Withdrawal and limitation of life support in paediatric intensive care.
OBJECTIVES: To compare the modes of death and factors leading to withdrawal or limitation of life support in a paediatric intensive care unit (PICU) in a developing country. METHODS: Retrospective analysis of all children (< 12 years) dying in the PICU from January 1995 to December 1995 and January 1997 to June 1998 (n = 148). RESULTS: The main mode of death was by limitation of treatment in 68 of 148 patients, failure of active treatment including cardiopulmonary resuscitation in 61, brain death in 12, and withdrawal of life support with removal of endotracheal tube in seven. There was no significant variation in the proportion of limitation of treatment, failure of active treatment, and brain death between the two periods; however, there was an increase in withdrawal of life support from 0% in 1995 to 8% in 1997-98. Justification for limitation was based predominantly on expectation of imminent death (71 of 75). Ethnic variability was noted among the 14 of 21 patients who refused withdrawal. Discussions for care restrictions were initiated almost exclusively by paediatricians (70 of 75). Diagnostic uncertainty (36% v 4.6%) and presentation as an acute illness were associated with the use of active treatment. CONCLUSIONS: Limitation of treatment is the most common mode of death in a developing country's PICU and active withdrawal is still not widely practised. Paediatricians in developing countries are becoming more proactive in managing death and dying but have to consider sociocultural and religious factors when making such decisions. (+info)
Preparing for medical emergencies in the dental office.
If you discover an unconscious patient in your office, attend to the ABCs while you evaluate the patient's medical history and piece together the events leading up to the emergency. These actions will help you arrive at a diagnosis. Then as the emergency cart and team arrive, you will be able to provide good, safe care to stabilize the patient and get him or her to a medical facility. (+info)
Medical cover at Scottish football matches: have the recommendations of the Gibson Report been met?
OBJECTIVES: To determine if doctors providing medical care at Scottish football stadiums meet the standards recommended by the Gibson Report. METHODS: A postal questionnaire and telephone follow up of doctors involved with the 40 Scottish League teams. RESULTS: 47% of the doctors had not attended any relevant resuscitation courses and 72% had no training in major incident management. CONCLUSIONS: The recommendations of the Gibson Report with regard to medical cover at football stadiums have not been fully implemented in Scotland. (+info)
Bone marrow transplant patients with life-threatening organ failure: when should treatment stop?
PURPOSE: To discuss issues surrounding life support in bone marrow transplant (BMT) patients, issues that may determine how far we go to keep a deteriorating BMT patient alive--and when we stop trying. How can we define survival chance in BMT patients, and when should prolongation of life be deemed inappropriate? Who should make the decision to terminate support? And how should life support be terminated? DESIGN: Prognostic factors that predict for almost certain nonsurvival have been identified in BMT patients with life-threatening organ failure. The concept of futility raises the question of how low the chance of survival must be before termination of life support is justified--but the concept is flawed, and the value judgments involved in decision making must also be considered. Then, once a decision is made, the manner of withholding or withdrawing life support is also open to discussion. CONCLUSION: Despite controversies, there are areas in which improvements to current practice might be considered. More data are required to determine survival chances of BMT patients with life-threatening organ failure. Greater attention might be devoted, in pretransplant counseling, to issues of intensive life support, with the patient's own views being ascertained before transplantation. And, because technologic possibilities are now imposing fewer boundaries, the problem of finite resources may need to be readdressed, with treatment limits being set down before transplantation. (+info)
Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state.
OBJECTIVES: Ethical issues have recently been raised regarding the appropriate care of patients in persistent vegetative state (PVS) in Japan. The purpose of our study is to study the attitudes and beliefs of Japanese physicians who have experience caring for patients in PVS. DESIGN AND SETTING: A postal questionnaire was sent to all 317 representative members of the Japan Society of Apoplexy working at university hospitals or designated teaching hospitals by the Ministry of Health and Welfare. The questionnaire asked subjects what they would recommend for three hypothetical vignettes that varied with respect to a PVS patient's previous wishes and the wishes of the family. RESULTS: The response rate was 65%. In the case of a PVS patient who had no previous expressed wishes and no family, 3% of the respondents would withdraw artificial nutrition and hydration (ANH) when the patient did not require any other life-sustaining treatments, 4% would discontinue ANH, and 30% would withhold antibiotics when the patient developed pneumonia. Significantly more respondents (17%) would withdraw ANH in the case of a PVS patient whose previous wishes and family agreed that all life support be discontinued. Most respondents thought that a patient's written advance directives would influence their decisions. Forty per cent of the respondents would want to have ANH stopped and 31% would not want antibiotics administered if they were in PVS. CONCLUSIONS: Japanese physicians tend not to withdraw ANH from PVS patients. Patients' written advance directives, however, would affect their decisions. (+info)
Major incidents: training for on site medical personnel.
OBJECTIVE: To assess the present levels of training for the medical incident officer (MIO) and the mobile medical team leader (MMTL) throughout the UK. METHOD: Postal questionnaire to consultants in charge of accident and emergency (A&E) departments seeing more than 30,000 patients a year. Information regarding MIO staffing and training and MMTL training and provision requested. RESULTS: A&E provides the majority of both MIOs and MMTLs in the event of a major incident. Virtually all MIOs are consultants or general practitioners. However, 63% of MMTLs are from hospital training grade staff. One third of hospitals required their designated MIO to have undertaken a Major Incident Medical Management and Support course and a quarter had no training requirement at all. Two thirds of MMTLs were expected to have completed an Advanced Trauma Life Support course, but in 21% there was no minimum training requirement. Training exercises are infrequent, and hence the exposure of any one individual to exercises will be minimal. CONCLUSION: There has been some improvement in major incident training and planning since 1992, but much remains to be done to improve the national situation to an acceptable standard. (+info)
Pediatric advanced life support: a review of the AHA recommendations. American Heart Association.
The etiologies of respiratory failure, shock, cardiopulmonary arrest and dysrhythmias in children differ from those in adults. In 1988, the American Heart Association implemented the pediatric advanced life support (PALS) program. Major revisions to the program were made in 1994, with further revisions in 1997. The PALS program teaches a systematic, organized approach for the evaluation and management of acutely ill or injured children. Early identification and treatment of respiratory failure and shock in children improve survival, from a dismal 10 percent to an encouraging 85 percent. Family physicians who care for acutely ill or injured children have a tremendous opportunity to save lives through implementation of the PALS information. (+info)
Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma.
BACKGROUND: In an environment characterized by cuts to health care, hospital closures, increasing reliance on home care and an aging population, more terminally ill patients are choosing to die at home. The authors sought to determine the care received by these patients when paramedics were summoned by a 911 call and to document whether do-not-resuscitate (DNR) requests influenced the care given. METHODS: The records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. Data were abstracted from paramedics' ambulance call reports according to a standardized template. The proportion of these patients described as having a terminal illness was determined, as was the proportion of terminally ill patients with a DNR request. The resuscitative efforts of paramedics were compared for patients with and without a DNR request. RESULTS: Of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminal illness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001). INTERPRETATION: Paramedics are frequently called to attend terminally ill patients with cardiac arrest. Current regulations are a source of conflict between the paramedic's duty to treat and the patient's right to limit resuscitative efforts at the time of death. (+info)