Refusal Of Treatment Research Articles

Description of the experience of a clinical ethics consultation service from 2019 to 2021

IntroductionClinical ethics consultation services (CEC) are useful model for ethical counselling, albeit with scarce implementation in European countries. This article shares the experience of one of the first ethics consultation services in Spain. Materials and methodsThis work is a retrospective, observational study of all consultations received by the CEC service at La Princesa University Hospital (Madrid, Spain) from September 1, 2019 to August 31, 2021. The demographic, logistic, and ethical variables of the cases were analyzed. ResultsA total of 63 cases were analyzed in which a total of 124 ethical conflicts were identified. Forty-one percent of the cases (n = 26) were emergency consultations and 38% (n = 24) were preferential inquiries. An initial evaluation was performed with 24 h in 50 cases (79%). The department that consulted most often was the Intensive Care Unit (9; 14%). The preferred contact methods were via pager (36; 57%), the electronic medical record system (13; 21%), or direct conversations with consulting team (7; 11%). The most common ethical conflicts were those related to the adequacy of treatment measures (24; 19%), refusal of treatment (19; 15%), communication with the patient or his/her family (29; 23%), or the patient's capacity (13; 11%). ConclusionCEC services provide quick, efficient assistance for resolving ethical problems in daily practice. Their implementation in Spain is feasible.

Indications for involuntary hospitalization for refusal of treatment in severe anorexia nervosa: a survey of physicians and mental health care review board members in Japan

BackgroundWhen a patient with anorexia nervosa refuses treatment despite a physically critical condition, the therapist considers involuntary inpatient treatment under the Mental Health Law. However, ethical and practical problems arise from its application. In this study, a survey of treatment providers for eating disorders and psychiatric review board members was conducted regarding indications for involuntary hospitalization under the Mental Health Act for refusal of treatment for anorexia nervosa.MethodsA survey of 212 physicians affiliated with the Japanese Society for Eating Disorders and 180 members of Mental Health Care Review Boards across Japan was conducted using six vignette cases of patients with anorexia nervosa refusing treatment.ResultsRegardless of the duration of illness or age of the patient, few physicians chose compulsory hospitalization with or without the consent of the family, while the largest number of physicians chose hospitalization for medical care and protection when there was family consent. Among committee members, only hospitalization for medical care and protection was determined to be appropriate when there was family consent. Both hospitalization for medical care and protection, and compulsory hospitalization were deemed appropriate in the absence of family consent. Committee members who adjudged refusal of treatment for anorexia nervosa as self-injurious behavior suggested that compulsory hospitalization was indicated.ConclusionsWhen a patient with life-threatening anorexia nervosa refuses inpatient treatment, hospitalization for medical care and protection is actively chosen if the patient’s family consents. Mental Health Care Review Board members considered this acceptable. However, if the family does not consent, the physicians did not choose compulsory hospitalization, and the psychiatric review board was divided on this. Consensus was not achieved in this regard.

Insulin Pump Therapy Efficacy and Key Factors Influencing Adherence in Pediatric Population-A Narrative Review.

Objective: we aimed to highlight the state of the art in terms of pediatric population adherence to insulin pumps. This study intends to underline the significance of identifying and minimizing, to the greatest extent feasible, the factors that adversely affect the juvenile population's adherence to insulin pump therapy. Materials and methods: articles from PubMed, Embase, and Science Direct databases were evaluated using the following search terms: adherence, pump insulin therapy, children, pediatric population, and type 1 diabetes, in combination with several synonyms such as compliance, treatment adherence, pump adherence, patient dropouts, and treatment refusal. Results: A better glycemic control is connected to a better adherence to diabetes management. We identify, enumerate, and discuss a number of variables which make it difficult to follow an insulin pump therapy regimen. Several key factors might improve adherence to insulin pump therapy: efficient communication between care provider and patients (including home-based video-visits), continuous diabetes education, family support and parental involvement, as well as informational, practical assistance, and emotional support from the society. Conclusions: every cause and obstacle that prevents young patients from adhering to insulin pumps optimally is an opportunity for intervention to improve glycemic control and, as a result, their quality of life.

