Life-sustaining Treatment Decisions Research Articles

Act on Hospice-palliative Care and Life-sustaining Treatment Decision-making and Institutional Measures for its Implementation

Act on Hospice-palliative Care and Life-sustaining Treatment Decision-making and Institutional Measures for its Implementation

353P - A prediction model for the intents regarding life-sustaining treatment decisions in patients with terminal cancer

BackgroundLife-Sustaining Treatment Decision systems have been in effect since February 2018 in South Korea. These systems ensure that medically insignificant life-sustaining treatments, which are undesired by the patient, are avoided. This study was designed to develop and verify an explanatory model of terminal cancer patients’ intent related to decisions regarding discontinuing or not performing meaningless, life-sustaining treatments in South Korea. MethodsData were collected from April 15 to July 10 2019, via a survey using self-reported questionnaires. A total of 220 patients, with terminal cancer, were recruited. The hypothetical model was constructed using four exogenous variables—family function, knowledge on life-sustaining treatment decisions, likelihood of the treatment outcome, and treatment burden—and three endogenous variables—attitudes towards, the efficacy of, and intent regarding life-sustaining treatment decisions. ResultsThe goodness-of-fit of this hypothetical model was x2=169.25, χ2/df=1.90, RMSEA=.07, RMR=0.02, GFI=.91, AGFI=.90, NFI=.97, CFI=.98, RMSEA=.06 The results demonstrated that knowledge on, attitudes towards, the efficacy of life-sustaining treatment decisions, and treatment burden all had significant and direct effects on participants’ intent regarding their treatment decisions. Family function was indirectly associated with participants’ intent regarding life-sustaining treatment decisions. These variables explained 88.8% of the total variance with respect to the intent regarding life-sustaining treatment decisions, with knowledge on these decisions being the most influential factor. ConclusionsThe results of this study suggest that, in order to improve terminal cancer patients’ intent regarding life-sustaining treatment decisions related to discontinuing or not performing meaningless life-sustaining treatments, nursing interventions should focus on enhancing their knowledge around this topic, as well as the efficacy of these choices. In particular, a patient’s family function is a crucial intervention strategy that can enhance their intent regarding life-sustaining treatment decisions. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Completion rate of physician orders for life-sustaining treatment for patients with metastatic or recurrent cancer: a preliminary, cross-sectional study

Background“End of life” is a difficult topic of conversation in East Asian cultures, even among patients and doctors who share a good rapport. In 2016, the Hospice, Palliative Care, and Life-Sustaining Treatment Decision-Making Act, which took the form of “Physician Orders for Life-Sustaining Treatment,” was introduced in South Korea. This study was conducted to investigate the completion rate of Physician Orders for Life-Sustaining Treatment in patients with advanced cancer on the active recommendation of physicians, as well as patients’ general attitudes toward end-of-life care.MethodsWe conducted a preliminary, cross-sectional descriptive survey on patients with advanced cancer. A total of 101 patients with advanced solid cancer agreed to participate in the study. The primary endpoint was the rate of completion of Physician Orders for Life-Sustaining Treatment based on a doctor’s suggestion. Written interviews were conducted to understand the perceptions and factors influencing patients’ decisions.ResultsOf the 101 patients, 72 (71.3%) agreed to prepare Physician Orders for Life-Sustaining Treatment. Patients who had an educational level of high school or higher were more likely to agree to complete Physician Orders for Life-Sustaining Treatment documentation as compared to the lower educational status group. More than half of the respondents who completed Physician Orders for Life-Sustaining Treatment documentation reported that they had more than a fair understanding of “life-sustaining care” or “Physician Orders for Life-Sustaining Treatment.” Participants’ reasons for Physician Orders for Life-Sustaining Treatment completion were diverse.ConclusionsWe found that highly educated patients, who understood the concept behind the policy well, tended to accept Physician Orders for Life-Sustaining Treatment without hesitation. Better education, information shared through the media, and conversations with health care providers might improve understanding of Physician Orders for Life-Sustaining Treatment in patients with cancer.

