Withholding and Withdrawing Dialysis in the Intensive Care Unit

Patel, Samir S.; Holley, Jean Lake

doi:10.2215/cjn.04040907

Cited by 32 publications

(31 citation statements)

References 46 publications

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“…The participants were informed of a decline in the patient’s clinical condition and asked to make a critical decision about the patient’s care, whether to accept or reject kidney dialysis (details available in Appendix A in S1 File). This decision was chosen as the focus because dialysis is a common end of life choice and often requires different shared decision making approaches [37]. After completing the simulated ICU decision making task, the participants rated the adequacy of shared decision making using the CollaboRATE instrument [38, 39], which measures the perception of efforts made to assure shared decision making on a 10-point interval scale.…”

Section: Methodsmentioning

confidence: 99%

Preliminary Identification of Coping Profiles Relevant to Surrogate Decision Making in the ICU

et al. 2016

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ObjectiveThe Intensive Care Unit (ICU) is a stressful environment for families of critically ill patients and these individuals are at risk to develop persistent psychological morbidity. Our study objective was to identify individual differences in coping with stress and information presentation preferences of respondents exposed to a simulated ICU experience.MethodsParticipants were recruited from a university and two community populations. Participants completed questionnaires that measured demographic information and characteristics that may be relevant to an individual’s ICU experience. Quality of life was measured by the EQ-5D, personality dimensions were examined with the abbreviated Big Five inventory, coping with stress was assessed with Brief COPE. Shared decision making preferences were assessed by the Degner Control Preferences Scale (CPS) and information seeking style was assessed with the Miller Behavioral Style Scale (MBSS). Social support was examined using an abbreviated version of the Social Relationship Index. Participants also completed a vignette-based simulated ICU experience, in which they made a surrogate decision on behalf of a loved one in the ICU.ResultsThree hundred forty-three participants completed the study. Three distinct coping profiles were identified: adaptive copers, maladaptive copers, and disengaged copers. Profiles differed primarily on coping styles, personality, quality of their closest social relationship, and history of anxiety and depression. Responses to the simulated ICU decision making experience differed across profiles. Disengaged copers (15%) were more likely to elect to refuse dialysis on behalf of an adult sibling compared to adaptive copers (7%) or maladaptive copers (5%) (p = 0.03). Notably, the MBSS and the CPS did not differ by coping profile.ConclusionDistinct coping profiles are associated with differences in responses to a simulated ICU experience. Tailoring communication and support to specific coping profiles may represent an important pathway to improving ICU experience for patients and families.

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Section: Methodsmentioning

confidence: 99%

Preliminary Identification of Coping Profiles Relevant to Surrogate Decision Making in the ICU

et al. 2016

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“…In this case, if the patient's neurologic status did not recover from PVS, dialysis would be withdrawn. Upon starting a time-limited trial, the patient, family, and all health care providers must be clear on the goals of treatment, assessment of outcomes, and duration of trial (18).…”

Section: Withholding and Withdrawing Dialysis In Severely Neurologicamentioning

confidence: 99%

Ethics and Health Policy of Dialyzing a Patient in a Persistent Vegetative State

Skold¹,

Lesandrini

Gorbatkin

2014

Clinical Journal of the American Society of Nephrology

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SummaryEach year, out-of-hospital cardiac arrests occur in approximately 300,000 Americans. Of these patients, less than 10% survive. Survivors often live with neurologic impairments that neurologists classify as anoxic-ischemic encephalopathy (AIE). Neurologic impairments under AIE can vary widely, each with unique outcomes. According to the American Academy of Neurology Practice Parameter paper, the definition of poor outcome in AIE includes death, persistent vegetative state (PVS), or severe disability requiring full nursing care 6 months after event. In a recent survey, participants deemed an outcome of PVS as "worse than dead." Lay persons' assessments of quality of life for those in a PVS provide assistance for surrogate decision-makers who are confronted with the clinical decision-making for a loved one in a PVS, whereas clinical practice guidelines help health care providers to make decisions with patients and/or families. In 2000, the Renal Physicians Association and the American Society of Nephrology published a clinical practice guideline, "Shared Decision-Making in the Appropriate Initiation of and Withdrawal from Dialysis." In 2010, after advances in research, a second edition of the guideline was published. The updated guideline confirmed the recommendation to withhold or withdraw ongoing dialysis in "patients with irreversible, profound neurological impairments such that they lack signs of thought, sensation, purposeful behavior and awareness of self and environment," such as found in patients with PVS. Here, the authors discuss the applicability of this guideline to patients in a PVS. In addition, they build on the guideline's conception of shared decision-making and discuss how continued dialysis violates ethical and legal principles of care in patients in a PVS.Clin J Am Soc A left heart catheterization with percutaneous intervention to an occluded coronary artery is performed. Anuric renal failure occurs from acute tubular necrosis soon after and dialysis is initiated. He also has complications of postanoxic encephalopathic seizures, lower gastrointestinal bleeding, and laboratory values consistent with shock-liver. He remains intubated without sedation. At both 24 and 72 hours-off sedation-the patient lacks corneal reflexes and has only extensor motor responses to pain. The neurology consultants diagnose him with severe anoxic brain injury and state in the medical record that the patient has a "poor prognosis." Two weeks after arrest, the patient is transferred from the initial hospital to a second hospital at the family's request. At the new hospital, the pulmonary and critical care team consults the neurology, renal, and palliative care teams to discuss the patient's care plan. Dialysis and ventilator support are continued. The primary team schedules a family meeting for the next day with palliative care, patient advocacy, social services, and the patient's wife and two grown children. The meeting centers on discussing the patient as a person, and the medical providers learn that Mr. A. was...

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“…In addition, basic recommendations and guidelines for dementia diagnosis are only available in some LAC (e.g., Chile, Argentina, and Brazil; Fuentes et al, 2008; Allegri, 2011; Caramelli et al, 2011; Chavez et al, 2011). In contrast, most of the EU countries have National Plans or guidelines for dementia diagnosis, the care for patients, and the recommended treatment (Winblad et al, 2016).…”

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confidence: 99%