Withdrawal Option Research Articles

On The Business Strategies of Major Foreign-Owned Multinational Corporations in Turkey After July 15 Coup Attempt

This study aims to fulfill a clear need for researches in both Turkish and foreign literature, and examined the options related to the alternative strategies of multinational companies (MNCs) in case of a possible coup and similar attempts in the countries. From this point of view, business management strategies of major foreign-owned MNCs in Turkey during and after the July 15 failed coup attempt are at the core of this study. In this sense, it has been observed that the major foreign-owned MNCs have implemented resistance and adaptation strategies instead of withdrawal option that end up with an increase in sales volume and profitability in Turkey. It has been seen in this study that the coup and coup attempts, on the one hand, may create a risky business climate for the business world, but on the other hand, bring business opportunities for foreign-owned MNCs’ higher profitability.

A theory of intermediated investment with hyperbolic discounting investors

Financial intermediaries may reduce welfare losses caused by hyperbolic discounting investors, who may liquidate their investment prematurely when the liquidation cost is low. In a competitive equilibrium, sophisticated investors are offered contracts with perfect commitment, and first best results are achieved; naïve investors are attracted by contracts that offer seemingly attractive returns in the long run but introduce discontinuous penalties for early withdrawal. If the investor types are private information, naïve investors withdraw early and cross-subsidize sophisticated investors. When a secondary market for long-term contracts opens for trading, financial intermediaries are compelled to offer contracts that have more flexible withdrawal options with linear schemes, and the welfare of naïve investors is improved. Arbitrage-free linear contracts allow for a unique term structure for interest rates that includes a premium for naïveté. Solvency requirements may limit competition for contracts and result in positive profits; banks that have capital are able to compete more aggressively, which improves investor welfare.

Ondansetron Does Not Reduce Withdrawal in Patients With Physical Dependence on Chronic Opioid Therapy.

Individuals taking opioids for an extended period of time may become physically dependent, and will therefore experience opioid withdrawal should they stop taking the medication. Previous work in animal and human models has shown that the serotonin (5-HT3) receptor may be implicated in opioid withdrawal. In this study, we investigated if ondansetron, a 5-HT3-receptor antagonist, could reduce the symptoms of opioid withdrawal after chronic opioid exposure in humans. In this double-blinded, randomized, crossover study, 33 chronic back pain patients (N = 33) were titrated onto sustained-release oral morphine for 30 days. After titration, participants attended 2 study sessions, 1 week apart, in which opioid withdrawal was induced with intravenous naloxone, with or without 8 mg intravenous ondansetron pretreatment. Opioid withdrawal symptoms were assessed by a blinded research assistant (objective opioid withdrawal score [OOWS]) and by the research participant (subjective opioid withdrawal score [SOWS]). Clinically significant signs of withdrawal were observed during both the ondansetron (ΔOOWS = 3.58 ± 2.22, P < 0.0001; ΔSOWS = 12.48 ± 11.18, P < 0.0001) and placebo sessions (ΔOOWS = 3.55 ± 2.39, P < 0.0001; ΔSOWS = 12.21 ± 10.72, P < 0.0001), but no significant differences were seen between the treatment sessions in either the OOWS or SOWS scores. We hypothesized that ondansetron would reduce opioid withdrawal symptoms in human subjects, but found no difference in withdrawal severity between ondansetron and placebo sessions. These findings suggest that more investigation may be necessary to determine if 5-HT3-receptor antagonists are suitable treatment options for opioid withdrawal.

