Life-prolonging Technologies Research Articles

'To improve quality of life': Diverging enactments of a value in nephrology clinical practices.

Quality of life has become a central value in the provision of healthcare for patients with chronic conditions. This has engendered debates in critical medical sociology on the non-neutral effects that valuing health and illness, medical interventions, and health care delivery in terms of quality of life yields. Focusing on the case of nephrology, this paper presents qualitative data collected in Austria of two dialysis units in which nephrologists initiated projects aimed towards 'the improvement of patients' quality of life'. Whereas the first involved nurses supporting patients in the administration of peritoneal dialysis at home, the second implied the provision of treatment and care exclusively focused on a well-being 'in the here and now' to patients. By conceptualising physicians as actors within networks of relations and values enacted in practices, it analyses how in both dialysis units reference to quality of life enabled nephrologists to problematise the provision of standard haemodialysis treatment to multi-morbid, elderly patients, to develop a new treatment protocol, and to interest and enrol others in the provision of healthcare according this new protocol. Valuing medical interventions in terms of quality of life not only leads to a governmentalization of living and an economisation of health. It also allows physicians to articulate a socio-medico-ethical problem - the availability of life-prolonging technologies for a growing population of elderly, multi-morbid patients - and develop solutions locally. What the solutions consist in may fundamentally differ, however.

Recommending Unfunded Innovative Cancer Therapies: Ethical vs. Clinical Perspectives among Oncologists on a Public Healthcare System-A Mixed-Methods Study.

Over the past decade, there has been a growing development of innovative technologies to treat cancer. Many of these technologies are expensive and not funded by health funds. The present study examined physicians’ perceptions of the ethical and clinical aspects of the recommendation and use of unfunded technologies for cancer treatment. This mixed-methods study surveyed 127 oncologists regarding their perceptions toward using unfunded innovative cancer treatment technologies, followed by in-depth interviews with 16 oncologists. Most respondents believed that patients should be offered all treatment alternatives, regardless of their financial situation. However, 59% indicated that they often face dilemmas regarding recommending new unfunded treatments to patients with financial difficulties and without private health insurance. Over a third (38%) stated that they felt uncomfortable discussing the cost of treatment with patients. A predictive model found that physicians facing patients whose medical condition worsened due to an inability to access new treatments, and who expressed the opinion that physicians can assist in locating funding for patients who cannot afford treatments, were more likely to recommend unfunded innovative therapies to patients (F = 5.22, R2 = 0.15, p < 0.001). Subsequent in-depth interviews revealed four key themes: economic considerations in choosing therapy, patient–physician communication, the public healthcare fund, and discussion of treatment costs. Physicians feel a professional commitment to offer patients the best medical care and a moral duty to discuss costs and minimize patients’ financial difficulty. There is a need for careful and balanced use of innovative life-prolonging technologies while putting patients at the center of discourse on this complex and controversial issue. It is essential to develop a psychosocial support program for physicians and patients dealing with ethical and psychosocial dilemmas and to set guidelines for oncologists to conduct a comprehensive and collaborative physician–patient discourse regarding all aspects of treatment.

The Conversation: A Vital Element of Nephrology Care for Older Americans Who are Medically Complex

The U.S. population is aging, supported in part by continued development of life-prolonging medical therapies and technologies. These innovations, including kidney replacement therapies, have been effective in providing additional options to patients facing serious illness, but they have also introduced a new level of complexity in the provider assessment of treatment for these patients. Health care providers are being tasked to decide if medical care is appropriate for an aging and medically complex population, a decision complicated by a variety of factors. Patient-focused conversations surrounding goals of care, prognosis, medical futility, and quality of life need to become part of the routine practice pattern for nephrology care in the United States.

