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1.
Lakartidningen ; 1212024 Jun 04.
Artigo em Sueco | MEDLINE | ID: mdl-38832570

RESUMO

Decisions to withdraw life sustaining treatment in the ICU are common, but there is little information about how treatment should be withdrawn. A pilot study showed that doctors withdraw life sustaining treatment in different ways even in identical cases. This variation can cause stress for ICU staff and relatives.  Our study investigated the decisions of doctors working in ICUs in Sweden regarding the withdrawal of life sustaining treatment for two fictitious patients. There was variation in if and how drug treatments should be withdrawn, as well as how ventilatory support should be withdrawn. Less experienced doctors tended to choose to prolong the dying process by weaning, even if it is unclear if that is preferable for the staff or for relatives.  Our study could be used in discussions in ICUs to try to understand how individual doctors make decisions about withdrawing life sustaining treatment.


Assuntos
Unidades de Terapia Intensiva , Suspensão de Tratamento , Humanos , Suspensão de Tratamento/legislação & jurisprudência , Suécia , Projetos Piloto , Cuidados para Prolongar a Vida , Atitude do Pessoal de Saúde , Masculino , Feminino , Tomada de Decisão Clínica , Competência Clínica , Inquéritos e Questionários , Padrões de Prática Médica , Assistência Terminal , Pessoa de Meia-Idade , Médicos/psicologia
2.
Crit Care Nurs Q ; 47(3): 218-222, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38860951

RESUMO

Moral distress can impact nurses and the care team significantly. A profession dedicated to the principles of caring and compassion is often subjected to patients receiving futile treatment. With the proliferation of extreme life-prolonging measures come the difficulties in the withdrawal of those medical modalities. If a prognosis is poor and care is perceived as curative rather than palliative, providers may often feel conflicted and distressed by their interventions. The American Association of Colleges of Nursing has expressed growing concern about an increase in the use of inappropriate life-support treatments related to futile care. The compelling case of a severely beaten 69-year-old homeless man who had cardiac-arrested and was resuscitated after an unknown amount of down-time, provides the contextual framework for this report. Ethical conflicts can become very challenging, which inevitably increases the suffering of the patient and their caregivers. Research findings suggest that health care organizations can benefit from enacting processes that make ethical considerations an early and routine part of everyday clinical practice. A proactive approach to ethical conflicts may improve patient care outcomes and decrease moral distress.


Assuntos
Futilidade Médica , Humanos , Idoso , Masculino , Futilidade Médica/ética , Cuidados para Prolongar a Vida/ética , Princípios Morais , Suspensão de Tratamento/ética , Estresse Psicológico , Pessoas Mal Alojadas/psicologia
4.
BMC Med Ethics ; 25(1): 59, 2024 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-38762493

RESUMO

BACKGROUND: The Patient Right to Autonomy Act (PRAA), implemented in Taiwan in 2019, enables the creation of advance decisions (AD) through advance care planning (ACP). This legal framework allows for the withholding and withdrawal of life-sustaining treatment (LST) or artificial nutrition and hydration (ANH) in situations like irreversible coma, vegetative state, severe dementia, or unbearable pain. This study aims to investigate preferences for LST or ANH across various clinical conditions, variations in participant preferences, and factors influencing these preferences among urban residents. METHODS: Employing a survey of legally structured AD documents and convenience sampling for data collection, individuals were enlisted from Taipei City Hospital, serving as the primary trial and demonstration facility for ACP in Taiwan since the commencement of the PRAA in its inaugural year. The study examined ADs and ACP consultation records, documenting gender, age, welfare entitlement, disease conditions, family caregiving experience, location of ACP consultation, participation of second-degree relatives, and the intention to participate in ACP. RESULTS: Data from 2337 participants were extracted from electronic records. There was high consistency in the willingness to refuse LST and ANH, with significant differences noted between terminal diseases and extremely severe dementia. Additionally, ANH was widely accepted as a time-limited treatment, and there was a prevalent trend of authorizing a health care agent (HCA) to make decisions on behalf of participants. Gender differences were observed, with females more inclined to decline LST and ANH, while males tended towards accepting full or time-limited treatment. Age also played a role, with younger participants more open to treatment and authorizing HCA, and older participants more prone to refusal. CONCLUSION: Diverse preferences in LST and ANH were shaped by the public's current understanding of different clinical states, gender, age, and cultural factors. Our study reveals nuanced end-of-life preferences, evolving ADs, and socio-demographic influences. Further research could explore evolving preferences over time and healthcare professionals' perspectives on LST and ANH decisions for neurological patients..