Early prognostication of neurological outcome by heart rate variability in adult patients with out-of-hospital sudden cardiac arrest

BackgroundMost deaths of comatose survivors of out-of-hospital sudden cardiac arrest result from withdrawal of life-sustaining treatment (WLST) decisions based on poor neurological prognostication and the family’s intention. Thus, accurate prognostication is crucial to avoid premature WLST decisions. However, targeted temperature management (TTM) with sedation or neuromuscular blockade against shivering significantly affects early prognostication. In this study, we investigated whether heart rate variability (HRV) analysis could prognosticate poor neurological outcome in comatose patients undergoing hypothermic TTM.MethodsBetween January 2015 and December 2017, adult patients with out-of-hospital sudden cardiac arrest, successfully resuscitated in the emergency department and admitted to the intensive care unit of the Niigata University in Japan, were prospectively included. All patients had an initial Glasgow Coma Scale motor score of 1 and received hypothermic TTM (at 34 °C). Twenty HRV-related variables (deceleration capacity; 4 time-, 3 geometric-, and 7 frequency-domain; and 5 complexity variables) were computed based on RR intervals between 0:00 and 8:00 am within 24 h after return of spontaneous circulation (ROSC). Based on Glasgow Outcome Scale (GOS) at 2 weeks after ROSC, patients were divided into good outcome (GOS 1–2) and poor outcome (GOS 3–5) groups.ResultsSeventy-six patients were recruited and allocated to the good (n = 22) or poor (n = 54) outcome groups. Of the 20 HRV-related variables, ln very-low frequency (ln VLF) power, detrended fluctuation analysis (DFA) (α1), and multiscale entropy (MSE) index significantly differed between the groups (p = 0.001), with a statistically significant odds ratio (OR) by univariate logistic regression analysis (p = 0.001). Multivariate logistic regression analysis of the 3 variables identified ln VLF power and DFA (α1) as significant predictors for poor outcome (OR = 0.436, p = 0.006 and OR = 0.709, p = 0.024, respectively). The area under the receiver operating characteristic curve for ln VLF power and DFA (α1) in predicting poor outcome was 0.84 and 0.82, respectively. In addition, the minimum value of ln VLF power or DFA (α1) for the good outcome group predicted poor outcome with sensitivity = 61% and specificity = 100%.ConclusionsThe present data indicate that HRV analysis could be useful for prognostication for comatose patients during hypothermic TTM.

연명의료결정법과 의료기관윤리위원회: 현황, 경험과 문제점*,**

Institutional Ethics Committees are responsible for reviewing, consulting, and educating about matters related to life-sustaining treatment, these committees should play a substantial role in implementing the Act in each hospital. However, there are few such committees and their operations have been limited in many respects. In this article we report on a survey that was carried out to assess the difficulties faced by 63 committee administrators. We also conducted focus-group interviews with seven medical professionals or administrators working in health care institutions in which a committee has been established. Subjects were asked about the difficulties these committees face in advising on foregoing life-sustaining treatment. The operational problems that were reported include the following: difficulties in accessing patients’ records of decisions concerning life-sustaining treatment, obstacles in using Shared Ethics Committees, legal and administrative complexities in diagnosing the end-of-life process, the lack of expertise of committee members and administrators, manpower shortages on the committees, and medical professionals’ negative views of the Act’s procedures for life-sustaining treatment decision-making. In order to deal with these problems, we suggest the following solutions: improving the accessibility of patients’ life-sustaining treatment decisions, encouraging the use of Shared Ethics Committees, defining the qualifications and training requirements for Committee members, establishing better communications among committee members; creating an educational system for medical professionals in order to improve their understanding of the committees’ role; and developing standard operating procedures for the committees.