Dispute Resolution or Escalation? The Strategic Gaming of Feedback Withdrawal Options in Online Markets

Many online markets encourage traders to make good after an unsatisfactory transaction by offering the opportunity to withdraw negative reputational feedback in a dispute resolution phase. Motivated by field evidence and guided by theoretical considerations, we use laboratory markets with two-sided moral hazard to show that this option, contrary to the intended purpose, produces an escalation of dispute. The mutual feedback withdrawal option creates an incentive to leave negative feedback, independent of the opponent’s behavior, to improve one’s bargaining position in the dispute resolution phase. This leads to distorted reputation information and less trust and trustworthiness in the trading phase. Buyers who refuse to give feedback strategically, even when it comes at a personal cost, mitigate the detrimental impact. It is also mitigated in markets with one-sided moral hazard and a unilateral feedback withdrawal option. The supplementary appendix is available at https://doi.org/10.1287/mnsc.2017.2802 . This paper was accepted by Uri Gneezy, behavioral economics.

Khiyar Al-Majlis (Option of Withdrawal before Parting) in Sale Contract, Contemporary Applications

This paper aims to study and analyze the notion of khiyar al-majlis from the viewpoints of prominent Schools of Islamic law. Khiyar al-majlis refers to an option for both contracting parties either to revoke or to continue with the contract before departing from the contracting session. This option is made lawful in Islamic law to ensure the absolute consent of the parties to the agreement and to give them adequate time to think carefully about the conclusion of the contract. However, the Hanafi and Maliki Schools do not advocate khiyar al-majlis, they advocate khiyar al-qabul (option of acceptance) instead. This study prefers the validity of khiyar al-majlis and discusses its applications. This is a qualitative study and classical references of the prominent Schools of Islamic law have been employed as the primary sources of the study. The study posits that in the case of a face to face contract khiyar al-majlis might be practical. But, in the case of online or distant contracts it is not practical because it would be difficult to determine whether the parties are continuing the session or not. Thus, in online contracts khiyar al-qabul is more practical and hence after making an offer and acceptance the contract is concluded, though the contracting session is prolonged.

Treatment of Severe Alcohol Withdrawal: A Focus on Adjunctive Agents.

Objective:To review adjunctive treatment options for severe alcohol withdrawal. Data Sources: The search strategy included a search of Ovid MEDLINE using keywords alcohol withdrawal, severe alcohol withdrawal, AWS, delirium tremens, delirium, dexmedetomidine, propofol, anticonvulsants, clonidine, and phenobarbital and included articles dated from January 1990 to March 2017. Study Selection and Data Extraction: All English-language clinical trials and case reports assessing the efficacy of adjunctive agents in severe alcohol withdrawal were evaluated. Data Synthesis: Although first-line pharmacotherapy for alcohol withdrawal continues to be benzodiazepines, literature does not clearly define adjunctive treatment options for severe alcohol withdrawal. During severe alcohol withdrawal patients may become unable to tolerate or may become unresponsive to high-dose benzodiazepines. Large doses of benzodiazepines may also result in oversedation, respiratory insufficiency, and worsening delirium. Conclusions: Phenobarbital and dexmedetomidine are both viable adjunctive treatment options for severe alcohol withdrawal. Current evidence has shown these agents decrease the dose requirements of benzodiazepines with limited incidence of adverse reactions. Propofol may also be a viable option in mechanically ventilated patients, but its lack of clear safety and efficacy advantages over current treatment options may limit its use in practice. Clonidine, oral anticonvulsants, and ketamine require further controlled clinical trials to clearly define their role in the treatment of severe alcohol withdrawal.

Assessment and forecasting of the subsurface drain of the Aral Sea, Central Asia

Mathematical simulation techniques have been used to study the subsurface water-lake system. The volume of the subsurface drain from the Syrdarya artesian basin (Kazakhstan) into the Aral Sea depression was computed subject to the geoinformation-mathematical model of its hydrogeological conditions. Since the surface and subsurface (underground) water are interconnected, their movement has been measured during the undisturbed period (1960), the epignostic (1961–2014) period, and for forecasting problems for 2044 under two water withdrawal options. The first forecast option assumes the same withdrawal volume of subsurface water level which existed at the end of 2014. The second forecast option envisages the model assignment (from the start of 2015) of the water withdrawal in the production volumes of the subsurface water approved by the National Reserves Committee of the Republic of Kazakhstan. The simulation results showed that the technogenic factors in the explored area have a significant impact on the movement of the subsurface and surface water. Reduction of the Syrdarya and Amudarya rivers flows, production of subsurface water with multiple water-intake and unowned self-flowing wellbores promoted the desiccation of the Aral Sea. The proposed mathematical simulation technique used to assess the subsurface drain proved its efficiency and can be used for surveying the similar subsurface water-lake systems.