Fluid illness

In response to the rising rate of end-stage renal disease (ESRD) in Guatemala, the public health system established a national community-based dialysis program to enable people living in rural areas to complete treatment in their homes. Here we explore how this newly available, life-prolonging technology has altered local worlds by transforming ESRD from an acute, life-ending illness into a managed chronic condition with an uncertain trajectory. Through case studies, we describe how living with dialysis influences family relations and caregiving in rural Guatemala. We find that dialysis interacts with an insufficient health care system, one that avoids life-ending complications but does not sufficiently manage life-altering symptoms. In addition, the need to care for people with ESRD for an uncertain amount of time may disrupt and strain family-based caregiving networks. Amid this meager health and social welfare infrastructure, life on dialysis exacerbates the chronic insecurity and structural inequality of life in postwar Guatemala. As both life and illness are prolonged through dialysis, the unceasing demands of the treatment and illness strain the webs of obligation and care that Guatemalan families and communities have developed to adapt to their decentralized and fragmented public health care system.

Partial Codes—A Symptom of a Larger Problem

sponsible, as thechaplainnoted, for theethical,moral, and financial debris of apartial code?The statewhoauthorized theuseof theadvance directive allowing a partial code? The hospital who permitted the partial code? The physicians? The patient? The family? All of the above? It’s an issue thatmerits further discussion, especially with an aging population in which resuscitative success declines,5 an ever-increasing use of life-prolonging medical technology that complicates theacceptanceofdeath, andnow,Medicare reimbursement for advance care discussions. So in theend,whenapatient survives apartial code, it canoften portendamessyandemotional futureforthefamilyaswellasthephysician,not tomention the financial repercussions for thehospital and family. As with Colorado’s advance directive, theMedical Orders for Scopeof Treatment (MOST) (http://coloradoadvancedirectives.com /wp-content/uploads/2014/07/1-MOST-Form-FINAL-2015.pdf) whichoffers thechoiceof full codeornocodewithnomenuofother options—perhaps codes should be an all or nothing event, not ”everything but intubation,” or “everything but cardioversion,” or “everything but intravenous medications,” or “everything but chest compressions.”Certainly, somewill arguesuchapolicy ispaternalistic and devoid of patient autonomy, but if the idea is to save a life and restorethepersontothe living,whywouldwenotperformafull code, even ifbriefandtime-limited, rather thanaresuscitative facade, such as chest compressionswithout intubation?

Substantial Life Extension and the Fair Distribution of Healthspans

One of the strongest objections to the development and use of substantially life-extending interventions is that they would exacerbate existing unjust disparities of healthy lifespans between rich and poor members of society. In both popular opinion and ethical theory, this consequence is sometimes thought to justify a ban on life-prolonging technologies. However, the practical and ethical drawbacks of banning receive little attention, and the viability of alternative policies is seldom considered. Moreover, where ethicists do propose alternatives, there is scant effort to consider their merits in light of developing world priorities. In response to these shortcomings, I distinguish four policy options and, on the basis of a plausible intuition about fairness, evaluate their implications for a fair distribution of healthy lifespans. I claim that even in developing nations it would be fairest to favor policies that promote equal access to at least one promising category of substantially life-extending intervention: calorie restriction mimetics.

Bereaved Caregiver Perspectives on the End-of-Life Experience of Patients With a Left Ventricular Assist Device.

For patients and their loved ones, decisions regarding the end of life in the setting of chronic progressive illness are among the most complex in health care. Complicating these decisions are increasingly available, invasive, and potentially life-prolonging technologies such as the left ventricular assist device (LVAD). To understand the experience of bereaved caregivers and patients at the end of life who have an LVAD. Semistructured, in-depth interviews were conducted between September 10 and November 21, 2014, with 8 bereaved caregivers of patients with an LVAD who were recruited from a single institution. Data were analyzed from December 13, 2014, to February 18, 2015, using a mixed inductive and deductive approach. Themes from semistructured interviews. The 8 caregivers (6 females) described 3 main themes that coalesced around feelings of confusion in the final weeks with their loved ones: (1) the process of death with an LVAD, (2) the legal and ethically permissible care of patients with an LVAD approaching death, and (3) fragmented integration of palliative and hospice care. Despite increasing use of LVADs in patients with advanced heart failure, bereaved caregivers of patients with an LVAD describe a high level of confusion at the end of life. There remains a need for the health care community to develop clear guidance on the management of patients with an LVAD at the end of life. Future work will focus on the educational process and the ideal timing and reiteration of such information to patients and families.

