Withholding versus withdrawing treatment: artificial nutrition and hydration as a model

Somers, Emma; Grey, Carl; Satkoske, Valerie

doi:10.1097/spc.0000000000000225

Cited by 9 publications

(4 citation statements)

References 23 publications

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“…While ethicists argue that withdrawal and nonescalation are morally equivalent, 25 clinicians note that the cultural, psychological, social, or emotional experience of the 2 modes of death are significantly different. [26][27][28] Despite the need for family centered communication, shared decision-making, and values-oriented communication regardless of the mode of death, discussions around withdrawal of life-sustaining technologies require different knowledge and skills than discussions around nonescalation or disclosure of a failed resuscitation. 26,29 Medical management, as well as important cultural and ethical considerations, varies widely by mode of death.…”

Section: Resident Exposure To Mode Of Deathmentioning

confidence: 99%

Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital

Trowbridge

Bamat

Griffis

et al. 2020

Academic Pediatrics

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OBJECTIVE: Pediatric residents are expected to be competent in end-of-life (EOL) care. We aimed to quantify pediatric resident exposure to patient deaths, and the context of these exposures. METHODS: Retrospective chart review of all deceased patients at one children's hospital over 3 years collected patient demographics, time, and location of death. Mode of death was determined after chart review. Each death was cross-referenced with pediatric resident call schedules to determine residents involved within 48 hours of death. Descriptive statistics are presented. RESULTS: Of 579 patients who died during the study period, 46% had resident involvement. Most deaths occurred in the NICU (30% of all deaths); however, resident exposure to EOL care most commonly occurred in the PICU (52% of resident exposures) and were after withdrawals of lifesustaining therapy (41%), followed by nonescalation (31%) and failed resuscitation (15%). During their postgraduate year (PGY)-1, <1% of residents encountered a patient death. During PGY-2 and PGY-3, 96% and 78%, respectively, of residents encountered at least 1 death. During PGY-2, residents encountered a mean of 3.5 patient deaths (range 0-12); during PGY-3, residents encountered a mean of 1.4 deaths (range 0-5). Residents observed for their full 3-year residency encountered a mean of 5.6 deaths (range 2-10). CONCLUSIONS: Pediatric residents have limited but variable exposure to EOL care, with most exposures in the ICU after withdrawal of life-sustaining technology. Educators should consider how to optimize EOL education with limited clinical exposure, and design resident support and education with these variable exposures in mind.

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Section: Resident Exposure To Mode Of Deathmentioning

confidence: 99%

Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital

Trowbridge

Bamat

Griffis

et al. 2020

Academic Pediatrics

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“…Moreover, families may have more difficulty trusting what they hear, and are more often asked to reconcile themselves to assisted hydration ceasing, rather than not starting. Although some ethicists may deny a distinction between acts and omissions, 37 participants suggested that they, patients and families find cessation of assisted hydration harder to process 38,39 ; the widely-used time-limited trial of assisted hydration is a practical solution. 40 The number and quality of hospital-based discussions about assisted hydration are unlikely to improve unless resources are less thinly stretched, and unless clinicians observe practice and receive education that engenders comfort with uncertainty and avoids dichotomous right-vs-wrong viewpoints.…”

Section: Discussionmentioning

confidence: 99%

Medical communication and decision-making about assisted hydration in the last days of life: A qualitative study of doctors experienced with end of life care

et al. 2022

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Background: The impact of assisted hydration on symptoms and survival at the end of life is unclear. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration near end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting these should occur with all dying people. Aim: To explore the views and experiences of doctors experienced in end-of-life care regarding communicating with patients and families and making decisions about assisted hydration at the end of life. Design: Qualitative study involving framework analysis of data from semi-structured interviews. Setting/participants: Sixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from hospitals, hospices and community services from October 2019 to October 2020. Results: Participants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides barriers to high-quality communication with dying patients and their families about assisted hydration, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Lack of inclusion of patients in decision-making about assisted hydration appears to be common practice. Conclusions: Proactive, routine discussion with dying people about hydration-related issues is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care.

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“…Experience of actively initiating discussions on LST withdrawal with patients' families was significantly related to LST decision discussions in this study. Withdrawing treatments is difficult and emotional for physicians and nurses, patients, and families [24,32]. Pressures on discussions about LST withdrawal may arise from patient prognosis, physician factors, nurse factors, concerns from patients' families, social factors, and economic factors [14].…”

Section: Discussionmentioning

confidence: 99%

Nurses’ Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study

Chang

Lin

Chen

et al. 2020

IJERPH

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This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged ≥ 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care.

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Withholding versus withdrawing treatment: artificial nutrition and hydration as a model

Cited by 9 publications

References 23 publications

Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital

Pediatric Resident Experience Caring for Children at the End of Life in a Children's Hospital

Medical communication and decision-making about assisted hydration in the last days of life: A qualitative study of doctors experienced with end of life care

Nurses’ Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study

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