401(K) Plans: DOL Could Take Steps to Improve Retirement Income Options for Plan Participants

What GAO Found: Workers relying in large part on their 401(k) plan in retirement may not always have a feasible way to make their savings last throughout retirement. Responses to GAO’s non-generalizable questionnaire from 11 401(k) plan record keepers — entities that manage participant account data and transactions for plans — showed that most plans covered by the questionnaire had not adopted products and services that could help participants turn their savings into a retirement income stream (referred to as lifetime income options in this report). Responses to the questionnaire represented more than 40 percent of all 401(k) assets and about a quarter of plans at the end of 2014. GAO found that of the plans covered by the questionnaire, about two-thirds did not offer a withdrawal option — payments from accounts, sometimes designed to last a lifetime — and about three-quarters did not offer an annuity — arrangements that can guarantee set payments for life. Concerns about legal risks and record keeper constraints may deter many plan sponsors — typically employers that provide 401(k) plans and establish investment and distribution options — from offering lifetime income options. The Department of Labor (DOL) issues regulations and guidance for plan sponsors and is responsible for educating and assisting them to help ensure the retirement security of workers. For example, DOL has prescribed steps plan sponsors can take to satisfy their fiduciary duties (i.e. act prudently and in the best interest of participants) when selecting an annuity provider for a 401(k) plan. However, according to industry stakeholders GAO interviewed, those steps are not often used because they include assessing “sufficient” information to “appropriately” conclude that the annuity provider will be financially able to pay future claims without definitions for those terms. Without clearer criteria to select an annuity provider, fear of liability may deter plan sponsors from offering annuities. Further, GAO found that a mix of lifetime income options to choose from is not usually available. DOL provides an incentive in the form of limited liability relief to plan sponsors who, among other things, provide participants at least three diversified investment options. However, no such incentive exists for plan sponsors offering a mix of lifetime income options. Without some degree of liability relief, plan sponsors may be reluctant to offer a diverse mix of lifetime income options to their participants. Lastly, stakeholders told GAO that record keepers may make only their own annuities available to the plans they service. DOL provides guidance on selecting service providers, but it does not encourage plan sponsors to seek choices from their service providers, which may prevent plans from having appropriate annuity options available to offer participants. Required minimum distributions (RMD) can offer a default for those who do not choose a lifetime income option by setting a minimum amount of taxable 401(k) income for those age 70 ½ or older, based on life expectancy. Some plan sponsors know how to administer RMDs, and some already choose to provide RMD payments calculated to last a lifetime. However, DOL’s guidance on default lifetime income is focused on a particular annuity type used only by a few plans. By issuing guidance encouraging plans to consider letting RMDs be the default distribution process for retiring participants, DOL may help create lifetime income for participants who do not choose an option. Why GAO Did This Study: As 401(k) plan participants reach retirement they face the challenge of making their savings last for an unknown lifespan, and many 401(k) plan sponsors do not offer options to help participants with this complex task. GAO was asked to review any related challenges and potential changes to help plan sponsors and participants. This report examines, among other things, what is known about the adoption of lifetime income options in 401(k) plans, barriers that deter plan sponsors from offering such options, and the defaults that exist for participants who do not choose a lifetime income option. GAO administered a non-generalizable questionnaire to record keepers, conducted a non-generalizable survey of 54 plan sponsors, and interviewed a range of stakeholders. What GAO Recommends: GAO makes seven recommendations to DOL, including that it clarify the criteria to be used by plan sponsors to select an annuity provider, consider providing limited liability relief for offering an appropriate mix of lifetime income options, issue guidance to encourage plan sponsors to select a record keeper that offers annuities from other providers, and consider providing RMD-based default lifetime income to retirees. DOL generally agreed, and described actions it would take to address the intent of the recommendations.