생애 마지막 단계에서 공유된 의사결정을 통한 연명의료결정 모델 연구

생애 마지막 단계에서 공유된 의사결정을 통한 연명의료결정 모델 연구

Effect of the Awareness of a Good Death and Perceptions of Life-sustaining Treatment Decisions on Attitudes of Intensive Care Nurses toward Terminal Care

Purpose The purpose of this study was to identify the extent to which intensive care unit (ICU) nurses’ perceptions of life-sustaining treatment decisions and “a good death” affect attitudes toward terminal care. Method Participants included 109 ICU nurses from three university hospitals. Data were collected using structured questionnaires, and collected data were analyzed using a t-test, ANOVA, the Scheffé test, Pearson correlation coefficients, and a multiple regression analysis (SPSS 24.0 program). Results Perceptions of life-sustaining treatment decisions and a sense of closeness (a constituent for the awareness of “a good death”) were positively correlated with terminal care attitudes. The factors affecting terminal care attitudes were a clinical career in ICU (β =.20, p =.035), a sense of closeness(β =.19, p =.041), and the perception of a lifesustaining treatment decision (β =.22, p =.017). This finding indicates that more than 10 years of experience in ICU, a greater sense of closeness, and a higher view of life-sustaining treatment decisions results in more positive attitudes toward terminal care. The explanatory power of these variables on terminal care attitudes was 14% (F=6.84, p < .001, Adj R2=.140). Conclusion A sense of closeness and the perception of life-sustaining treatment decisions were identified as the factors affecting terminal care attitudes. Thus, various programs must be developed to raise awareness among ICU nurses of “a good death” and perceptions of life-sustaining treatment decisions. Key Words: Intensive care unit, Death, Terminal care, Attitude 주요어: 중환자실, 죽음, ì—°ëª ì¹˜ë£Œ, ìž„ì¢ ê°„í˜¸

연명의료결정법 1주기 평가와 종양내과 의사로서 느끼는 법과 임상현장의 괴리

More than a year has passed since the implementation of the “Act on Decisions on Life-sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life” (hereafter the “Life-Sustaining Treatment Decisions Act”) in South Korea. Although there have been complaints about the complicated legal documents that the law requires patients to complete when choosing to end life-sustaining treatment, overall this new law has been well received and more patients than expected have made use of the provisions of this law since it was implemented. However, it is now time to reconsider whether the law is serving the purpose for which it was originally designed. I argue in this article that while the expressed purpose of the Life-Sustaining Treatment Decisions Act is to respect and enhance patient autonomy, in practice the law seems to do more to reduce socio-economic burden than to protect patient autonomy. Furthermore, this law is transforming the ethical culture within the practice of medicine into a bureaucracy. Greater public debate on this matter is needed to ensure that the Life-Sustaining Treatment Decisions Act serves the purpose for which it was originally designed.

연명의료결정법과 환자자율성 증진에 관한 문제제기: 미국 환자자기결정권 제정 이후 논쟁분석*,**

In February 2018 the “Act on Decisions on Life-sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life” (hereafter the “Life-Sustaining Treatment Decisions Act”) went into effect in South Korea.” In order learn the lesson for Korean physicians’ practice in end-of-life care, we reviewed the debates surrounding the passage of similar legislation in the US. In particular, we examined the debates concerning the “Patient Self-Determination Act,” which was implemented in the US in 1991. We systemically searched for related medical articles on PubMed online and reviewed 17 articles that were retrieved through this search. One of the main findings of this review is that most of the articles expressed support for the Patient Self-determination Act on the grounds that it would enhance patient autonomy. In contrast with this, the Korean medical society criticized the Life-Sustaining Treatment Decisions Act on the grounds that it would undermine physician authority and limit respect for patient autonomy. This reflects the fact that Korean physicians are unfamiliar or uncomfortable with the idea of respecting patient autonomy as a way of furthering the patient’s best interests. In this article I argue that the reasons for welcoming the provisions of the Life-Sustaining Treatment Decisions Act are not only legal, but also medical and ethical: the law can improve the end-of-life care that is given in healthcare settings. However, in order to achieve this goal, patients must be fully informed about their rights and physicians should initiate discussions about advance care planning, as part of general health care, before serious illness arises.

