Decisions near the end of life: professional views on life-sustaining treatments.

Solomon, Mildred Z.; OʼDonnell, Lydia; Jennings, Bruce; Guilfoy, Vivian; Wolf, Susan M.; Nolan, Kathleen; Jackson, Rebecca; Koch‐Weser, Dieter; Donnelley, Strachan

doi:10.2105/ajph.83.1.14

Cited by 532 publications

(246 citation statements)

References 60 publications

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“…25 The general reluctance to withdraw technological support is not unique to parents. For many providers, withdrawing treatment feels worse than never having initiated the treatment, 26 even though ethically the 2 choices are considered the same. It is imperative that nurses support and educate patients' parents so the Table 3 Analysis of data on supportive behaviors in end-of-life care 1.…”

Section: Discussion Obstacle Resultsmentioning

confidence: 99%

Pediatric Nurses’ Perceptions of Obstacles and Supportive Behaviors in End-of-Life Care

Beckstrand

Rawle

Callister

et al. 2010

American Journal of Critical Care

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Background Each year 55 000 children die in the United States, and most of these deaths occur in hospitals. The barriers and supportive behaviors in providing end-of-life care to children should be determined. Objective To determine pediatric intensive care unit nurses' perceptions of sizes, frequencies, and magnitudes of selected obstacles and helpful behaviors in providing end-of-life care to children. Method A national sample of 1047 pediatric intensive care unit nurses who were members of the American Association of Critical-Care Nurses were surveyed. A 76-item questionnaire adapted from 3 similar surveys with critical care, emergency, and oncology nurses was mailed to possible participants. Nurses who did not respond to the first mailing were sent a second mailing. Nurses were asked to rate the size and frequency of listed obstacles and supportive behaviors in caring for children at the end of life. Results A total of 474 usable questionnaires were received from 985 eligible respondents (return rate, 48%). The 2 items with the highest perceived obstacle magnitude scores for size and frequency means were language barriers and parental discomfort in withholding and/or withdrawing mechanical ventilation. The highest supportive behavior item was allowing time alone with the child when he or she has died. Conclusions Pediatric intensive care unit nurses play a vital role in caring for dying children and the children's families. Overcoming language and communication barriers with children's families and between interdisciplinary team members could greatly improve the end-of-life experience for dying children.

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Section: Discussion Obstacle Resultsmentioning

confidence: 99%

Pediatric Nurses’ Perceptions of Obstacles and Supportive Behaviors in End-of-Life Care

Beckstrand

Rawle

Callister

et al. 2010

American Journal of Critical Care

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show abstract

“…Treatment preferences of surveyed populations, physicians, nurses, patients and their families and proxies, medical students, and the general public are available. 6,7,[10][11][12][13][14][15][16][17][18] Although data exist on lifesustaining treatments for certain diagnoses and among deceased patients, these are less suited for investigating utilization in common advance directive scenarios. The present study compares preferences selected in a general advance directive survey and actual treatment practices for patients with conditions described in the advance directive scenarios.…”

Section: Discussionmentioning

confidence: 99%

Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

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OBJECTIVE:The movement for advance planning of endof-life care was motivated in part by the assumption that medical intervention for terminally ill patients varies from what these patients would prefer. We examined the validity of this assumption by comparing actual life-sustaining treatment practices for patients in critical illness scenarios and surveyed patients' advance care preferences. MEASUREMENTS AND MAIN RESULTS:We selected at random and reviewed 7,400 inpatient medical records from a single urban teaching hospital during the period just prior to the Patient Self-Determination Act. Records of 198 patients with conditions that matched advance directive scenarios were examined, and practices to withhold or withdraw seven life-sustaining treatments were documented. Practices were compared with surveyed preferences of 102 members of the general public and 495 outpatients who were followed by the same physicians as the 198 patients. Concordance of practices and preferences for the 19 surveyed outpatients who eventually fell into one of the scenarios was also evaluated. One hundred sixty-seven inpatient cases met review criteria for the scenario coma with a small chance of recovery . Hospital patients received medical interventions that were not consistently greater or less than the preferences of the surveyed outpatients or members of the general public. Resuscitation, the most frequently withheld treatment (94% of cases), was withheld more often than surveyed preferences to decline it (56% of outpatients, p Ͻ .001). Four treatments-mechanical breathing, artificial nutrition, major surgery, and hemodialysis-were utilized comparably to surveyed outpatients' preferences (range p ‫؍‬ .704-.055). Antibiotics and artificial hydration were withheld (9% and 6%, respectively) less often than surveyed outpatient's prior preferences to decline them (48% and 52%, respectively, p Ͻ .001 for each). Conversely, treatments given to the 19 surveyed patients who subsequently developed one of the illness scenarios were often incongruent with the patients' prior preferences. Again, in some cases more interventions were provided (26 of 63 declined treatments were given), and in some cases less (10 of 21 desired treatments were withheld). CONCLUSIONS:This study does not support the assumption that, collectively, patients' advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients' specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization. L ife-sustaining treatment decisions made for unconscious patients in the absence of advance directives are often assumed, first, to be discordant with individuals' prior preferences, 1 and second, to result in more treatments at the end of life than patients would have wanted....

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“…Nevertheless, it is easier to endorse this principle than to apply it. There is no question that withdrawing feels different to families and clinicians because the temporal link between the decision and death imposes a sense of responsibility that is difficult to allay with intellectual arguments about causality [3,4]. The concept of a ''no escalation of treatment'' order relies on this cognitive bias to overcome barriers to implementing a treatment plan that includes withdrawal of life-sustaining treatment.…”

mentioning

confidence: 99%

“No escalation of treatment” as a routine strategy for decision-making in the ICU: con

Thompson

2014

Intensive Care Med

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Decisions near the end of life: professional views on life-sustaining treatments.

Cited by 532 publications

References 60 publications

Pediatric Nurses’ Perceptions of Obstacles and Supportive Behaviors in End-of-Life Care

Pediatric Nurses’ Perceptions of Obstacles and Supportive Behaviors in End-of-Life Care

Comparing utilization of life-sustaining treatments with patient and public preferences

“No escalation of treatment” as a routine strategy for decision-making in the ICU: con

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