A Review of Methamphetamine Dependence and Withdrawal Treatment: A Focus on Anxiety Outcomes

Rates of anxiety disorders among individuals who use methamphetamine are estimated to be as high as 30.2%. The presence of an anxiety disorder in methamphetamine users is associated with higher rates of relapse, non-adherence to treatment and poorer outcomes relative to methamphetamine users without an anxiety disorder. A review investigating current treatment options for methamphetamine dependence or withdrawal from methamphetamine was conducted using PubMed, CINAHL and PsycINFO. The focus of the review was trials that utilized an intervention and collected anxiety as an outcome measure. Seven studies were included in the review, and five of these studies examined a pharmacotherapy option, one studied a psychosocial intervention and one study investigated exercise as an intervention. Some of the pharmacotherapy studies and the study of exercise were associated with improvements in mood and/or a reduction in methamphetamine use. Concerns of sample size and measurement of anxiety were raised. Future well-designed research with large sample sizes is warranted to examine how to manage anxiety among methamphetamine users.

Assessing the Demand for Micropensions Among India's Poor

Using new data from a field experiment in India, we test hypotheses about micropension design in a poor population. We elicit demand for the basic micropension in addition to variants with different minimum withdrawal ages, government match rates, and options for lump sum withdrawal. A majority (80%) of respondents report interest in the micropension, and the amount they are willing to contribute would be enough to cover about 40% of expected old-age consumption. We find that prospective policyholders value the inability to access the assets until a particular age. We also find that they respond positively to the government match rate.

Assessing the Demand for Micropensions among India's Poor.

Using new data from a field experiment in India, we test hypotheses about micropension design in a poor population. We elicit demand for the basic micropension in addition to variants with different minimum withdrawal ages, government match rates, and options for lump sum withdrawal. A majority (80%) of respondents report interest in the micropension, and the amount they are willing to contribute would be enough to cover about 40% of expected old-age consumption. We find that prospective policyholders value the inability to access the assets until a particular age. We also find that they respond positively to the government match rate.

147 Successful Strategies Supporting Recruitment, Intervention Delivery and Retention Targets in a Randomized Controlled Trial of a Complex Intervention

Background: Complex interventions are widely used in modern health care practice and are defined as those having potentially interacting components. Evaluation can be challenging due to difficulties in logistics, standardisation and delivery. In addition, there can be difficulty recruiting to time and to target (particularly in multicentre studies) and minimising attrition and data loss. We report how the RAFT study [a seven-centre randomized controlled trial (RCT) comparing a complex group cognitive-behavioural (CB) intervention with standard care for the reduction of fatigue impact in patients with RA) is implementing successful strategies to meet recruitment, intervention delivery and retention targets. The study requires patients to make a substantial commitment over a 2 year period and for the intervention to be delivered by routine clinical staff trained for this purpose. Methods: The following strategies were agreed upon during the planning and design phase: Maximising recruitment: Funded research nurse time at all seven sites; mailshot option for approach; recruitment posters for clinics; flexible and pragmatic approach to session attendance; telephone, email and postal contact; newsletter and regular knowledge exchange between the central trial management team and sites; weekly recruitment updates and reviews. Ensuring intervention delivery: Flexible course dates and times set by each site, regular communication with the central management team to discuss foreseeable issues and preventative actions, provision of real-time clinical supervision and full-time telephone/email support. Minimising attrition and data loss: Primary outcome collection by telephone, ensuring regular personal contact; secondary data collection by postal questionnaire, reducing the number of hospital visits; telephone reminders; partial withdrawal options; personalized letters and thank you cards. Patient involvement: We had a number of acceptability and feasibility consultations with our two patient partners. Both partners had prior experience attending the intervention, were co-applicants on the grant proposal and continue to provide a patient perspective as members of the trial management group. Results: Our target was to recruit 300 participants with no recent medication changes and a fatigue level ≥6 (on a 1–10 scale where 10 is totally exhausted). During the 2 year recruitment phase, 333 participants were randomized (11% over target). All 28 programmes successfully delivered, with 7/7 sites and 14/15 tutors remaining fully engaged with the study. Retention at 6 months is currently 92.5% (sample size allows for 20% attrition). Data returned by those reaching the 6 month time point are 100% for the primary outcome and 97% for secondary outcomes. Conclusion: Advanced planning and consistent application of these strategies has ensured success so far. A flexible and pragmatic approach, regular communication between local and central teams, personal contact with participants and extensive patient partner input are key components.

