Life-sustaining Treatment For Patients Research Articles

Should Neurologists Discuss the Cost of Life-Sustaining Treatment for Patients with DNR Orders?

Should Neurologists Discuss the Cost of Life-Sustaining Treatment for Patients with DNR Orders?

Physicians' and Nurses' Preferences in Using Life-Sustaining Treatments

The aim of this study was to examine physicians' and nurses' preferences regarding the use of life-sustaining treatments (LST) for severely ill elderly patients, and the patient- and social-centered factors that influence them. Physicians and nurses working in Israeli general hospitals completed structured questionnaires referring to their preferences for using LST in three severe health conditions (metastatic cancer, mental illness and being bedridden/incontinent). The participants were also asked about factors influencing these preferences, including patients' wishes, quality of life, religiosity and the current law. Both physicians and nurses indicated that they would use less LST for patients with metastatic cancer than with those suffering from the other two health conditions. Our findings indicate that the attitudes of professionals involved in these processes are influenced not only by the patient's condition but also by their professional orientations and personal values. Open communication among professionals for clarifying the various beliefs, as well as the antecedents of these beliefs, is important for the benefit of professional teams, patients and families.

SYMPTOM RELIEF IN THE LAST WEEK OF LIFE: IS DEMENTIA ALWAYS A LIMITING FACTOR?

SYMPTOM RELIEF IN THE LAST WEEK OF LIFE: IS DEMENTIA ALWAYS A LIMITING FACTOR?

An empirical analysis of the decision-making of limiting life-sustaining treatment for patients with advanced chronic obstructive pulmonary disease in Hong Kong, China

Objectives: To understand the prognostic and quality-of-life considerations surrounding life-sustaining treatment decisions for patients with advanced chronic obstructive pulmonary disease (COPD) in Hong Kong China. Methods: A documentary review of 49 COPD patients and 19 patient case studies from the medical departments of 2 hospitals were undertaken to examine the practices of DNI decision-making (do not perform mechanical ventilation and cardiopulmonary resuscitation). Statistical, event, and thematic analyses were conducted to delineate the prognostic and quality-of-life factors that shaped the not for intubation and mechanical ventilation (DNI) decisions. Results: Three major treatment-limiting decision-making patterns existed in practice: 1) Patient-initiated and shared decision-making with physician (n = 14); 2) Physician-initiated and shared decision-making with the patient/family members (n = 24); and 3) Physician-initiated DNI decision-making with patient family, but without patient participation due to mental incapacity (n = 11). Prognostic considerations include physiological parameters, performance status, concomitant diseases, therapeutic regimens, and the utilization of medical services. Three major themes were delineated regarding the way in which the patients evaluated their life quality in the context of DNI status. They are prognostic awareness, illness burdens, and existential concerns. Discussion: A decision-making framework used by patients/families/physicians to limit life-sustaining treatments in patients with advanced COPD is delineated. Observations regarding how treatment limiting decision-making for patients with advanced chronic illnesses can be improved in Hong Kong are discussed.

Influence of alterations in forgoing life-sustaining treatment practices on a clinical sepsis trial

To evaluate the timing of foregoing life-sustaining treatments in patients enrolled in a sepsis trial and to determine their influence on patient outcome and trial results. Subset of patients in a prospective, randomized, double-blind, placebo-controlled study. Twenty-three academic medical centers. Enrolled patients who had life-sustaining therapies withheld or withdrawn. The number of patients, types of disorders and interventions, reasons, and timing of withholding and withdrawing life-sustaining treatments and their effect on mortality and trial results were assessed. Foregoing of life-sustaining therapies took place in 117 (22%) of 543 patients and occurred within 72 hrs of study drug administration in 38 (32%) patients. Withholding treatment (60%) was more common than withdrawing treatment (40%), but withdrawing treatment was more frequent (51%) than withholding treatment (20%) in the first 72 hrs of the trial (p < .01). Sixty-one (52%) patients had severe underlying disorders with a poor prognosis. The hospital mortality rate was 94% (of the 117 patients). The mean time (SEM) from withholding or withdrawing of treatment until death was 2.83 +/- 0.57 and 0.32 +/- 0.13 days, respectively (p < .001). Patients who had therapies foregone in the first 24, 48, and 72 hrs after receiving the study drug had higher mortality rates in the first 72 hrs (p < .01). A substantial number of patients enrolled in a sepsis trial had severe underlying diseases and had foregoing of therapies early in the course of the trial, which led to a higher early mortality rate. Enrollment of patients in clinical trials with severe underlying disorders with a high likelihood of having therapies foregone may bias the potential for showing the efficacy of new therapeutic modalities.

Who Decides?