United Arab Emirates Population-Based Acute Leukaemia Registry: Acute Myeloid Leukemia Real-World Data

Population-based registries may provide data useful for clinical decisions in patients' populations not well presented by clinical studies, which is essential to establish recommendations for the management of patients in the real world. The aim of the first Sheikh Shakhbout Medical City (SSMC) ongoing acute leukaemia registry is to obtain information about the demography, clinical presentation, genetic markers, risk stratification and disease response of patients with diverse ethnicities and backgrounds .The registry includes newly diagnosed adults with acute leukaemia, admitted to SSMC from June 2021 onward. SSMC acute leukaemia registry is an observational retrospective and prospective study. Electrical medical records were used to collect data, and coding was used for each variable based on the 2017 European leukaemia network (ELN) and the 2016 European society for medical oncology (ESMO) clinical practice guidelines. A total of 41 patients were registered between June 2021 and May 2022, 18 patients with acute myeloid leukaemia (AML), 3 acute promyelocytic leukaemia (APL) , and 1 blastic plasmacytoid dendritic cell neoplasm (BPDCN). Seventy three percent (n=16) of patients are males, and 27% (n=6) are females. Eighteen percent of patients (n=4) are older than 65 years of age, 2 of them with antecedent myelodysplastic syndrome. About 54% of patients are Arab, 32% are South Asian, and 14% are Southeast Asian (Table 1). Forty percent of patients with normal karyotype which is close to previously reported percentage in Grimwade D et al, MRC AML 10 Trial. Blood 1998. Though our patients median age is 47 years at time of diagnosis, according to the 2017 ELN molecular stratification, about 32% of our patient group have adverse prognosis, which is higher compared to other clinical trials including the ones with older patients population (Grimwade D et al, MRC AML11 trial. Blood 2001). Four patients are FLT3-ITD positive, accounts for 22% which is similar to the reported percentage in Papaemmanuil E et al, Genomic Classification and Prognosis in AML. N Engl J Med. 2016. Two patients are IDH1 positive, 1 patient is IDH2 positive, accounts for 5% compared to the reported 1% in Dohner H et al, Diagnosis and management of AML in adults. Blood. 2017 Jan. Seven patients have other abnormal Next generation sequencing (NGS) results, 2 patients have negative NGS and 6 patients have unknown cytogenetic risk group. Induction chemotherapy includes standard-dose cytarabine 100-200 mg/m2 continuous infusion x 7 days with idarubicin 12 mg/m2 x 3 days in 33% of patients with AML, single dose of gemtuzumab ozogamicin 3 mg/m2 in addition to standard-dose cytarabine 200 mg/m2 continuous infusion x 7 days with daunorubicin 60 mg/m2 x 3 days in 17% of patients, hypomethylating agents with or without venetoclax in 22% of patients, and 28% of patients were not treated for various reasons including death and refusal of treatment. The 3 patients with APL are low-risk (WBC count ≤10,000/mcL) as per Sanz MA et al, Management of APL. Blood. 2019 . All treated with all-trans retinoic acid (ATRA) 45 mg/m2 in two divided doses daily and arsenic trioxide (ATO) 0.15 mg/kg IV daily. The patient with BPDCN was treated with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone, alternating with high-dose methotrexate and cytarabine. About 43% of patients achieved complete response (CR) or CR with incomplete hematologic recovery (CRi) post-induction as per the 2017 ELN guidelines. SSMC is one of the leukaemia centres in Abu Dhabi, United Arab Emirates (UAE), where petroleum and natural gas are the main industry. UAE population consists of mixed ethnicities with different socioeconomic backgrounds where consanguinity is common and air pollution exposure at home countries is a big possibility. Despite the fact that our patient population is small, and statistically significant analysis might not be possible at this stage, we believe that our patient population demographics and genetic markers are not well-reflected in the standard guidelines. With longer observation and time the SSMC acute leukaemia registry promises to provide interesting data that may shed important input for better treatment algorithms. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Comparison of Bitterness Intensity between Prednisolone and Quinine in a Human Sensory Test Indicated Individual Differences in Bitter-Taste Perception.