연명의료결정제도에 대한 고찰

연명의료결정제도에 대한 고찰

Serious Choices: A Systematic Environmental Scan of Decision Aids and Their Use for Seriously Ill People Near Death.

Seriously ill people near death face difficult decisions about life-sustaining treatments such as cardiopulmonary resuscitation and mechanical ventilation. Patient decision aids may improve alignment between patients' preferences and the care they receive, but the quantity, quality, and routine use of these tools are unknown. We conducted a systematic environmental scan to identify all decision aids for seriously ill people at high risk of death facing choices about life-sustaining treatments, assess their quality, and explore their use in clinical settings. We searched MEDLINE, Google, and mobile application stores and surveyed experts. We included 27 decision aids in our scan. Concerning content, 14 of 27 decision aids for seriously ill people near death were for people with specific diseases and conditions (ie, advanced cancer or kidney disease); 11 concerned individual life-sustaining treatment decisions (ie, cardiopulmonary resuscitation or mechanical ventilation). Only two focused on more general care pathways (ie, life-sustaining intervention, palliative care, and hospice). Twenty-four of 27 decision aids presented options in a balanced way; 23 identified funding sources, and 19 of 27 reported their publication date. Just 11 used plain language. A minority, 11 of 27, listed evidence sources, five documented rigorous evidence-synthesis methods, six disclosed competing interests, and three offered update policies. Preliminary results suggest that few health systems use decision aids in routine patient care. Although many decision aids exist for life-sustaining treatment decisions during serious illness, the tools are deficient in some key quality areas.

Characterizing Life-Sustaining Treatment Decisions of Seriously Ill Veterans During Pilot Testing of the Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative (QI742)

Characterizing Life-Sustaining Treatment Decisions of Seriously Ill Veterans During Pilot Testing of the Veterans Health Administration’s Life-Sustaining Treatment Decisions Initiative (QI742)

A Rapid Qualitative Synthesis of Insights from the Veterans Administration Life-Sustaining Treatment Decisions Initiative (LSTDI) National Implementation (QI703)

A Rapid Qualitative Synthesis of Insights from the Veterans Administration Life-Sustaining Treatment Decisions Initiative (LSTDI) National Implementation (QI703)

Reversals in Decisions about Life-Sustaining Treatment and Associated Factors among Older Patients with Terminal Stage of Cardiopulmonary Disease

The purpose of this study was to investigate the frequency, patterns, and factors of reversals in decisions about life-sustaining treatment (LST) among older patients with terminal-stage chronic cardiopulmonary disease. This was a retrospective correlational descriptive study based on medical chart review. De-identified patient electronic medical record data were collected from 124 deceased older patients with terminal-stage cardiopulmonary disease who had made reversals of LST decisions in an academic tertiary hospital in 2015. Data were extracted about the reversed LST decisions, LST treatments applied before death, and patients' demographic and clinical factors. Multivariate logistic regression analysis was used to identify the factors associated with the reversal to higher intensity of LST treatment. The use of inotropic agents was the most frequently reversed LST treatment, followed by cardiopulmonary resuscitation, intubation, ventilator therapy, and hemodialysis. Inconsistency between the last LST decisions and actual treatments occurred most often in hemodialysis. One-third of the reversals in LST decisions were made toward higher intensity of LST treatment. Patients who had lung diseases (vs. heart diseases); were single, divorced, or bereaved (vs. married); and had an acquaintance as a primary decision maker (vs. the patients themselves) were significantly more likely to reverse the LST decisions to higher intensity of LST treatment. This study demonstrated the complex and turmoil situation of the LST decision-making process among older patients with terminal-stage cardiopulmonary disease and suggests the importance of support for patients and families in their LST decision-making process.