<h3>Background:</h3> Physician specialty training is associated with variations in the use of medical treatment for specific diseases. <h3>Objective:</h3> To examine whether physicians' specialties predict differences in willingness to use life-sustaining treatments. <h3>Methods:</h3> One hundred fifty-eight physicians (response rate, 85%) who cared for 378 hospitalized patients with end-stage congestive heart failure, chronic obstructive pulmonary disease, malignant neoplasms, or hepatic cirrhosis were interviewed to assess their thresholds for use of specific life-sustaining treatments. Their patients were then followed up to determine whether decisions were made to use or withhold cardiopulmonary resuscitation, ventilator support, or intensive care. Physicians' attitudes, their stated thresholds for treatment use, and their use of these treatments in daily practice were compared by specialty group. <h3>Results:</h3> Physicians recommended cardiopulmonary resuscitation and ventilator support for patients with end-stage congestive heart failure or chronic obstructive pulmonary disease if the chance for survival was at least 48%, but they required a predicted survival of at least 74% for patients with cancer. For a patient with end-stage congestive heart failure or chronic obstructive pulmonary disease, cardiologists were consistently more willing than other physicians to use life-sustaining treatments. In practice, decisions to use or withhold such treatments were made for 151 patients with end-stage diseases. Compared with other physicians, cardiologists were least likely to issue orders to withhold treatment and most likely to use life-sustaining treatments for patients they treated. Oncologists rarely used such treatments and issued orders to withhold these treatments much more often. <h3>Conclusion:</h3> Physician specialty is associated with differences in willingness to use, and in actual use of, life-sustaining treatments. (Arch Intern Med. 1996;156:785-789)

Who decides? Physicians' willingness to use life-sustaining treatment

Physician specialty training is associated with variations in the use of medical treatment for specific diseases. To examine whether physicians' specialties predict differences in willingness to use life-sustaining treatments. One hundred fifty-eight physicians (response rate, 85%) who cared for 378 hospitalized patients with end-stage congestive heart failure, chronic obstructive pulmonary disease, malignant neoplasms, or hepatic cirrhosis were interviewed to assess their thresholds for use of specific life-sustaining treatments. Their patients were then followed up to determine whether decisions were made to use or withhold cardiopulmonary resuscitation, ventilator support, or intensive care. Physicians' attitudes, their stated thresholds for treatment use, and their use of these treatments in daily practice were compared by specialty group. Physicians recommended cardiopulmonary resuscitation and ventilator support for patients with end-stage congestive heart failure or chronic obstructive pulmonary disease if the chance for survival was at lease 48%, but they required a predicted survival of at least 74% for patients with cancer. For a patient with end-stage congestive heart failure or chronic obstructive pulmonary disease, cardiologists were consistently more willing than other physicians to use life-sustaining treatments. In practice, decisions to use or withhold such treatments were made for 151 patients with end-stage diseases. Compared with other physicians, cardiologists were least likely to issue orders to withhold treatment and most likely to use life-sustaining treatments for patients they treated. Oncologists rarely used such treatments and issued orders to withhold these treatments much more often. Physician specialty is associated with differences in willingness to use, and in actual use of, life-sustaining treatments.

Neuropathological findings in the brain of Karen Ann Quinlan. The role of the thalamus in the persistent vegetative state.

Karen Ann Quinlan had a cardiopulmonary arrest in 1975 and died 10 years later, having never regained consciousness. Her story prompted a national debate about the appropriateness of life-sustaining treatment in patients who are in a persistent vegetative state and led to the development of medicolegal guidelines for the care of such patients. This report describes the neuropathologic features of Quinlan's brain. The entire brain and spinal cord were systematically sampled for histologic examination. The brain stem and central cerebrum were embedded en bloc and serially sectioned. Three-dimensional computer reconstructions helped visualize the topographic features of the lesions. Contrary to expectation, the most severe damage was not in the cerebral cortex but in the thalamus, and the brain stem was relatively intact. The neuropathological findings included extensive bilateral thalamic scarring, bilateral cortical scars primarily in the occipital pole and parasagittal parieto-occipital region, and bilateral damage to cerebellar and focal-basal-ganglia regions. The brain stem and basal forebrain and the hypothalamic components of the ascending arousal systems and brainstem regions critical to cardiac and respiratory control were undamaged. The lesions were consistent with hypoxia-ischemia after the cardiopulmonary arrest. Although the neuropathological findings in the case of Karen Ann Quinlan were complex, the disproportionately severe damage in the thalamus as compared with the cerebral cortex supports the hypothesis that the thalamus is critical for cognition and awareness and may be less essential for arousal.

Ethics, brain damage and ending lives

The problem of patients in the persistent vegetative state is beset by complex ethical and philosophical issues to do with the nature of persons and our ethical duties towards them. Many discussions obscure the main ethical considerations. In this paper, I approach the problem through a philosophical analysis of the concept of a person and the attributes that ground our ethical responsibilities to persons. I argue that we are under no ethical obligation to continue lifesustaining treatment for patients properly diagnosed as being in the persistent vegetative state or with other severe brain damaged conditions. This, of course, is compatible with our trying to do our best for such patients until the prognosis is clear.