Prednisolone is a frequently prescribed steroid with a bitter, unpalatable taste that can result in treatment refusal. Oral suspensions or powder dosage forms are often prescribed, particularly to pediatric patients, as they improve swallowability and ease of dose adjustment. Consequently, the bitterness of prednisolone is more apparent in these dosage forms. Few studies have investigated prednisolone's bitterness. Thus, in this study, 50 adults evaluated the bitterness of prednisolone using the generalized Labeled Magnitude Scale (gLMS), in comparison with quinine, a standard bitter substance. Overall, prednisolone-saturated solution demonstrated the same extent (mean gLMS score: 46.8) of bitterness as 1 mM quinine solution (mean gLMS score: 40.1). Additionally, large individual differences were observed in the perception of the bitterness of prednisolone and quinine. Perceived flavors of some drugs are reportedly associated with bitter-taste receptor (TAS2Rs) polymorphisms. Therefore, we investigated the relationship between subjects' genetic polymorphisms of TAS2R19, 38, and 46, and their sensitivity to bitterness. Although a relationship between TAS2R19 polymorphisms and the perception of quinine bitterness was observed, no significant relationship was found between the perceived bitterness of prednisolone and the investigated genes. Ultimately, the results show that despite individual differences among subjects, the cause of prednisolone's strong bitterness is yet to be elucidated.

Myocardial Perfusion SPECT Imaging Radiomic Features and Machine Learning Algorithms for Cardiac Contractile Pattern Recognition

A U-shaped contraction pattern was shown to be associated with a better Cardiac resynchronization therapy (CRT) response. The main goal of this study is to automatically recognize left ventricular contractile patterns using machine learning algorithms trained on conventional quantitative features (ConQuaFea) and radiomic features extracted from Gated single-photon emission computed tomography myocardial perfusion imaging (GSPECT MPI). Among 98 patients with standard resting GSPECT MPI included in this study, 29 received CRT therapy and 69 did not (also had CRT inclusion criteria but did not receive treatment yet at the time of data collection, or refused treatment). A total of 69 non-CRT patients were employed for training, and the 29 were employed for testing. The models were built utilizing features from three distinct feature sets (ConQuaFea, radiomics, and ConQuaFea + radiomics (combined)), which were chosen using Recursive feature elimination (RFE) feature selection (FS), and then trained using seven different machine learning (ML) classifiers. In addition, CRT outcome prediction was assessed by different treatment inclusion criteria as the study’s final phase. The MLP classifier had the highest performance among ConQuaFea models (AUC, SEN, SPE = 0.80, 0.85, 0.76). RF achieved the best performance in terms of AUC, SEN, and SPE with values of 0.65, 0.62, and 0.68, respectively, among radiomic models. GB and RF approaches achieved the best AUC, SEN, and SPE values of 0.78, 0.92, and 0.63 and 0.74, 0.93, and 0.56, respectively, among the combined models. A promising outcome was obtained when using radiomic and ConQuaFea from GSPECT MPI to detect left ventricular contractile patterns by machine learning.

Do Not Resuscitate (DNR) Orders from an Islamic Perspective

In modern medicine and technologies, it is commonly accepted and recognized by the laws in western countries that patients have decision-making rights regarding the end of their lives. While people can choose medical cardiopulmonary resuscitation (CPR), some may refuse it for personal, moral, social, or religious reasons. Sometimes, when treatment is futile, it is possible to make an end-of-life decision with a recommendation from a doctor. Therefore, issues that must be addressed in both ethical and Islamic terms surround end-of-life decisions. One of these issues involves Do-NotResuscitate (DNR) orders. DNR is a decision that means treatment methods are not applied to a patient when their breathing or heart has stopped for some reason. This decision is taken either because of a testament signed by the person when they were healthy or because the doctor cannot perform any curative intervention. In this study, the status and applicability of DNR orders will be investigated from an Islamic Bioethics perspective, and fatwas will be cited to clarify the status of DNR orders in Islam. Additionally, because DNR is essentially the refusal or withholding of medical treatment, the provisions of Islam concerning seeking medical treatment and withholding treatment have been extensively researched. This study aims to demonstrate that DNR instructions are Islamically applicable in cases where treatment is unnecessary, considering classical and contemporary Islamic sources.

Assessing Barriers to Insulin Therapy among Omani Diabetic Patients Attending Three Main Diabetes Clinics in Muscat, Oman.