Parent & Child Perceptions of Child Health after Sibling Death.

BackgroundUnderstanding children’s health after a sibling’s death and what factors may affect it is important for treatment and clinical care. This study compared children’s and their parents’ perceptions of children’s health and identified relationships of children’s age, gender, race/ethnicity, anxiety, and depression and sibling’s cause of death to these perceptions at 2 and 4 months after sibling death.Methods64 children and 48 parents rated the child’s health “now” and “now vs before” the sibling’s death in an ICU or ER or at home shortly after withdrawal of life-prolonging technology. Children completed the Child Depression Inventory and Spence Children’s Anxiety Scale. Sibling cause of death was collected from hospital records.ResultsAt 2 and 4 months, 45% to 54% of mothers’ and 53% to 84% of fathers’ ratings of their child’s health “now” were higher than their children’s ratings. Child health ratings were lower for: children with greater depression; fathers whose children reported greater anxiety; mothers whose child died of a chronic condition. Children’s ratings of their health “now vs before” their sibling’s death did not differ significantly from mothers’ or fathers’ ratings at 2 or 4 months. Black fathers were more likely to rate the child’s health better “now vs before” the death; there were no significant differences by child gender and cause of death in child’s health “now vs before” the death.ConclusionsChildren’s responses to a sibling’s death may not be visually apparent or become known by asking parents. Parents often perceive their children as healthier than children perceive themselves at 2 and 4 months after sibling death, so talking with children separately is important. Children’s perceptions of their health may be influenced by depression, fathers’ perceptions by children’s anxiety, and mother’s perceptions by the cause of sibling death.

An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units

There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered. This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units. The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care). The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term "potentially inappropriate" should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan they believe is appropriate. Conflicts regarding potentially inappropriate treatments that remain intractable despite intensive communication and negotiation should be managed by a fair process of conflict resolution; this process should include hospital review, attempts to find a willing provider at another institution, and opportunity for external review of decisions. When time pressures make it infeasible to complete all steps of the conflict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should seek procedural oversight to the extent allowed by the clinical situation and need not provide the requested treatment. (3) Use of the term "futile" should be restricted to the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal. Clinicians should not provide futile interventions. (4) The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used. The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

Abstract 334: Confusion: Bereaved Caregiver Perspectives on the End-of-Life Experience with a Left Ventricular Assist Device

Background: For patients and their loved ones, decisions at the end-of-life in the setting of chronic progressive illness are among the most complex in medicine. Complicating these decisions are increasingly available, invasive, and potentially life-prolonging technologies. One such technology is the left ventricular assist device (LVAD). Understanding the experience of dying with an LVAD can guide efforts to minimize distress for patients and their caregivers. Objective: To synthesize caregivers’ perspectives about the caregiver and patient experience with care transitions at end-of-life with LVAD. Methods: We conducted semi-structured, in-depth interviews with bereaved caregivers of patients with LVADs previously cared for at the University of Colorado. We excluded caregivers if the patient’s death had occurred greater than 3 years prior to the interview date. Data were analyzed using a mixed inductive and deductive approach. Results: Between September and November 2014, 8 bereaved caregivers were interviewed. Interview durations ranged from 31-65 minutes (mean=40). The majority (n=5) were widows of the patients; other caregivers included 2 friends and a mother. Caregivers described three main themes that coalesced around feelings of confusion in those final days and weeks with their loved ones: 1) confusion about the process of death with an LVAD: “[my daughter] said ‘You know Mom, he probably can't die. Even though he wants to. Because everything is keeping him going’”; 2) confusion about the legal and ethically permissible care of patients approaching death with an LVAD: “They don't actually turn it off until certain signs aren't there, ‘cause as long as there’s a chance you know? It would be considered murder.”; 3) confusion about the fragmented integration of palliative and hospice care: “He was bleeding again. And I didn't know what to do. I didn't know if we could take him to the ER? And I really didn't understand palliative care, in its entirety.” Conclusions: Despite increasing use of LVADs in patients with advanced heart failure, bereaved caregivers of LVAD patients describe a high level of confusion at the end of life: about the nature of the death, about the medical decisions to be made, and about the support services provided. There remains a need to develop LVAD-specific support for caregivers, as well as hospice and palliative care programs, to manage complex patient care needs at the end-of-life.

