-Idade , Neoplasias/mortalidade , Países Baixos , Ontário , Pneumonia/mortalidade , Recidiva , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque Séptico/mortalidade , Hemorragia Subaracnóidea/terapia , Suspensão de Tratamento
7.
Scand J Trauma Resusc Emerg Med ; 27(1): 81, 2019 Aug 28.
Artigo em Inglês | MEDLINE | ID: mdl-31462245

RESUMO

BACKGROUND: Multilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt. METHOD: Semi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis. RESULT: All physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical. CONCLUSION: Decisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.


Assuntos
Atitude do Pessoal de Saúde , Lesões Encefálicas/terapia , Tomada de Decisão Clínica , Cuidados Críticos , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Emoções , Humanos , Noruega , Fatores de Tempo
8.
Neonatal Netw ; 38(2): 69-79, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31470369

RESUMO

PURPOSE: The transition from the NICU to home is a complicated, challenging process for mothers of infants dependent on lifesaving medical technology, such as feeding tubes, supplemental oxygen, tracheostomies, and mechanical ventilation. The study purpose was to explore how these mothers perceive their transition experiences just prior to and during the first three months after initial NICU discharge. DESIGN: A qualitative, descriptive, longitudinal design was employed. SAMPLE: Nineteen mothers of infants dependent on lifesaving technology were recruited from a large Midwest NICU. MAIN OUTCOME VARIABLE: Description of mothers' transition experience. RESULTS: Three themes were identified pretransition: negative emotions, positive cognitive-behavioral efforts, and preparation for life at home. Two posttransition themes were negative and positive transition experiences. Throughout the transition, the mothers expressed heightened anxiety, fear, and stress about life-threatening situations that did not abate over time despite the discharge education received.


Assuntos
Serviços de Assistência Domiciliar/organização & administração , Cuidados para Prolongar a Vida , Mães/psicologia , Alta do Paciente , Adulto , Tecnologia Biomédica/instrumentação , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Cuidados para Prolongar a Vida/métodos , Cuidados para Prolongar a Vida/organização & administração , Cuidados para Prolongar a Vida/psicologia , Estudos Longitudinais , Papel do Profissional de Enfermagem , Pesquisa Qualitativa , Percepção Social , Cuidado Transicional/organização & administração
9.
JAMA ; 322(6): 557-568, 2019 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-31408142

RESUMO

Importance: The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice. Observations: Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice. Conclusions and Relevance: The role of extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.


Assuntos
Oxigenação por Membrana Extracorpórea , Insuficiência Respiratória/terapia , Adulto , Teorema de Bayes , Humanos , Cuidados para Prolongar a Vida/métodos
10.
Am J Hosp Palliat Care ; 36(8): 727-733, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31256612

RESUMO

OBJECTIVES: The aim of this study was to examine the preferences of home caregivers on patient advance care planning (ACP), including life-sustaining treatment (LST) and the factors relating to these preferences. BACKGROUND: Personalized ACP aims to respect the autonomy and choices of terminally ill patients regarding end-of-life care. However, there have been cases wherein doctors must instead discuss ACP with surrogates (including caregivers) for various reasons such as dementia, intractable neurologic diseases, and cerebrovascular accident. METHODS: In this cross-sectional study, self-written questionnaires (filled by individuals themselves) were distributed to 506 in-home caregivers in 6 Japanese prefectures; the questionnaires contained items on caregiver and patient demographics, number of people living together in a caregiver's home (aside from patients), care duration, comprehension level of doctors' explanations regarding their patient's condition, patient diseases, whether caregivers have or have not told patients about their disease, level of nursing care, and caregiver LST preference (preferred or not preferred). The questionnaire package also contained the Burden Index of Caregiver-11, Patient Health Questionnaire-9, and Short Form-8 Health Survey. RESULTS: Valid responses were obtained from 309 caregivers. More than half of them were not sure of their patient's LST preference. Sex, number of people living together in a care home, comprehension level of doctors' explanations, and care duration were found to be the significant factors relating to caregivers' LST preference (P < .05). CONCLUSION: Health providers should be cognizant of the background factors relating to caregiver ACP preference when deciding on LST for terminal patients.


Assuntos
Planejamento Antecipado de Cuidados/estatística & dados numéricos , Cuidadores/psicologia , Assistência Terminal/psicologia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Tomada de Decisões , Feminino , Humanos , Japão , Cuidados para Prolongar a Vida/psicologia , Masculino , Pessoa de Meia-Idade , Preferência do Paciente , Índice de Gravidade de Doença , Fatores Sexuais , Fatores Socioeconômicos , Fatores de Tempo
11.
Int J Qual Stud Health Well-being ; 14(1): 1632110, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31213147

RESUMO

Purpose: This study aimed to clarify the experiences of caregivers desiring to refuse life-prolonging treatment for their elderly parents at the end of life. Methods: A semi-structured interview was performed for four family caregivers who wanted to refuse life-prolonging treatment suggested by the physicians. Results: In this study, four caregivers who refused life-prolonging treatment suggested by the physicians for their elderly parents completed semi-structured interviews. The obtained data were analyzed in relation to the theme "Experiences of caregivers who desire to refuse life-prolonging treatment for their elderly parents at the end of life." As a result, 38 subcategories and 12 categories were extracted. Conclusions: Participants in this study initially had a negative view of life-prolonging treatment. However, they agonized over the decision when they received conflicting advice from the physicians. The participants indicated that physicians' advice and attitudes complicated their decisions to reject life-prolonging treatment for their elderly parents.