This study aimed to identify the main barriers that prevent patients with diabetes mellitus from accepting insulin therapy. This cross-sectional study was conducted from May to December 2019. Convenience sampling was used to recruit participants from three diabetes clinics in Muscat, Oman. Eligible participants were interviewed in person based on a pre-prepared questionnaire. The questionnaire, which was administered in Arabic, includes demographic data and 19 specific items on barriers to insulin therapy. A total of 201 participants (response rate: 93%) were enrolled in the study. The most common barriers were as follows: concern of frequent blood glucose checking (36.3%), long-term injections (33.8%), side-effects of insulin (29.9%) and weight gain (29.4%). Needle phobia was considered a barrier by only 9% of the participants. Overall, 125 (62.2%) participants were willing to initiate insulin therapy despite the presence of these barriers and only 20 (10%) of them were influenced by these barriers to such a degree that they rejected the insulin therapy. The majority of participants had no identifiable reasons to stop them from accepting insulin therapy. Effective strategies should be developed to address each of the main barriers to improve acceptance and adherence to insulin therapy.

Disparities in substance use treatment retention: An exploration of reasons for discharge from publicly funded treatment

Although Delaware is the seventh smallest state in the country (including Washington, D.C.) in terms of population size, it has the second highest drug overdose death rate. The Delaware Division of Substance Abuse and Mental Health has increased attention in identifying disparities in treatment outcomes. We explored reasons for discharge from publicly-funded treatment in Delaware with special attention to populations at risk for health inequities, with a focus on covariates of treatment non-completion. Using secondary data collected from publicly-funded treatment providers, we analyzed data from individuals that were admitted to substance use treatment between 2015 and 2019 and had been discharged in 2019. We did this by using logistic and multinomial regression, focusing on non-completion treatment outcomes such as failure to meet requirements, loss of contact, and treatment refusal. Clients who were Black or African American, compared to white clients, were more likely to be lost contact with, administratively discharged, or marked as failing to meet treatment requirements than having a completed treatment discharge. Women were 30% less likely than men to have “failed to meet treatment requirements” compared to completing treatment. Further investigation is needed into these patterns. While treatment quality cannot be assessed using this data, the results point to a need for closer study of disparities in treatment related to race, ethnicity, gender, employment, criminal justice involvement, and type of drug used. Treatment providers should be made aware of culturally informed care, as well as client-created goals, in order to reduce disparities in exit from treatment.

One novel ACOT7–NPHP4 fusion gene identified in one patient with acute lymphoblastic leukemia: a case report

BackgroundAcute lymphoblastic leukemia (ALL) is a type of heterogeneous hematopoietic malignancy that accounts for approximately 20% of adult ALL. Although ALL complete remission (CR) rate has increased to 85–90% after induction chemotherapy, 40–50% of patients eventually relapsed. Therefore, it is necessary to improve the outcomes of ALL via accurate diagnosis and individualized treatments, which benefits in part from molecular biomarkers. Here, we identified a new fusion gene, Acyl-CoA Thioesterase 7–Nephrocystin 4 (ACOT7–NPHP4), in a 34-year-old patient with ALL. The fusion gene contributed to chemoresistance to doxorubicin and acted as a new molecular marker.Case presentationA 34-year-old male patient was diagnosed with ALL (common B cell) based on clinical manifestations and laboratory results. Although the patient received two cycles of the hyper-CVAD-L regimen as chemotherapy, the induction treatment failed. Because of the refusal of further treatments, the patient died of rapid progression of ALL one month later. Finally, a new fusion transcript, ACOT7–NPHP4, was detected in the patient’s lymphoblastic leukemia cells via RNA sequencing.ConclusionThis is the first report of a patient with ALL carrying an ACOT7–NPHP4 fusion gene. These findings may help understand the impact of ACOT7–NPHP4 in clinical molecular monitoring and drug resistance to doxorubicin; furthermore, its leukemogenesis will be essential to explore in future.

Voice rehabilitation after laryngectomy: problems, complications and ways of their elimination

Voice rehabilitation after laryngectomy: problems, complications and ways of their elimination

Descripción de la experiencia de un servicio de consultoría en ética clínica en el período 2019-2021