Critical Care of Patients With AIDS

We sought to review the clinical and ethical issues surrounding critical care for patients with the acquired immunodeficiency syndrome (AIDS). We reviewed published studies and abstracts dealing with the outcome of critical care for patients with AIDS, decision making about life-sustaining treatments in patients with AIDS, and infection control in the intensive care unit. We also consulted with a number of experts in the field. We selected outcome studies in which patients with documented AIDS or infection with the human immunodeficiency virus (HIV) were analyzed. We rejected data concerning patients with suspected or presumed AIDS and data concerning presumed cases of Pneumocystis carinii pneumonia (PCP). Most AIDS patients who require critical care do so because of respiratory failure caused by PCP. Although studies early in the epidemic reported survival rates to hospital discharge of 0% to 14%, recent studies demonstrate improved survival rates of 36% to 55%. Treatment for patients with PCP and respiratory failure should include either intravenous trimethoprim-sulfa-methoxazole or pentamidine isethionate, as well as adjuvant corticosteroids. Patients with AIDS may require critical care for many other indications, including seizures, sepsis, and hypotension, or reasons unrelated to their immunodeficiency. In general, such patients have a better prognosis than those with respiratory failure. The provision of critical care for PCP and respiratory failure specifically or AIDS generally cannot be considered futile. Therefore, decisions about the use of critical care should be guided by the particular clinical situation and the patient's preferences. More research is needed to elucidate the reasons for the improving survival for patients with PCP and respiratory failure and the predictors of such survival.

Artificial heart and assist devices: Directions, needs, costs, societal and ethical issues

Beliefs around deactivation of a left ventricular assist device (LVAD) vary substantially among clinicians, institutions, and patients. Therefore, we sought to understand perspectives regarding LVAD deactivation among cardiology and hospice/palliative medicine (HPM) clinicians.We administered a 41-item survey via electronic mail to members of 3 cardiology and 1 HPM professional societies. A convergent parallel mixed-methods design was used. From October through November 2011, 7168 individuals were sent the survey and 440 responded. Three domains emerged: (1) LVAD as a life-sustaining therapy; (2) complexities of the process of LVAD deactivation; and (3) legal and ethical considerations of LVAD deactivation. Most respondents (cardiology 92%; HPM 81%; P = .15) believed that an LVAD is a life-sustaining treatment for patients with advanced heart failure; however, 60% of cardiology vs 2% of HPM clinicians believed a patient should be imminently dying to deactivate an LVAD (P < .001). Additionally, 87% of cardiology vs 100% of HPM clinicians believed the cause of death following LVAD deactivation was from underlying disease (P < .001), with 13% of cardiology clinicians considering it to be a form of euthanasia or physician-assisted suicide.Cardiology and HPM clinicians have differing perspectives regarding LVAD deactivation. Bridging the gaps and engaging in dialog between these 2 specialties is a critical first step in creating a more cohesive approach to care for LVAD patients.

Life-sustaining treatment for patients with AIDS

Physicians increasingly are being called upon to make difficult decisions about intensive care for patients with the acquired immunodeficiency syndrome (AIDS). AIDS patients who require intensive care have a poor prognosis; the in-hospital mortality rate of those receiving mechanical ventilation for P carinii pneumonia is 86-100 percent in most studies. However, in the past year, two studies documenting improved outcome have been published. Physicians should understand these outcome data and use well-established ethical principles to allow informed competent patients with AIDS to express their preferences regarding intensive care. Patients should be encouraged to provide advanced directives regarding life-sustaining treatments or to designate surrogate decision-makers to be consulted should they lose mental competence. The health care system should provide alternatives to the ICU for compassionate terminal care. However, arbitrary policies denying intensive care to AIDS patients for whom it is medically indicated and desired are not warranted.

Life-Sustaining Treatment for Patients with AIDS

Physicians increasingly are being called upon to make difficult decisions about intensive care for patients with the acquired immunodeficiency syndrome (AIDS). AIDS patients who require intensive care have a poor prognosis; the in-hospital mortality rate of those receiving mechanical ventilation for P carinii pneumonia is 86-100 percent in most studies. However, in the past year, two studies documenting improved outcome have been published. Physicians should understand these outcome data and use well-established ethical principles to allow informed competent patients with AIDS to express their preferences regarding intensive care. Patients should be encouraged to provide advanced directives regarding life-sustaining treatments or to designate surrogate decision-makers to be consulted should they lose mental competence. The health care system should provide alternatives to the ICU for compassionate terminal care. However, arbitrary policies denying intensive care to AIDS patients for whom it is medically indicated and desired are not warranted.