Assuntos
Cuidadores/psicologia , Cuidados para Prolongar a Vida , Assistência Terminal , Idoso , Tomada de Decisões , Humanos , Entrevistas como Assunto , Japão , Pesquisa Qualitativa
14.
Neuron ; 102(3): 526-528, 2019 05 08.
Artigo em Inglês | MEDLINE | ID: mdl-31071287

RESUMO

In recent years, rapid technological developments in the field of neuroimaging have provided new methods for assessing residual cognition, detecting consciousness, and even communicating with patients who clinically appear to be in a vegetative state. Here, I highlight some of the major implications of these developments, discuss their scientific, clinical, legal, and ethical relevance, and make my own recommendations for future directions in this field.


Assuntos
Lesão Encefálica Crônica/diagnóstico por imagem , Encéfalo/diagnóstico por imagem , Estado de Consciência , Cuidados para Prolongar a Vida , Estado Vegetativo Persistente/diagnóstico por imagem , Conscientização , Interfaces Cérebro-Computador , Erros de Diagnóstico , Eletroencefalografia , Ética Médica , Neuroimagem Funcional , Humanos , Cuidados para Prolongar a Vida/ética , Cuidados para Prolongar a Vida/legislação & jurisprudência , Imagem por Ressonância Magnética , Recuperação de Função Fisiológica , Espectroscopia de Luz Próxima ao Infravermelho
15.
Int J Gynaecol Obstet ; 146(2): 149-156, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31127869

RESUMO

The aim of the present study is to assess the ethical, legal, and social issues of brain death in pregnancy through a literature review, and, based on the review results, to provide ethical and social guidelines. A search of PubMed using MeSH terms was conducted and yielded 844 results for the period from 1979 to 2017. After articles were screened based on the title and abstract content, 45 were found to refer to the existing ethical, social, and legal implications in cases of brain death during pregnancy, and 40 articles were selected as the source for our set of ethical and social guidelines. From the findings of the study, issues referring to the legitimacy and justification of performing a corporeal support procedure have been identified, as have the issues focusing on fetus or mother, and, finally, those relating to the decision-making process. Given the increasing number of successful births after a diagnosis of brain death during pregnancy, there is justification for an ethical duty to continue prolonged corporeal support, even if there is little likelihood of success, despite the apparent absence of a legal duty, and relying on the international jurisdictional discrepancies in the attribution of legal rights to the fetus.


Assuntos
Morte Encefálica , Complicações na Gravidez , Tomada de Decisões , Feminino , Feto , Humanos , Cuidados para Prolongar a Vida/ética , Guias de Prática Clínica como Assunto , Gravidez
16.
J Med Syst ; 43(6): 155, 2019 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-31025119

RESUMO

The 30-day surgical mortality metric is endorsed by the National Quality Forum for value-based purchasing purposes. However, its integrity has been questioned, as there is documented evidence of hospital manipulation of this measure, by way of inappropriate palliative care designation and changes in patient selection. To determine if there is evidence of potential manipulation, we retrospectively analyzed 1,725,291 surgical admissions from 158 United States hospitals participating in the National Inpatient Sample from 2010 to 2011. As a way of evaluating unnecessary life-prolonging measures, we determined that a significant increase in mortality rate after post-operative day 30 (day 31-35) would indicate manipulation. We compared the post-operative mortality rates for each hospital between Post-Operative Day 26-30 and Post-Operative Day 31-35 using Wilcoxon signed-rank tests. After application of the Bonferroni correction, the results showed that none of the hospitals had a statistically significant increase in mortality after post-operative day 30. This analysis fails to impugn the integrity of this measure, as we did not identify any evidence of potential manipulation of the 30-day surgical mortality metric.


Assuntos
Qualidade da Assistência à Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Propriedade , Características de Residência , Medição de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
17.
Dimens Crit Care Nurs ; 38(3): 123-130, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30946118