IntroductionClinical ethics consultation services (CEC) are useful model for ethical counselling, albeit with scarce implementation in European countries. This article shares the experience of one of the first ethics consultation services in Spain. Materials and methodsThis work is a retrospective, observational study of all consultations received by the CEC service at La Princesa University Hospital (Madrid, Spain) from September 1, 2019 to August 31, 2021. The demographic, logistic, and ethical variables of the cases were analyzed. ResultsA total of 63 cases were analyzed in which a total of 124 ethical conflicts were identified. Forty-one percent of the cases (n=26) were emergency consultations and 38% (n=24) were preferential inquiries. An initial evaluation was performed with 24hours in 50 cases (79%). The department that consulted most often was the Intensive Care Unit (9; 14%). The preferred contact methods were via pager (36; 57%), the electronic medical record system (13; 21%), or direct conversations with consulting team (7; 11%). The most common ethical conflicts were those related to the adequacy of treatment measures (24; 19%), refusal of treatment (19; 15%), communication with the patient or his/her family (29; 23%), or the patient's capacity (13; 11%). ConclusionCEC services provide quick, efficient assistance for resolving ethical problems in daily practice. Their implementation in Spain is feasible.

Social and legal problems of discrimination by age in the medical field

The article aims to analyze the medical and legal aspects of human equality. Discrimination in the medical field affects both medical personnel and patients. The authors have used the method of comparison of legal regulations of various states, the systematic method, which allowed to reconcile the approaches: medical and legal and the synergistic method as a method of development of a modern globalizing society. It has been found that the typical policy of agism includes the requirement to examine elderly physicians as to their competence or skills without objective and substantiated reasons. Everything leads to the conclusion that, discrimination of elderly patients manifests itself in treating them with less respect and courtesy and providing a worse level of services in medical institutions. Discrimination of gediatric patients is caused by their lack of legal opportunity to express their opinion on consent or voluntary refusal of treatment, including vaccinations.

Factors influencing “no treatment” decisions in advanced stage cancers.

77 Background: Several studies have attempted to explore treatment refusal in patients with cancer (CA). We performed a study that focused on patients with advanced CAs, characterizing those in this group that refused therapy. Based on this study, we sought to determine if some variables significantly correlated with ‘no treatment’ decisions, compared with a group of similar patients who accepted therapy. Methods: Our inclusion criteria were patients aged 18-75 years, diagnosed with stage IV CAs (per the American Joint Committee on Cancer staging) between 1/1/2010 and 12/31/2015 and refused therapy (Cohort 1). A randomly selected group of patients with stage IV CAs who accepted treatment in the same timeframe were used for comparison (Cohort 2). We used Proc SurveySelect and a simple random sampling method to create Cohort 2. Geisinger Health System’s data was used. Results: We found 508 patients for cohort 1, and 100 patients for cohort 2. The significance level was < 0.05. Female sex was associated with treatment acceptance (51/100, 51.0%) compared with refusal (201/508, 39.6%); p = 0.03. There was no association between treatment decision and race, marital status, BMI, tobacco use, previous CA history, or family CA history. Government-funded insurance was associated with therapy refusal (337/508, 66.3%) than acceptance (35/100, 35.0%); p < 0.0001. Cohort 1 had an older population compared with cohort 2 (p < 0.0001). The mean age of cohort 1 was 63.1 years (standard deviation (σ) 8.1), and 59.2 (σ 9.9) in cohort 2. The most common malignancy site in both cohorts was the respiratory system but this was not related to treatment decisions. Patients with pancreatic CA tended to refuse treatment (p = 0.0009). Only 19.1% (97/508) in cohort 1 were referred to palliative medicine, with 18% (18/100) in cohort 2; p = 0.8. There was an insignificant trend for patients who accepted treatment to have more comorbidities per the Charleston Comorbidity Index (CCI) (p = 0.08). The mean CCI in cohort 1 was 6.5 (σ 3.7), and 8.0 (σ 3.9) in cohort 2. Treatment of psychiatric disorders after CA diagnosis was inversely associated with treatment refusal (p < 0.0001). Conclusions: Male sex, older age, government-funded health insurance, and pancreatic CAs were associated with treatment refusal in advanced CA patients. Those who refused treatment were not increasingly referred to palliative medicine. Treatment of psychiatric disorders after CA diagnosis was associated with treatment acceptance.[Table: see text]

Characterizing “no treatment” decisions in patients with advanced-stage cancers.