Providing Care at the End of Life: An Examination of Biblical Principles

In our modern age, the line between life and death has become more and more blurred. This often leaves the family and friends of terminally ill patients to wonder how to make decisions about their loved one in the light of their Christian faith. The growth of modern life-prolonging technologies has given rise to a plethora of new and confusing technical terms. This paper will attempt to wade through these terms and definitions by looking at several scriptural situations dealing with the end of life. I will then highlight the biblical principles that must transcend every end of life situation. I should note that many end of life issues deal with technologies that simply did not exist during biblical times. Scripture will therefore not speak directly to every issue. That does not mean, however, that the truths to which the Bible speaks are not still relevant.

The Evolution of Advance Directives

THERE ARE 2 WIDELY KNOWN PROBLEMS WITH END-OFlife care in the United States. First, care often does not reflect patients’ values and preferences. Second, end-of-life care constitutes a disproportionate amount of health care expenditures. There is a need to improve the value of health care spending because of changing economic and political climates and because Medicare and Medicaid costs account for nearly a quarter of the federal budget. Despite recognition that advance directives have conceptual limitations, their appeal persists because of the theoretical possibility that advance directives can simultaneously improve the patient centeredness of care and decrease health care expenditures near the end of life. The evolution of advance directives has mirrored that of many new medical technologies: initial unbridled enthusiasm evolved into skepticism as empirical evidence raised questions about the current practice, followed by a wiser, more constrained application. In contrast to early studies suggesting little benefit of advance directives, recent observational and interventional studies in selected populations suggest that advance directives substantially improve the patient centeredness of care near the end of life. However, the evidence about the effect of advance directives on costs is conflicting and incomplete. In this issue of JAMA, Nicholas and colleagues make an innovative contribution by examining whether the association between advance directives and financial expenditures varies according to a region’s average level of Medicare spending. To accomplish this, the authors linked data from the Health and Retirement Study—in which decedents’ surrogates were queried about whether patients had a treatment-limiting directive—with Medicare claims data. Two findings are especially important. First, in regions characterized by high levels of Medicare spending, treatment-limiting directives were associated with modestly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care; however, similar associations were not observed in low-spending regions. Second, advance directives specifying limits on treatment were more common in areas with lower levels of end-of-life spending. The study is limited by the paucity of information regarding the content of patients’ directives and lingering questions about whether the use of surrogates’ reports about the content of advance directives is a reliable measurement strategy. As the authors note, the observational nature of the data precludes causal inferences about whether interventions to increase the use of advance directives will decrease costs. In light of these limitations and the relatively small absolute magnitude of cost savings observed, these findings are insufficient to justify changes in health policy regarding advance directives. Nevertheless, the authors have opened new avenues of inquiry to understand the effects of advance directives and have highlighted the potential importance of local practice norms on the outcomes associated with advance directives. The results raise several important questions about the “mechanisms of action” of advance directives. First, what might explain the finding of lower end-of-life care costs among patients with treatment-limiting directives in high-spending regions? The most obvious explanation that advance directives reduced the application of expensive life-prolonging technologies prior to death does not appear to be the entire explanation because there was not a significant difference in use between patients with and without treatment-limiting directives. An alternative explanation, which was not assessed in the study, is that treatment-limiting directives affected the duration of use of life support rather than the incidence of its application. This distinction is crucial because it raises the possibility that the work advance directives do may be different from the work they were conceived to do. Advance directives were originally designed to allow patients to determine in advance what treatment they would receive in the event of their incapacity. Instead, it may be that treatment-limiting advance directives work not by making the decisions but by giving surrogates and physicians psychological permission to cease life support at some point. This hypothesis is consistent with substantial empirical evidence that surrogates are reluctant to not do everything for patients and experience substantial distress when they believe they do not understand patients’ values. This distinction is important because it may signal the need to refocus advance care planning efforts to help surrogates and clini-