Assuntos
Planejamento Antecipado de Cuidados , Preferência do Paciente , População Urbana , Humanos , Masculino , Feminino , Taiwan , Idoso , Pessoa de Meia-Idade , Adulto , Tomada de Decisões , Cuidados para Prolongar a Vida/ética , Idoso de 80 Anos ou mais , Suspensão de Tratamento/ética , Hidratação/ética , Demência/terapia , Apoio Nutricional/ética , Assistência Terminal/ética , Adulto Jovem , Inquéritos e Questionários , Estado Vegetativo Persistente/terapia
6.
J Pain Symptom Manage ; 68(1): 53-60, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38574875

RESUMO

CONTEXT: Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings. OBJECTIVES: To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents. METHODS: In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis. RESULTS: We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%). CONCLUSIONS: During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.


Assuntos
Asiático , Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Humanos , Masculino , Feminino , Idoso , Estudos Retrospectivos , Pessoa de Meia-Idade , Cuidados para Prolongar a Vida/estatística & dados numéricos , Documentação , População Branca , Assistência Terminal , Idoso de 80 Anos ou mais , Estados Unidos , Ordens quanto à Conduta (Ética Médica) , Diretivas Antecipadas , Planejamento Antecipado de Cuidados
7.
Med Intensiva (Engl Ed) ; 48(5): 247-253, 2024 05.
Artigo em Inglês | MEDLINE | ID: mdl-38538498

RESUMO

OBJECTIVE: The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study. DESIGN: Planned substudy of patients from ETHICUS II study. SETTING: 12 Spanish ICU. PATIENTS OR PARTICIPANTS: Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months. INTERVENTIONS: Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death. MAIN VARIABLES OF INTEREST: Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death. RESULTS: A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316 (59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives. CONCLUSIONS: The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.


Assuntos
Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Humanos , Masculino , Espanha/epidemiologia , Feminino , Unidades de Terapia Intensiva/estatística & dados numéricos , Idoso , Suspensão de Tratamento/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Pessoa de Meia-Idade , Reanimação Cardiopulmonar/estatística & dados numéricos , Seguimentos
8.
J Crit Care ; 82: 154797, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38554544

RESUMO

PURPOSE: Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA). MATERIALS AND METHODS: This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world. RESULTS: LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered. CONCLUSIONS: Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.


Assuntos
Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Assistência Terminal , Suspensão de Tratamento , Humanos , África do Sul , Estudos Prospectivos , Masculino , Feminino , Pessoa de Meia-Idade , Qualidade de Vida , Idoso , Tomada de Decisões , Adulto
9.
J Korean Med Sci ; 39(6): e73, 2024 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-38374632

RESUMO

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.


Assuntos
Hospitalização , Suspensão de Tratamento , Humanos , Estudos de Casos e Controles , Custos e Análise de Custo , Tomada de Decisões , Cuidados para Prolongar a Vida
10.
Anaesthesia ; 79(6): 638-649, 2024 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-38301032

RESUMO

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.


Assuntos
Parada Cardíaca , Suspensão de Tratamento , Humanos , Parada Cardíaca/terapia , Unidades de Terapia Intensiva , Cuidados para Prolongar a Vida , Fatores de Tempo
12.
Chest ; 165(4): 950-958, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38184166

RESUMO

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.


Assuntos
Cuidados para Prolongar a Vida , Suspensão de Tratamento , Humanos , Estudos Transversais , Inquéritos e Questionários , Hospitais , Tomada de Decisões
14.
J Crit Care ; 79: 154439, 2024 02.
Artigo em Inglês | MEDLINE | ID: mdl-37832351

RESUMO

PURPOSE: Several initiatives have recently focused on raising awareness about limitations of treatment in Poland. We aimed to assess if the propensity to limit LST among elderly patients in 2018-2019 increased compared to 2016-2017. METHODS: We analysed Polish cohorts from studies VIP1 (October 2016 - May 2017) and VIP2 (May 2018 - May 2019) that enrolled critical patients aged >80. We collected data on demographics, clinical features limitations of LST. Primary analysis assessed factors associated with prevalence of limitations of LST, A secondary analysis explored differences between patients with and without limitations of LST. RESULTS: 601 patients were enrolled. Prevalence of LST limitations was 16.1% in 2016-2017 and 20.5% in 2018-2019. No difference was found in univariate analysis (p = 0.22), multivariable model showed higher propensity towards limiting LST in the 2018-2019 cohort compared to 2016-2017 cohort (OR 1.07;95%CI, 1.01-1.14). There was higher mortality and a longer length of stay of patients with limitations of LST compared to the patients without limitations of LST. (11 vs. 6 days, p = 0.001). CONCLUSIONS: The clinicians in Poland have become more proactive in limiting LST in critically ill patients ≥80 years old over the studied period, however the prevalence of limitations of LST in Poland remains low.