Travelers’ conversion behavior at foreign cash withdrawals: An experimental study

The introduction of dynamic currency conversion (DCC, also known as currency choice) at ATMs provides an ideal testing environment for traveler behavior when confronted with a currency choice. DCC provides travelers with the choice to conduct a transaction in local currency or in their home currency. This research note is based on a DCC experiment in which travelers were offered the choice between two withdrawal options. For each year of age, respondents were 0.4% more likely to opt for DCC. Gender also mattered, as females were 13.5% more likely to choose DCC. The level of the markup on the DCC transaction is not associated with DCC usage. Furthermore, the choice at the ATM transaction is unrelated to a traveler’s internal reference price, even though this price can be directly compared to a given exchange rate on the ATM screen. The empirical evidence thus rejects rational behavior by travelers.

Fine needle aspiration biopsy proves increased T-lymphocyte proliferation in tumor and decreased metastatic infiltration after treatment with doxorubicin bound to PHPMA copolymer carrier

Introduction: Fine needle aspiration biopsy (FNAB) is an easy method with an option of repetitive withdrawal of cell material.Methods: First, mice were inoculated with mouse T-lymphoma, after 10 d the samples from tumor, lymph nodes and spleen gained by FNAB and excision were analyzed by flow cytometry. Tumor progression was compared to the control group simultaneously. Then, 10 d after tumor cell inoculation free doxorubicin (DOX) or different PHPMA DOX conjugates were injected. Cell material was analyzed to detect subpopulations of lymphocyte infiltrate, and levels of cytokines in correlation with progression or regression of the disease.Results: FNAB has no influence on the tumor’s growth or survival of experimental animals. After treatment with PHPMA conjugates there was a significant increase of T-lymphocyte subpopulations in tumor microenvironment compared to controls or free DOX, but only in mice with confirmed macroscopic regression of tumor within two weeks. Mice treated with conjugates showed significantly lower cancer infiltration of lymph nodes and spleen.Conclusion: FNAB provides a great benefit to in vivo monitoring of cell changes directly in the tumor after treatment. The number of infiltrating T-lymphocytes increases in correlation with consecutive tumor eradication after treatment with PHPMA. This proves that not only direct cytotoxic but also imunostimulating effect are necessary for successful treatment.

Prevention of de novo hepatitis B with adefovir plus vaccination in recipients of liver transplants from core antibody-positive donors

