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BACKGROUND: In ICUs, many patients are unable to participate in decision-making regarding life-sustaining treatments. This study evaluated the opinions of family members about family and physician participation in life-sustaining treatment decisions and examined factors that influence those decisions. METHODS: This was a prospective exploratory observational study that used convenience sampling. Inquiry interviews were conducted over a 3-year period, with 126 family members (out of 303 potential participants) of patients with acute-on-chronic respiratory failure, who had been admitted to the respiratory ICU and were dependent on invasive or noninvasive mechanical ventilation. Patients of < 18 years old, with a stay of < 3 days, and oncologic patients were excluded. RESULTS: Ninety-eight percent (123/126) of the participant family members had an opinion about their involvement in decision-making about life-sustaining treatments. Physician choice was preferred by 54/123 (44%), 55/123 (45%) wished to share the decision with the physician, and 14/123 (11%) wished the family to decide. All the patients were incompetent at the time of inquiry. Autonomy prior to admission to the respiratory ICU influenced the decision. CONCLU-SIONS: A majority of the families relied on physicians to help in the decision-making process about life-sustaining treatments in patients with acute-on-chronic respiratory diseases. From the family's point of view, the principle of autonomy can be exercised by delegating the decision-making process to the physician. To assume a uniform ethical conduct is to antagonize the definition of ethics.
In medical practice, the treatment and prognosis in the end of life has associated to ethical dilemmas, which are established in conformity with individual or collective beliefs and values. Dysthanasia from Greek, means to make death difficult, and it is currently an ethical problem with significant consequences. Considering that death itself has two moments, the process of death and the moment of death, dysthanasia is the undue prolongation of the process of death with the help of technological devices that allows the life sustaining procedures. Although it is through the technological advances that the moment of death can be delayed, it is the beliefs and values that are deep rooted in the sub conscience of the physicians that are responsible for the demeanor of end of life ethical dilemmas. Beliefs and values when encompassed in areas like phenomenology of knowledge, dialectic of technology, conflict of values and existentialism and metaphysics, can somehow explain this issue that is current, emerging and compelling.
Background Studies evaluating risk factors for poor outcomes with COVID-19 infection report gender variation. Impact of estrogen on immune regulation may be one factor contributing to better outcomes in women. This study evaluates the impact of menopausal status and other risk factors on health outcomes in women hospitalized with COVID-19 infection. Methods Data from 1863 non-pregnant women admitted to the Lifespan Hospital System in Rhode Island with COVID-19 infection during the first wave (March 1 - June 30, 2020) and second wave (July 1, 2020 - February 28, 2021) were analyzed. Subjects were categorized as pre-menopausal (age less than 45 years), perimenopausal (age 45 to 55 years), and post-menopausal (age greater than 55 years). Multivariate models to look for risk factors associated with severe illness (i.e. intensive care unit admissions, mechanical ventilation and death) controlled for menopause status, race/ethnicity, insurance type, wave of COVID-19, body mass index, diabetes (DM), hyperglycemia, hypertension (HTN), pulmonary disease, cardiovascular disease (CVD) and chronic kidney disease (CKD). Results In our cohort, pre-, peri- and pre, peri and post- menopausal status represented 12.8, 10.4 and 76.8% of the study population, respectively. The mean (± SD) age was 67.57 ±18.0 with 61.4% White/Caucasian, 20% Hispanic/Latino and 1.7% Black. 98.4% had commercial or government-sponsored health insurance. Hyperglycemia (Blood glucose > 180mg/dL on two occurrences) was noted in 26.8% of hospitalized women. Compared to pre- and peri- menopausal status, post- menopausal status was associated with a higher prevalence of Hyperglycemia (OR 1.59 [1.23-2.07]), DM 1.90 (1.50-2.42), HTN 5.06 (4.02-6.37), Pulmonary disease 1.35 (1.07-1.70) and CKD 3.7 (2.58-5.42). Post-menopausal status was also associated with higher mortality (OR 8.6 [2.7-27.6]), severe illness (OR 5.7 [1.3-23.9]), readmission (OR 1.5 [1.04-2.2]) and longer length of hospital stay (OR 1.6 [1.2-2.2]). Adjusted model identified, hyperglycemia (OR 14.8 [4.5-48.8]) and first wave (OR 2.7 [1.1-6.4]) to be independent risk factors for severe illness in post-menopausal women admitted to the hospital with COVID -19 infection. Conclusion While patients with comorbidities are known to be at greater risk for complications related to COVID-19 infection, menopausal status has rarely been considered a risk factor. Recognizing underlying risk factors in females, particularly menopausal females with COVID-19, can help clinicians attempt to identify patients at a higher risk of COVID-19 complications and drive early, more aggressive interventions to mitigate risk in this population. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.
Dysthanasia or any of its synonyms is a consequence of excessive technical science, without any reasonable chance of achieving a therapeutic benefit for the patient. Medical futility is a distressing ethical dilemma of intensive care medicine. Its recognition has led to a precept support in various institutions and organizations. Not withdrawing or withholding mechanical ventilation in certain circumstances can be considered as a paradigmatic model of medical futility. The understanding of this posture implies a philosophical approach and reflexion of medical practice.
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