Assuntos
Cuidados para Prolongar a Vida , Assistência Terminal , Idoso , Humanos , Idoso de 80 Anos ou mais , Polônia/epidemiologia , Prevalência , Tomada de Decisões , Cuidados Críticos
15.
Prehosp Disaster Med ; 38(6): 749-756, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37877361

RESUMO

BACKGROUND: Pediatric patients transferred by Emergency Medical Services (EMS) from urgent care (UC) and office-based physician practices to the emergency department (ED) following activation of the 9-1-1 EMS system are an under-studied population with scarce literature regarding outcomes for these children. The objectives of this study were to describe this population, explore EMS level-of-care transport decisions, and examine ED outcomes. METHODS: This was a retrospective review of patients zero to <15 years of age transported by EMS from UC and office-based physician practices to the ED of two pediatric receiving centers from January 2017 through December 2019. Variables included reason for transfer, level of transport, EMS interventions and medications, ED medications/labs/imaging ordered in the first hour, ED procedures, ED disposition, and demographics. Data were analyzed with descriptive statistics, X test, point biserial correlation, two-sample z test, Mann-Whitney U test, and 2-way ANOVA. RESULTS: A total of 450 EMS transports were included in this study: 382 Advanced Life Support (ALS) runs and 68 Basic Life Support (BLS) runs. The median patient age was 2.66 years, 60.9% were male, and 60.7% had private insurance. Overall, 48.9% of patients were transported from an office-based physician practice and 25.1% were transported from UC. Almost one-half (48.7%) of ALS patients received an EMS intervention or medication, as did 4.41% of BLS patients. Respiratory distress was the most common reason for transport (46.9%). Supplemental oxygen was the most common EMS intervention and albuterol was the most administered EMS medication. There was no significant association between level of transport and ED disposition (P = .23). The in-patient admission rate for transported patients was significantly higher than the general ED admission rate (P <.001). CONCLUSION: This study demonstrates that pediatric patients transferred via EMS after activation of the 9-1-1 system from UC and medical offices are more acutely ill than the general pediatric ED population and are likely sicker than the general pediatric EMS population. Paramedics appear to be making appropriate level-of-care transport decisions.


Assuntos
Serviços Médicos de Emergência , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Assistência Ambulatorial/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência , Estudos Retrospectivos , Cuidados para Prolongar a Vida/estatística & dados numéricos
18.
BMC Palliat Care ; 22(1): 145, 2023 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-37773128

RESUMO

BACKGROUND: One of the most important and ethically challenging decisions made for children with life-limiting conditions is withholding/withdrawing life-sustaining treatments (LST). As important (co-)decision-makers in this process, physicians are expected to have deeply and broadly developed views. However, their attitudes and experiences in this area remain difficult to understand because of the diversity of the studies. Hence, the aim of this paper is to describe physicians' attitudes and experiences about withholding/withdrawing LST in pediatrics and to identify the influencing factors. METHODS: We systematically searched Pubmed, Cinahl®, Embase®, Scopus®, and Web of Science™ in early 2021 and updated the search results in late 2021. Eligible articles were published in English, reported on investigations of physicians' attitudes and experiences about withholding/withdrawing LST for children, and were quantitative. RESULTS: In 23 included articles, overall, physicians stated that withholding/withdrawing LST can be ethically legitimate for children with life-limiting conditions. Physicians tended to follow parents' and parents-patient's wishes about withholding/withdrawing or continuing LST when they specified treatment preferences. Although most physicians agreed to share decision-making with parents and/or children, they nonetheless reported experiencing both negative and positive feelings during the decision-making process. Moderating factors were identified, including barriers to and facilitators of withholding/withdrawing LST. In general, there was only a limited number of quantitative studies to support the hypothesis that some factors can influence physicians' attitudes and experiences toward LST. CONCLUSION: Overall, physicians agreed to withhold/withdraw LST in dying patients, followed parent-patients' wishes, and involved them in decision-making. Barriers and facilitators relevant to the decision-making regarding withholding/withdrawing LST were identified. Future studies should explore children's involvement in decision-making and consider barriers that hinder implementation of decisions about withholding/withdrawing LST.


Assuntos
Médicos , Assistência Terminal , Humanos , Criança , Cuidados para Prolongar a Vida , Atitude , Suspensão de Tratamento , Tomada de Decisões
20.
J Bioeth Inq ; 20(3): 457-466, 2023 09.
Artigo em Inglês | MEDLINE | ID: mdl-37380828

RESUMO

In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.


Assuntos
Cuidados Críticos , Cuidados para Prolongar a Vida , Humanos , Estudos Retrospectivos , Estudos de Coortes , Suspensão de Tratamento , Tomada de Decisões
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