We previously reported the use of adefovir (ADV) in preventing de novo hepatitis B virus (HBV) infections in recipients of hepatitis B core antibody–positive (HBcAb+) liver transplantation (LT).1 We further hypothesized that prophylaxis could be discontinued in recipients who develop an acquired immunity from post-LT vaccination. Reviewing our vaccination data with longer term follow-up, we found new cases of de novo HBV despite ADV. We now report our vaccination results and another 1.1 years of follow-up. Our methodology is described in our initial report.1 We enrolled 16 recipients (mean age = 54 ± 11 years, median follow-up = 2.9 years) of HBcAb+ livers who received ADV monoprophylaxis after LT. A double-dose recombinant hepatitis B surface antigen (HBsAg) vaccine (Engerix-B, GlaxoSmithKline) was administered monthly for 3 months 12 to 18 months after LT. Recipients with hepatitis B surface antibody (HBsAb) levels > 500 mIU/mL after 6 months were given the option of ADV withdrawal. Seventy-five percent (12/16) were vaccinated. Overall, 38% (6/16) developed HBsAb+: 3 patients had titers > 500 mIU/mL and were weaned off ADV (over periods of 4, 4, and 22 months), whereas another 3 patients had titers < 500 mIU/mL (range = 5-367 mIU/mL). None of the patients who developed HBsAb developed de novo HBV, regardless of their antibody titers. None of the recipients who were HBsAb− before LT developed durable HBsAb titers. Surprisingly, 4 of the 16 recipients (25%), all of whom were HBsAb−/HBcAb− before LT, became HBsAg+ 1.0 to 3.5 years after LT, whereas this happened to only 1 recipient in our initial report.1 For 2 recipients, serum HBV DNA remained undetectable (<40 IU/mL); the other 2 recipients had elevated HBV DNA levels (86 and 1.7 × 108 IU/mL). None had evidence of clinically active hepatitis. Recipients were successfully switched to entecavir or tenofovir with or without emtricitabine with complete suppression of HBV DNA. Numerically, the patients who developed de novo HBV were more likely to have their ADV dose adjusted or substituted for renal insufficiency [75% (3/4) versus 42% (5/12), P = 0.56]. It is unclear why ADV declined in efficacy over time. Dose adjustments for renal insufficiency (from daily administration to administration every 2-3 days), which occurred for 62% (10/16), may have led to inadequate drug levels and breakthrough. Only 1 recipient was nonadherent. However, because more potent agents are available, on the basis of our latest follow-up data, we would not recommend ADV for preventing de novo HBV. Additionally, post-LT HBV vaccination does not reliably induce acquired immunity; it remains to be seen whether the recipients of prophylaxis will continue to have durable HBsAb titers. Matthew S. Chang, M.D.1 Sonja K. Olsen, M.D.2 Elsa M. Pichardo, M.D.2 Scott Heese, M.P.H.2 Jessica B. Stiles, B.S.N.2 James V. Guarrera, M.D.2 Jean C. Emond, M.D.2 Robert S. Brown Jr, M.D., M.P.H.2 1Division of Gastroenterology, Hepatology, and Endoscopy Brigham and Women's Hospital Boston, MA 2Center for Liver Disease and Transplantation NewYork-Presbyterian Hospital/Columbia University and Weill Cornell Medical College New York, NY

Non-Callable Time Deposits in Light of Basel III and Polish Banking Law

Basel Committee proposal of liquidity measures (LCR&NSFR) contain quantification of risk of various deposit classes. According to Basel 3, there is no significant difference in stability between time deposits with early withdrawal option and demand deposits. Only deposits where there is no early redemption option (or, for retail, if withdrawal penalty is higher than interest) receive better regulatory weights. Such deposits, most stable in terms of systemic risk, cannot be introduced in Poland, because civil code and banking law regulations, their interpretations and related court rulings make them practically impossible. It is proposed that the regulations be adequately amended and the most stable class of deposits be supported by regulatory tools similar or identical to Basel 3 constructs.The Polish version of this paper can be found at: http://ssrn.com/abstract=2274108