Implementation of Antimicrobial Stewardship Programs in End-of-Life Care.

Many terminal patients at the end-of-life have been receiving antimicrobial therapy despite concerns including futile use, potential lack of efficacy, increased patient burden, excess costs, high risk of adverse effects, and increased antimicrobial resistance. Thus, the implementation of antimicrobial stewardship programs (ASPs) in end-of-life care needs to be discussed. But, the topics of antimicrobial therapy and ASPs have not been addressed in the Life-Sustaining Treatment Decision Act enacted in the Korea in February 2016. Antimicrobial therapy should be included in the decision-making framework for end-of-life care similar to other life-sustaining treatment decisions. If the antimicrobial therapy is legally considered as a life-sustaining treatment which can be withdrawn or withheld in patients at the end-of-life, the feasibility of implementing ASPs among this patient population may improve. Various researches on antimicrobial therapy for patients at the end-of-life need to be conducted and collaborations are required between ASPs professionals and many other concerned parties involved in the legislative process of the Life-Sustaining Treatment Decision Act. This review aims to summarize previous studies on the use of antimicrobials for end-of-life care and reveal important aspects for applying ASPs to this population in Korea.

Attitudes of the General Public, Cancer Patients, Family Caregivers, and Physicians Toward Advance Care Planning: A Nationwide Survey Before the Enforcement of the Life-Sustaining Treatment Decision-Making Act

ContextTo respect a patient's wish for end-of-life care, “the Act on Decisions on Life-Sustaining Treatment for Patients at the End-of-Life” was enacted in South Korea in 2016. Current understanding of people who would be involved in advance care planning (ACP) is crucial to disseminate it systematically. ObjectivesThe objective of this study was to investigate awareness and attitudes toward ACP in South Korea. MethodsA multicenter, nationwide cross-sectional study was conducted a survey regarding ACP among four groups that would have different positions and experiences: 1,001 cancer patients, 1,006 family caregivers, 928 physicians, and 1,005 members of the general public. ResultsA total of 16% of the general population, 33% of the patients and caregivers, and 61% of the physicians had knowledge of advance directives. More than 63% of the general population, above 72% of the patients and caregivers, and 97% of the physicians were willing to do so when the disease status was aggravated or terminal. The possibility for changing the plan, uncertainty as to whether directives would actually be followed, and psychological discomfort were common reasons for not wanting to engage in ACP. Routine recommendations for a specific medical condition, heightened accessibility, and health insurance support were common factors that could help facilitate ACP. ConclusionOur findings suggest that strategies for promoting ACP should reflect different perspectives among the general public, patients, family caregivers, and physicians. Public advocacy, resources for approaching and integrating ACP into routine health care, as well as systematic support provisions are needed.

A Comprehensive Approach to Eliciting, Documenting, and Honoring Patient Wishes for Care Near the End of Life: The Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative

There is an emerging consensus that clinicians should initiate a proactive "goals of care conversation" (GoCC) with patients whose serious illness is likely to involve decisions about life-sustaining treatments (LSTs) such as artificial nutrition, ventilator support, or cardiopulmonary resuscitation. This conversation is intended to elicit the patient's values, goals, and preferences as a basis for shared decisions about treatment planning. LST decisions are often postponed until the patient is within days or even hours of death and no longer able to make his or her goals and preferences known. Decisions then fall to surrogates who may be uncertain about what the patient would have wanted. The Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative (LSTDI) was designed to ensure that patients' goals, values, and preferences for LSTs are elicited, documented, and honored across the continuum of care. The LSTDI includes a coordinated set of evidence-based strategies that consists of enterprisewide practice standards for conducting, documenting, and supporting high-quality GoCCs; staff training to enhance proficiency in conducting, documenting, and supporting GoCCs; standardized, durable electronic health record tools for documenting GoCCs; monitoring and information technology tools to support implementation and improvement; a two-year multifacility demonstration project conducted to test and refine strategies and tools and to identify strong practices; and a program of study to evaluate the LSTDI and identify strategies critical to improving care for patients with serious illness. The LSTDI moves beyond traditional advance care planning by addressing well-documented barriers to goal-concordant care for seriously ill patients.