76 Background: Cancer (CA) is one of the leading causes of death worldwide. In 2020 CA was the second leading cause of mortality in the US. Novel treatments for various malignancies are discovered each passing year. Despite these advancements, some patients refuse to receive treatment. Our study focused on characterizing the group of patients with advanced malignancies who refused therapy. Methods: We performed a retrospective chart review of patients diagnosed with advanced malignancies, aged 18-75 years, between 01/01/ 2010 and 12/31/2015, who refused any therapy. We used Geisinger Health System’s data. Results: Our search provided 644 patients who met our inclusion criteria. The mean age of patients was 63.2 years (standard deviation (σ) 8.3). Female patients made up 40.4% (260/644), while 59.6% (384/644) were male. Most patients were Caucasian (96.9%, 624/644), 1.9% (12/644) were Black; 0.6% (4/644) were Asian, and 0.6% (4/644) were of unknown racial background. Marital status was evenly distributed with 50.0% (322/644) being married and 50.0% (322/644) being non-married. Most of the study population (52.3%, 337/644) had government-funded insurance at the time of CA diagnosis; 46.6% (300/644) had private insurance, and 1.1% (7/644) had no insurance. Stage 3 disease, according to American Joint Committee on Cancer staging was noted in 21.1% (136/644), while 78.9% (508/644) had stage 4 disease. The mean BMI was 28.2 (σ 8.3). Most patients were either overweight or obese (60.6%, 350/577; 67 patients did not have data on BMI available). A history of cigarette smoking was present in 73.0% (438/600). Adenocarcinomas (323/639, 50.5%) were the most prominent histological subtype. The most common site of malignancy was the respiratory system (220/644, 34.2%). Only 9.6% (62/644) of patients had a history of previous CA, while a family history of CA was present in 29.5% (190/644). Most patients (62.1%, 400/644) had a Charleston Comorbidity Index (CCI) > 5; the mean CCI was 6.4 (σ 3.7). In 17.1% (110/644) a palliative medicine referral was made. Substance use disorders were present in 23.8% (153/644); 14.4% (93/644) had a history of depression, and anxiety 10.1% (65/644). Conclusions: Male patients made up a larger proportion of the group of advanced-stage patients who declined therapy. The racial distribution in this group of patients appeared to reflect the local population. Most patients who refused therapy had stage 4 disease, and they appeared to have severe underlying comorbidities, with an average CCI >5. Despite treatment refusal, a surprisingly low percentage of patients were referred to palliative medicine.[Table: see text][Table: see text]

S2592 Ethical Decision Making in Endoscopic Treatment of a Jehovah’s Witness With Severe Upper Gastrointestinal Bleeding

Introduction: For endoscopic procedures, informed consent elevates patient autonomy and circumvents medical paternalism. However, when procedures carry significant risk of harm, clinicians may unintentionally overlook patient preferences when making decisions. We present the case of a Jehovah’s Witness with upper gastrointestinal bleeding who was offered endoscopic intervention despite a high risk of peri-procedural mortality, with emphasis placed on the shared-decision making process. Case Description/Methods: A 77-year-old female Jehovah’s Witness presented with hematemesis and hemoglobin of 4.9 grams/deciliter (g/dL). Endoscopy demonstrated a duodenal ulcer with a visible vessel. Due to the inability to transfuse blood and risk of provoking further bleeding, the decision was made to forego clipping or cauterization and treat only with hemostatic powder (Figure 1). On hospital day 3 she experienced new melena with decrease in hemoglobin to 2.8 g/dL. Although providers were hesitant to offer repeat endoscopy given her lack of hemodynamic reserve, a nuanced discussion with the patient elucidated her wish to undergo all possible interventions even at high risk of death (Figure 2). Endoscopy was performed despite low hemoglobin, which redemonstrated the duodenal ulcer with a large pulsatile visible vessel. The ulcer was injected with epinephrine and an over-the scope clip was successfully placed (Figure 3). She initially stabilized, however on hospital day 5 she developed recurrent melena with hemodynamic instability. After discussion with her family, she was transitioned to comfort care measures and expired that evening. Discussion: When faced with the possibility of patient harm, gastroenterologists may intentionally withhold interventions due to a desire to act in what is perceived to be in the best interest of the patient. Ethically, however, acting by omission devalues both patient autonomy and the right to self-determination in care. This effect may be amplified by pre-existing stigma such as with the Jehovah’s Witness wherein refusal of blood products may be erroneously interpreted to imply a broader refusal of other life-saving treatments. In this case, through juxtaposition of two procedures, we demonstrate that this phenomenon can be circumvented via thoughtful discussion of all potential options with patients, regardless of physician preference. We hope to highlight the importance of this ethical concept when approaching patients for informed consent.Figure 1.: Ulcer with visible vessel on initial endoscopy, treated only with hemostatic powder. (2) Four-box model approach to ethical decision making in this case. (3) Same ulcer on repeat endoscopy, now with a pulsatile visible vessel, treated with an over-the-scope clip.