Characterization of residence time variability in a managed monomictic reservoir

The average length of time land‐borne compounds remain within an aquatic system is one of the key parameters controlling its biochemical processes. This study explores the magnitude and sources of daily, seasonal, and interannual variability of river water residence time in the Sau Reservoir, a prototypical example of a Mediterranean water supply. Daily estimates of residence time from 1998 to 2005 were obtained from a series of tracer experiments simulated with a one‐dimensional physical model, based on actual observations and synthetic scenarios. Results highlight that multiple in situ factors, both natural and managed by humans, affect the residence time in reservoirs. Simulated residence times varied on average ∼30% on a daily basis, as a result of natural meteorological (17%) and river inflow temperature (11%) variability. The management of withdrawal depths largely controlled the seasonal variations: The practice of withdrawing water from the shallowest outlet, which was close to the intrusion level of summer inflows, promoted shorter residence times in summers than winters. Interannual variability was primarily associated with the natural variability of inflow volume (25%), and secondarily with surface meteorology (8%). Excessive withdrawals prior to and during long dry periods, however, drastically reduced the reservoir storage capacity and withdrawal options, leading to shorter residence times in dry years. The flushing time, calculated as the ratio of storage volume and flow rates, captured the trends in annual mean residence times reasonably well but not daily and seasonal residence times.

A Dynamic GAP Framework by Relaxing the Assumptions Behind the GAP and Duration GAP

This paper lists the assumptions behind the GAP and Duration GAP. These are related to parallel and synchronous changes in interest rates, changes in volume and composition of portfolio, early withdrawal and prepayment options, and convexity. The impact of the relaxation of these assumptions on the net interest income and economic value at risk are illustrated using examples. The movement to a dynamic GAP framework is facilitated by the discussion of assumption and impact of their relaxation.

Engagement, Withdrawal, and Social Reform: Confucian and Contemporary Perspectives

Concern with social and moral reform plays an important thematic role in the Analects , and the text discusses a number of possible responses to a morally failing society. This essay offers an account of engagement, withdrawal, and social reform in the Analects , then places the issue of social reform in a contemporary context through a comparative and critical discussion of the Analects and the book Habits of the Heart , by Robert Bellah et al. It is argued that Confucius rejects the option of complete withdrawal from society, even where such withdrawal aims to preserve personal moral integrity. However, Confucius also cautions against deep involvement with corrupt regimes and suggests that reformers must withdraw from particular institutions when moral engagement is impossible within them. The recommendations found in Habits of the Heart strikingly parallel many of those in the Analects , particularly in emphasizing individual engagement and reinvigoration of tradition as sources of social renewal. Although traditions require critical examination in contemporary contexts, the idea—found in both texts—that engagement in social reform can benefit the reformer as well as society more broadly remains important and relevant today.

Compassionate extubation in a hospice: strengthening the links between hospice and paediatric intensive care

Children with complex chronic life-limiting conditions, although well known to their carers locally, are often unknown to the paediatric intensive care (PICU) team on admission. End-of-life discussions involving the withdrawal of mechanical ventilation can be especially difficult if the patient9s family are in unfamiliar surroundings. The option of compassionate extubation at home occasionally appears as a topic in the literature. Aim To present two case reports of compassionate hospice extubation by a PICU team in two terminally ill paediatric patients. Method Two case reports. The authors9 PICU recently transferred two paediatric patients with life-limiting conditions to hospices for compassionate extubation. This was facilitated over a relatively short period of time and was much appreciated by the patients9 families and care-givers. Literature relevant to home/hospice extubation is reviewed. With some PICUs serving a large area geographically, patients and their families can sometimes be over 100 km away from home. Compassionate extubation at home involves a huge amount of preparation and time. Comprehensive discussions with the family, nursing staff, physicians and the local multidisciplinary care-giving team are required. In case 1, the authors describe a 10-year-old child with a premature ageing syndrome, Cockayne9s syndrome, who was ventilated for acute respiratory failure associated with pneumonia. Case 2 describes a child with partial trisomy 18 with influenza A subtype H1N1 pneumonia. Both families welcomed the option of withdrawal of mechanical ventilation closer to home, but not actually in their family home. Conclusions To ensure quality end-of-life care, those caring for critically ill children must be adequately prepared in the principles and practice of palliative care. Compassionate extubation outside of the hospital setting should be an additional option for patients and parents. Further training, creation and implementation of guidelines should ensure we have a workforce capable of meeting the needs of our communities.