Evolution of medical ethics in resuscitation and end of life

Mentzelopoulos, Spyros D.; Haywood, Kirstie L.; Cariou, Alain; Mantzanas, Michail; Bossaert, Leo

doi:10.1016/j.tacc.2016.08.001

Cited by 17 publications

(23 citation statements)

References 80 publications

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“…37 Whether pertaining to patients with SUDs or patients from diverse cultural backgrounds, the ethical principle of justice indicates that all patients should have fairly allocated access to healthcare. 20 This includes the patient's right to be identified for SICs and the right to a culturally appropriate engagement in SICs.…”

Section: Discussionmentioning

confidence: 99%

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The Surprise Question and Serious Illness Conversations: A pilot study

Le¹,

Lee

Desai

et al. 2021

Nurs Ethics

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Background: Serious Illness Conversations aim to discuss patient goals. However, on acute medicine units, seriously ill patients may undergo distressing interventions until death. Objectives: To investigate the feasibility of using the Surprise Question, “Would you be surprised if this patient died within the next year?” to identify patients who would benefit from early Serious Illness Conversations and study any changes in the interdisciplinary team’s beliefs, confidence, and engagement as a result of asking the Surprise Question. Design: A prospective cohort pilot study with two Plan-Do-Study-Act cycles. Participants/context: Fifty-eight healthcare professionals working on Acute Medicine Units participated in pre- and post-intervention questionnaires. The intervention involved asking participants the Surprise Question for each patient. Patient charts were reviewed for Serious Illness Conversation documentation. Ethical considerations: Ethical approval was granted by the institutions involved. Findings: Equivocal overall changes in the beliefs, confidence, and engagement of healthcare professionals were observed. Six out of 23 patients were indicated as needing a Serious Illness Conversation; chart review provided some evidence that these patients had more Serious Illness Conversation documentation compared with the 17 patients not flagged for a Serious Illness Conversation. Issues were identified in equating the Surprise Question to a Serious Illness Conversation. Discussion: Appropriate support for seriously ill patients is both a nursing professional and ethical duty. Flagging patients for conversations may act as a filtering process, allowing healthcare professionals to focus on conversations with patients who need them most. There are ethical and practical issues as to what constitutes a “serious illness” and if answering “no” to the Surprise Question always equates to a conversation. Conclusion: The barriers of time constraints and lack of training call for institutional change in order to prioritise the moral obligation of Serious Illness Conversations.

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Section: Discussionmentioning

confidence: 99%

“…19 The provision of emotional and spiritual support is important in these circumstances. 12,19 The ethical principle of beneficence depends greatly on the patient's perspective on QOL and outcomes, 20 so SICs would help nurses determine what would most benefit the patient from the patient's own perspective.…”

Section: Introductionmentioning

confidence: 99%

The Surprise Question and Serious Illness Conversations: A pilot study

Le¹,

Lee

Desai

et al. 2021

Nurs Ethics

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“…[28][29][30] A similar problem is encountered when assessing patient capacity to request withdrawal of lifesustaining treatment when the circumstances and potential sequelae are open to interpretation , for example when a patient requests a 'Do not resuscitate' order when capacity is questioned or when further treatment is considered futile. 31,32 In the current literature on VAD there are warnings about the 'slippery slope' which predicts the abuse of vulnerable groups in society such as the disabled, 33 however other research does not support this finding 34,35 To protect patients, avenues should be provided for confidential discussions with appropriately trained staff to ensure patients are making an autonomous choice. Some participants were concerned about the capacity of a patient to make an informed decision in the late stage of illness, especially when 'unbearable suffering' was present.…”

Section: Discussionmentioning

confidence: 99%

Introducing Voluntary Assisted Dying: Staff Perspectives in an Acute Hospital

Digby

McDougall

Gold

et al. 2020

Int J Health Policy Manag

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Background: Voluntary assisted dying (VAD) was legalised in Victoria, Australia in June 2019. Physicians can now assist patients to end their lives by providing drugs for self-administration at their voluntary and competent request (or for physician administration in limited circumstances). This study investigates the opinions of clinicians on the implementation of the legislation in one Victorian hospital. Methods: This exploratory survey study was conducted at a 600-bed acute hospital in Melbourne, Australia in Jan 2019. 382 clinicians completed one or more qualitative questions. Participants commented on VAD, potential workplace challenges and staff support required. Free-text responses were analysed using inductive content analysis. Results: Six themes: (1) Polarised views; (2) Fear of conflict; (3) Emotional burden; (4) Vulnerable patients; (5) Organisational challenges; (6) Decision-making. There were diverse views including objections to VAD for religious or ethical reasons, and whole-hearted support based on a compassionate response to suffering and the right of patients to self-determination. Participants feared conflict between colleagues, families and patients, and aggression towards staff. Clinicians called for educational and psychological support. There was concern that vulnerable patients may be coerced to opt for VAD to lessen the burden on families or the health system. Clinicians feared workloads would increase with the introduction of VAD. Patient decision-making capacity in this context must be firmly established before proceeding, and thorough assessments for depression, and optimal symptom management must be implemented before VAD is approved. A dedicated VAD team was suggested to support staff and manage VAD patients. Conclusion: Participants expressed polarised opinions about VAD and showed considerable anxiety about its introduction. Additional education and support are required to ensure that clinicians understand details of the legislation and their professional and personal options. Tolerance and respect for alternative viewpoints must be advocated within the organisation and more broadly.

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“…The national guidelines require that residents in 24‐hour NH care have treatment plans easily available, which must include a medical emergency care plan for acute situations and end‐of‐life care—DNAR alone is not a sufficient treatment plan 16,23‐25 . Communication between the patient and/or proxies and attending physician about treatment goals may ease the conversations on LCOs, the harms and benefits of different treatments and increase both the patient's and proxies' understanding about the inevitably approaching end of life 4,26 . The situation is always suboptimal if the HEMS physician on‐scene has to make LCOs for patients who—and whose proxies—have not previously understood the severity of the overall situation 27 …”

Section: Discussionmentioning

confidence: 99%

“…Sometimes, the acute deterioration of the patient results from the end stage of a terminal illness rather than an unexpected event 3 . In these situations, the HEMS physician may decide to limit life‐sustaining therapies (LST) and proceed with palliative care procedures, respecting the ethical principles of medicine: patient autonomy, beneficence, non‐maleficence, justice, dignity and honesty 4 …”

Section: Introductionmentioning

confidence: 99%

Limiting treatment in pre‐hospital care: A prospective, observational multicentre study

Kangasniemi

Setälä

Olkinuora³

et al. 2020

Acta Anaesthesiol Scand

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Background: Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in pre-hospital care. Methods: A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a 6-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included. Results: There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n = 5895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n = 133, 74%). The most frequent new LCO was 'termination of cardiopulmonary resuscitation' only (n = 61, 36%), while 'no intensive care' combined with some other LCO was almost as common (n = 54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n = 153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients' background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients' medical records were available in 67 (20%) of the missions. Conclusion: Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians' work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.

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Evolution of medical ethics in resuscitation and end of life

Cited by 17 publications

References 80 publications

The Surprise Question and Serious Illness Conversations: A pilot study

The Surprise Question and Serious Illness Conversations: A pilot study

Introducing Voluntary Assisted Dying: Staff Perspectives in an Acute Hospital

Limiting treatment in pre‐hospital care: A prospective, observational multicentre study

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