Refus transfusionnel

After a twenty-year hiatus, the issue of transfusion refusal issued by Jehovah's Witnesses comes up in legal news with the decision of May 20, 2022 rendered by the Council of State. During these 20 years the rights of patients and the autonomy of the person have been considerably strengthened. Although the refusal of treatment is clearly stated in the law, the High Administrative Court nevertheless maintains its position.

Effect of Health Disparities on Refusal of Trimodality Therapy in Localized Esophageal Adenocarcinoma: A Propensity Score Matched Analysis of the National Cancer Database.

Factors associated with refusal of multimodality therapy in patients with localized esophageal adenocarcinoma (EA) remain unknown. We hypothesized that sociodemographic disparities affect decision to pursue optimal trimodally therapy for patients with EA. NCDB for esophageal cancer (2004-2017) was utilized. Included were patients diagnosed with cT3-T4 cN0 or cTany N1-3 EA of the mid-lower esophagus. Annual institutional esophagectomy volumes were categorized as low (<20/year) and high (≥20/year). Conditional logistic regression was used to identify predictors of refusal of offered treatment. Kaplan Meier method was used to compare survival. 13091 patients met selection criteria, mean age was 62.4 ± 9.6 years and 11581 (88.5%) were males. 633 (4.8%) patients refused at least one component of recommended treatment (chemotherapy, radiation, and esophagectomy), most commonly refusal of surgery (N = 554, 4.2%). On multivariable analysis, factors predictive of treatment refusal included older age, female gender, black race, no insurance, low income (below poverty), mid-esophageal tumors, and treatment at low-volume centers. Patients who were recommended treatment but refused had significantly worse survival than those who adhered to treatment (median 23.1 ± 1.1 vs. 32.1 ± 1.2months; P < .001). In this study, sociodemographic disparities and center volume were among factors predictive of therapy refusal in patients with localized esophageal adenocarcinoma. While understanding potential reasons for treatment refusal is critical, this data suggests that socioeconomic variables may drive patient decisions.

Monotherapy or complex treatment? Tactics of managing patients with Alzheimer’s disease and vascular dementia

Objective . To compare 2 treatment tactics: complex and monotherapy in outpatient practice of patients with vascular dementia and Alzheimer’s disease. Materials and methods . The study included patients diagnosed with vascular dementia and Alzheimer’s disease who received monotherapy with memantine and patients who received complex treatment (nootropics, vasodilators) of the disease, with MMSE scores from 3 to 23 points and a clock drawing test from 0 up to 9 points. Results . In the study group, the majority were women. Almost half of the patients had a disability group. Patients and their relatives had the best compliance where complex therapy of the disease was prescribed. Conclusion . There is a lack of alertness in the development of dementia among the population - this leads to its late detection and refusal of treatment at the initial stage. There were no statistically significant differences in complex or monotheraputic treatment. The use of tuning to one or a group of drugs in choosing a strategy for the treatment of dementia helps to maintain compliance between the patient’s doctor and his relatives.

A Standardized Approach to Treatment Over Objection in Patients Lacking Decision-Making Capacity Secondary to Neurologic Disease

Neurologic diseases, ranging from Alzheimer dementia to mass lesions in the frontal lobe, may impair decision making. When patients with neurologic disease lack decision-making capacity, but refuse treatment, should they be treated over their objection? To address this type of ethical dilemma in medical illness, Rubin and Prager developed a standardized 7-question approach: (1) How imminent is harm without intervention? (2) What is the likely severity of harm without intervention? (3) What are the risks of intervention? (4) What are the logistics of treating over objection? (5) What is the efficacy of the proposed intervention? (6) What is the likely emotional effect of a coerced intervention? (7) What is the patient's reason for refusal? We describe the application of the standardized Rubin/Prager approach as a checklist to the case of a 50-year-old woman with a large frontal lobe meningioma, who lacked capacity as a result of the meningioma, but refused surgery. This approach may be applied to similar ethical dilemmas of treatment over objection in patients lacking capacity as a result of neurologic disease.