RESUMO

Extracorporeal life support (ECLS) is an external medical device to treat critically ill patients with cardiovascular and respiratory failure. In a nutshell, ECLS is only a "bridging" mechanism that provides life support while the heart and/or the lungs is recovering either by therapeutic medical interventions, transplantation, or spontaneously. Extracorporeal life support has been developed since 1950s, and many studies were conducted to improve ECLS techniques, but unfortunately, the survival rate was not improved. Because of Dr Bartlett's success in using ECLS to treat neonates with severe respiratory distress in 1975, ECLS is made as a standard lifesaving therapy for neonates with severe respiratory distress. However, its use for adult patients remains debatable. The objectives of this study are to outline and provide a general overview of the use of ECLS especially for adult patients for the past 10 years and to elaborate on the challenges encountered by each stakeholder involved in ECLS. The data used for this study were extracted from the ELSO Registry Report of January 2018. Results of this study revealed that the number of ECLS centers and the use of ECLS are increasing over the year for the past decade. There was also a shift of the patient's age category from neonatal to adult patients. However, the survival rates for adult patients are relatively low especially for cardiac and extracorporeal cardiopulmonary resuscitation cases. To date, the complications are still the major challenge of ECLS. Other challenges encountered by the stakeholders in ECLS are the limited amount of well-trained and experienced ECLS teams and centers, the limited government expenditure on health, and the lack of improvement and development of ECLS techniques and devices. Further studies are needed to evaluate the value of ECLS for adult patients.


Assuntos
Enfermagem de Cuidados Críticos , Estado Terminal , Oxigenação por Membrana Extracorpórea/métodos , Oxigenação por Membrana Extracorpórea/enfermagem , Cuidados para Prolongar a Vida/métodos , Adulto , Humanos , Taxa de Sobrevida
18.
J Law Med ; 26(3): 538-548, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30958647

RESUMO

In 2018 the United Kingdom Supreme Court decided in An NHS Trust v Y [2018] 3 WLR 751; [2018] UKSC 46 that the time had come to move on from the "good practice" requirement in Airedale NHS Trust v Bland [1993] AC 789 for hospitals and doctors to obtain court approval before life-prolonging treatment can be withheld or withdrawn from a patient in a permanent vegetative state (PVS). It held that it is no longer necessary to involve the court in every case before life-sustaining clinically assisted nutrition and hydration (CANH) can be withdrawn. Provided the provisions of the Mental Capacity Act 2005 (England and Wales) and relevant professional guidance are followed, and there is no difference of medical opinion or lack of agreement from interested parties, in particular family members, with the proposed course of action, legal permission is not required. The ruling applies to PVS patients, as well as, more controversially, those in a minimally conscious state (MCS), the newer diagnosis identified post-Bland. This commentary summarises the Supreme Court's decision, and considers some implications for England and Wales, as well as for Australia and New Zealand, where there is no recommended practice of, much less any legal requirement for hospitals to seek court approval, even in disputed cases.


Assuntos
Cuidados para Prolongar a Vida/legislação & jurisprudência , Estado Vegetativo Persistente , Suspensão de Tratamento , Austrália , Inglaterra , Hospitais/ética , Humanos , Nova Zelândia , Reino Unido , País de Gales
19.
JAMA Netw Open ; 2(4): e192036, 2019 04 05.
Artigo em Inglês | MEDLINE | ID: mdl-30977852

RESUMO

Importance: Despite its spread in much of the United States and increased international interest, the Physician Orders for Life-Sustaining Treatment (POLST) paradigm still lacks supporting evidence. The interrater reliability of the POLST form to translate patients' values and preferences into medical orders for care at the end of life remains to be studied. Objective: To assess the interrater reliability of the medical orders documented in POLST forms. Design, Setting, and Participants: This cross-sectional study was conducted in a public university hospital in southeastern Brazil. Two independent researchers interviewed the same patients or decision-making surrogates (n = 64) during a single episode of hospitalization within a time frame of 1 to 7 days. Eligible participants were hospitalized adults aged 21 years or older who were expected to remain hospitalized for at least 4 days and whose attending physician responded no to the question, Would I be surprised if this patient died in the next year? Data collection occurred between November 1, 2015, and September 20, 2016, and first data analyses were performed on October 3, 2016. Main Outcomes and Measures: Interrater reliability as measured by κ statistics. Results: Of the 64 participants interviewed in the study, 53 (83%) were patients and 11 (17%) were surrogates. Patients' mean (SD) age was 64 (14) years, and 35 patients (55%) and 8 surrogates (73%) were women. Overall, in 5 cases (8%), disagreement in at least 1 medical order for life-sustaining treatment was found in the POLST form, changing from the first interview to the second interview. The κ statistic for cardiopulmonary resuscitation was 0.92 (95% CI, 0.80-1.00); for level of medical intervention, 0.89 (95% CI, 0.76-1.00); and for artificially administered nutrition, 0.92 (95% CI, 0.83-1.00). Conclusions and Relevance: The high interrater reliability of the medical orders in POLST forms appears to offer further support for this advance care planning paradigm; in addition, the finding that this interrater reliability was not 100% underscores the need to ensure that patients or their surrogates have decision-making capacity and to confirm that the content of POLST forms accurately reflects patients' current treatment preferences.


Assuntos
Planejamento Antecipado de Cuidados/normas , Atitude Frente a Morte , Cuidados para Prolongar a Vida/psicologia , Preferência do Paciente/psicologia , Assistência Terminal/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Estudos Transversais , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Médicos/psicologia , Reprodutibilidade dos Testes , Assistência Terminal/psicologia , Traduções
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