Patient Perceptions on the Use of Advance Directives and Life Prolonging Technology

Use of advance directives is underutilized despite the Patient Self Determination Act of 1990. This study was undertaken to determine use and opinions of advance directives by patients at a multidisciplinary. Institutional Review Board-approved prospective survey of patients age 18 and over. Of 306 participants, 77 (25.2%) had a durable power of attorney and 45 (14.7%) had living wills. Of these, 226 (73.9%) responded that it was important to make health care wishes known to their doctor. Only 36 (15.9%) had done so. A total of 266 (86.9%) felt it was important to discuss health care wishes with their family and only 160 (60.1%) had done so. While adequately describing use and attitudes toward advance directives, it is significant to note that patients believe their wishes for end-of-life care will be honored; however, they fail to take the necessary steps to guarantee this.

Shades of Gray

In just two years, the first of the 78 million baby boomers will turn sixty-five, and the long-anticipated graying of America will begin in earnest. By 2030, the number of Americans over sixty-five will double from the current 35 million to a stunning 71.5 million, or 20 percent of the population. While the proportion of people older than sixty-five is expected to peak in 2030, the so-called oldest old will continue to grow in number: those aged eighty-five and older will climb from the current 5.3 million to 21 million in 2050. It is this group that presents the greatest challenges because over half are significantly limited in their basic functioning (bathing, dressing, or walking, for example), and about one-third have cognitive impairment. Figuring out how best to respond to our oldest citizens is a political, financial, medical, and ethical problem. The ethical issues were first comprehensively laid out by Daniel Callahan in his much-maligned but critically important 1987 book, Setting Limits: Medical Goals in An Aging Society. Callahan begins by asking how we should regard aging and death. Should we accept human finitude and accordingly seek ways of enhancing quality in life's last phase, or should we continually seek to prolong life? Callahan comes down on the side of accepting aging as part of the human condition. His endorsement of age-based restrictions on life-prolonging technology rests on his belief that we have to come to terms with aging. Mortality is of course nothing new, nor is the quest for immortality. What has changed is the proportion of people surviving to old age and the technical possibility of extending average life expectancy (and possibly maximum life expectancy). But whether we should strive to further expand the limits of human existence or not, we have an obligation to figure out how best to care for those who are physically or cognitively frail. Just what that responsibility entails, and whether it falls on families or government or a combination of both, is the next major ethical issue confronting an aging society. The answer to this question is intimately linked to people's views of aging and death. Patients and families may be more likely to seek extreme life-prolonging measures if they are not reconciled to the inevitability of death. Defining the appropriate care of patients near the end of life is also closely linked to the third major ethical dilemma discussed by Callahan--the just allocation of scarce resources. Regardless of whether it is ever appropriate to utilize invasive and marginally effective treatment in older people near the end of life, inflicting pain and suffering on a person close to death becomes harder to justify when the treatment is also expensive. Arguably, the central ethical issue arising in an aging society is how to balance the demands of older people for medical care against competing demands by other segments of society. Devoting increasing amounts of money and effort to the medical care of older people comes at a price. Combined federal spending on Medicare and Medicaid is already 4.6 percent of the gross domestic product and, according to Congressional Budget Office projections, is expected to soar to 20 percent in 2050. At the current rate, just about half of every tax dollar will go to funding these two programs by midcentury. Outlays for Medicare (the major payer for medical care for older people and the main source of the increased costs) and Medicaid (the major payer for nursing home care) will drive out support for education, roads, and national security. We are already choosing to spend our health care dollars on the elderly at the expense of the young: a ninety-year-old with advanced dementia who cannot walk, speak, or recognize her family will have her stay in the intensive care unit paid for by Medicare when she develops pneumonia and respiratory failure, but according to the Institute of Medicine, eighteen thousand people will die each year from preventable diseases because they had no health insurance. …

Attitudes concerning euthanasia: Australia at the turn of the 21st Century

With rapid developments in life-prolonging technologies and increases in average life expectancy, euthanasia has become an increasingly topical issue. This paper contributes to the euthanasia debate an analysis of Australian attitudes to assisted suicide, active non-voluntary as well as passive non-voluntary euthanasia. Between 1993 and 2002, Australians supported access to voluntary euthanasia of the terminally ill, but had reservations when death was not imminent. The age of patients was relatively unimportant in these considerations. Non-voluntary euthanasia of babies and adults received widespread approval only when particular situations could be defined as ‘letting die’ rather than ‘killing’.