무연고자의 연명의료결정: 제도적 관점에서*

The National Bioethics Committee of Korea recommended that hospital ethics committees should be allowed to make life-sustaining treatment decisions on behalf of patients without surrogate (family or friends). However, no such provision is included in the Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for patients at the End of Life (hereafter the “Act on Decisions in Life-sustaining Treatment”). While the Health and Welfare Committee of the Korean National Assembly did attempt to include such a provision in the form of an amendment to the aforementioned act, the Legislation and Judiciary Committee rejected it on the grounds that it did not specify the precise legal requirements of the hospital ethics committees. In other countries, including Taiwan, Japan, the U.S., and the U.K., there are laws or guidelines governing the medical decision-making process for patients without surrogate. In this article, we review the background of this issue, the current practices in other countries, and the relevant legislative process. We suggest that a system should be established in Korea for making life-sustaining treatment-decisions for patients without surrogate.

Comparison of Life-Sustaining Treatment in Terminal Cancer Patients between a Cancer and Hospice Unit after Do-Not-Resuscitate Orders

Purpose: The purpose of this study was to compare the differences in the performance of life-sustaining treatment after signing a donot-resuscitate (DNR) order between terminal cancer patients who died in the cancer unit and hospice unit. Methods: We performed a retrospective analysis of 174 patients who died in the cancer unit (CU) and 68 patients who died in the hospice unit (HU) from January 1, 2016 to December 31, 2016 at a hospital specializing in cancer treatment. Results: The rate of life-sustaining treatment administration was lower for patients who died in the HU than that of those who died in the CU. The period until death after signing a DNR order was 7 days for CU patients and 19.5 days for the HU patients. The period from admission to death was also significantly longer in HU patients (32.5 days) than that in CU patients (21.5 days, p<.001). Of the patients who died in the CU, 54% were referred to the HU but did not use the service. Most of the people who signed DNR informed consents were spouses and offspring; only 4.6% of patients signed DNRs. Conclusion: It is hard to say that life-sustaining treatment increases the survival period, but it can improve symptom control and quality of life in hospices. Activation of consultation-based hospice is necessary for patients who cannot use the hospice unit. To increase patient’s active participation in the life-sustaining treatment decision of terminal cancer patients, it is necessary that an advanced practice nurse specialized in counseling and education is involved in the decision.

한국의 대학병원에서 의료진들이 겪는 윤리적 문제 현황 및 임상윤리자문서비스의 필요성 조사*

The purpose of this study was to investigate the nature and number of ethical conflicts faced by physicians and nurses working at university hospitals in South Korea and also to assess the need for clinical ethics consultation services. Data collection was conducted from August 6 to 24, 2015 at three university hospitals in metropolitan areas; a total of 316 physicians and nurses participated in the study. The results showed that 85.1% of physicians and 76.6% of nurses answered that they had experienced ethical problems more than once a year during the course of their career, and about one third of respondents experienced such conflicts at least once every three months. For physicians, ethical dilemmas arose most often in the context of end-of-life care, mainly in terminating life-sustaining treatment (65.7%) and notifying patients of the end of medical treatment (63.6%). Ethical dilemmas experienced by nurses related primarily to difficult care decisions other than life-sustaining treatment (73.9%), impaired decision-making in patients (66.7%), and dealing with surrogate decision-makers (66.7%). When faced with ethical dilemmas, healthcare professionals usually made decisions informally by themselves or in consultation with close colleagues. More than 97% of respondents answered that they needed a clinical ethics consultation service. Future research should focus on how the ethics consulting services described in the Life-sustaining Treatment Decision-making Act of 2018 can be developed into an effective model for solving ethical problems that arise in medical practice.