Impact of life-prolonging technologies on end-of-life care in India

Impact of life-prolonging technologies on end-of-life care in India

INACTIVATING A TOTAL ARTIFICIAL HEART: SPECIAL MORAL PROBLEMS

It seems generally correct that patients (or their valid surrogates) should be able to withdraw consent for the use of the total artificial heart (TAH) just as they presently may withdraw consent for other life-prolonging technologies such as the ventilator, but lingering moral problems remain with such decisions. First, should patients be permitted to demand actual removal of the TAH rather than mere deactivation? Second, forgoing other life-prolonging technologies is normally considered "indirect" killing and is therefore judged legal (as well as moral to those who accept only indirect killing). As long as the society includes irreversible stoppage of the heart as one of the criteria for death, however, stopping a TAH will be considered direct killing, i.e., murder. To circumvent this inconsistency, society must change its conclusion that stopping other life-prolonging technologies is merely indirect killing, explicitly legalize direct killing by means of stopping a TAH, or revisit the definition of death to eliminate the cardiac standard for death from the definition of death. Assuming that the stopping of the TAH with patient or surrogate consent is acceptable, we must then face the question of whether physicians who believe the TAH is serving no purpose can unilaterally stop the device against the wishes of a patient or surrogate who believes it is still serving a worthwhile purpose. Clinicians should be presumed authoritative in determining the predicted effect of the TAH, but, if the TAH can temporarily prolong life for a patient in a way that is desired by the patient or surrogate, case law, professional society recommendation, and moral analysis all support the conclusion that the TAH must be continued even against the conscientious objection of the physician.

Negotiating Cross-Cultural Issues at the End of Life

Culture fundamentally shapes how individuals make meaning out of illness, suffering, and dying. With increasing diversity in the United States, encounters between patients and physicians of different backgrounds are becoming more common. Thus the risk for cross-cultural misunderstandings surrounding care at the end of life is also increasing. Studies have shown cultural differences in attitudes toward truth telling, life-prolonging technology, and decision-making styles at the end of life. Using 2 case studies of patients, one of an African American couple in the southern United States and the other of a Chinese-American family in Hawaii, we outline some of the major issues involved in cross-cultural care and indicate how the patient, family, and clinician can navigate among differing cultural beliefs, values, and practices. Skilled use of cross-cultural understanding and communication techniques increases the likelihood that both the process and outcomes of care are satisfactory for all involved.

End of Life Care and Decision Making: How Far We Have Come, How Far We Have to Go

While enormous progress has been made in improving the quality of care and the decision-making process for patients at the end of life, as a society we still have far to go to ensure that dying patients and their families have a comfortable and dignified death. In particular, reexamination and reconfiguration of our current decision framework is essential as our elderly population with chronic disease and slowly fatal conditions expands. With less certain disease paths and more complex and ambiguous choices, the growth of this geriatric population challenges us to develop a broader conceptualization of end of life care planning, so that end of life considerations are integrated into a larger anticipatory framework addressing options and needs as patients gradually decline. Within this framework hospice becomes a natural, integrated option along a continuum of care planning, rather than an abrupt alternative at a late stage of illness. End of life care planning must positively anticipate a robust array of needs and concerns well beyond the dramatic decisions to withhold or withdraw life-prolonging technologies usually found in advance directives. To embrace this broader framework it is critical that primary care physicians as well as disease specialists receive training in fundamental aspects of both geriatric and palliative care. Professionals from both of these disciplines must share expertise with each other, and should collaborate in advocacy efforts to effectuate changes in the clinical, policy and legislative arenas.

Setting Limits: Evolving Views about Futile Medical Treatments

Setting Limits: Evolving Views about Futile Medical Treatments