Perspectives, preferences, care practices, and outcomes among older and middle-aged patients with late-stage cancer.
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PURPOSE: To evaluate relationships among physician and cancer patient survival estimates, patients' perceived quality of life, care preferences, and outcomes, and how they vary across middle-aged and older patient groups. PATIENTS AND METHODS: Subjects were from the Study to Understand Prognoses and Preferences for Risks of Treatments (SUPPORT) prospective cohort studied in five US teaching hospitals (from 1989 to 1994), and included 720 middle-aged (45 to 64 years) and 696 older (> or = 65 years) patients receiving care for advanced cancer. Perspectives were assessed in physician and patient/surrogate interviews; care practices and outcomes were determined from hospital records and the National Death Index. General linear models were used within age groups to obtain adjusted estimates. RESULTS: Although most patients had treatment goals to relieve pain, treatment preferences and care practices were linked only in the older group. For older patients, preference for life-extending treatment was associated with more therapeutic interventions and more documented discussions; cardiopulmonary resuscitation (CPR) preference was linked to more therapeutic interventions and longer survival. For middle-aged patients, better perceived quality of life was associated with preferring CPR. In both groups, patients' higher survival estimates were associated with preferences for life-prolonging treatment and CPR; physicians' higher survival estimates were associated with patients' preferences for CPR, fewer documented treatment limitation discussions about care, and actual 6-month survival. More discussions were associated with readmissions and earlier death. More aggressive care was not related to outcomes. CONCLUSION: Fewer older patients preferred CPR or life-prolonging treatments. Although older patients' goals for aggressive treatment were related to care, this was not so for middle-aged patients. Aggressive care was not related to prolonged life in either group. (+info)
Resuscitation of the preterm infant against parental wishes.
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Over the past 40 years, the norms on who is to make treatment decisions for newborns, and on what standards, have been significantly altered and revised. Today the standard for treatment of newborns is the "best interest" of the child. A recent ruling of the Texas Supreme Court authorizing a doctor to resuscitate a potentially viable very premature newborn over the parents' objection is a challenge to that standard. (+info)
Withdrawing may be preferable to withholding.
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The majority of deaths on the intensive care unit now occur following a decision to limit life-sustaining therapy, and end-of-life decision making is an accepted and important part of modern intensive care medical practice. Such decisions can essentially take one of two forms: withdrawing -- the removal of a therapy that has been started in an attempt to sustain life but is not, or is no longer, effective -- and withholding -- the decision not to make further therapeutic interventions. Despite wide agreement by Western ethicists that there is no ethical difference between these two approaches, these issues continue to generate considerable debate. In this article, I will provide arguments why, although the two actions are indeed ethically equivalent, withdrawing life-sustaining therapy may in fact be preferable to withholding. (+info)
Action ethical dilemmas in surgery: an interview study of practicing surgeons.
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BACKGROUND: The aim of this study was to describe the kinds of ethical dilemmas surgeons face during practice. METHODS: Five male and five female surgeons at a University hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of physicians and nurses about ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. RESULTS: No gender differences were found in the kinds of ethical dilemmas identified among male and female surgeons. The main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The dilemmas included starting or withholding treatment, continuing or withdrawing treatment, overtreatment, respecting the patients and meeting patients' expectations. The main focus in the narratives was on ethical dilemmas concerning the patients' well-being, treatment and care. The surgeons narrated about whether they should act according to their own convictions or according to the opinions of principal colleagues or colleagues from other departments. Handling incompetent colleagues was also seen as an ethical dilemma. Prioritization of limited resources and following social laws and regulations represented ethical dilemmas when they contradicted what the surgeons considered was in the patients' best interests. CONCLUSION: The surgeons seemed confident in their professional role although the many ethical dilemmas they experienced in trying to meet the expectations of patients, colleagues and society also made them professionally and personally vulnerable. (+info)
The implications of the David Glass case for future clinical practice in the UK.
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A recent decision of the European Court of Human Rights (ECtHR) raises issues of considerable importance to medical practitioners and paediatricians in particular. The case concerns the parental right to withhold consent to medical intervention that doctors believe to be necessary in a child's best interests. The dramatic facts of this case (in which a boy's family felt they had to fight for his life) has significant repercussions for clinical practice. This is discussed in the light of previous and recent cases that have involved babies, infants and children. The worrying trend to use the Courts to resolve these difficult clinical cases is discussed. (+info)
Do weekend plan standard forms improve communication and influence quality of patient care?
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Weekends are critical times in an inpatient stay, when daily review of patients is not routine and the usual team of doctors responsible for a patient's care is often not available. Communication between the patient's own doctors and the on call team is vital for continuity of care and to maintain patient safety. The provision and completeness of weekend plans was assessed before and after the introduction of a standard form. The introduction of the form led to a significant improvement in the proportion of notes containing a weekend plan and the proportion of notes containing a resuscitation decision (p<0.05), which will have a significant impact on patient care. (+info)
Is neonatal intensive care justified in all preterm infants?
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A proactive policy of resuscitation at birth and prompt initiation of intensive care have been shown to be associated with an improvement in the survival of very preterm infants in both institution-based and population-based studies. As a greater percentage of live births were offered intensive care, the survival rate rose progressively in all birth weight and gestation subgroups among extremely low birth weight infants, including those who were born at borderline viability between 23 weeks and 25 weeks of gestational age. Their quality-adjusted survival rate also rose progressively, since the large gains in survival over time had not been offset by significant increases in survival with disability. Cost-effectiveness and cost-utility ratios remained stable overall, with efficiency gains in the smaller infants over time, as more such infants were being born in Level III perinatal centers with the regionalization of perinatal-neonatal healthcare programs. National and international surveys of obstetricians and neonatologists on their perception of viability and their management decisions in extremely preterm infants have shown significant variations on the application use of intensive care in those born extremely preterm. If doctors believe that such infants have little prospect for intact survival, their management would be suboptimal or delayed, thus creating a self-fulfilling prophecy. Both developed and developing countries need to develop appropriate policies for initiating and withdrawing intensive care, taking into consideration their own cultural, social, and economic factors. (+info)
Process of care and mortality of stroke patients with and without a do not resuscitate order in the West Midlands, UK.
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OBJECTIVE: . To compare the process of care of stroke patients with and without a do not resuscitate (DNR) order. DESIGN: Retrospective case note review with prospective follow up of mortality. SETTING: Seven acute hospitals, with stroke units, in the West Midlands, UK. PARTICIPANTS: A random sample of patients (n = 702) admitted to hospital with acute stroke over a twelve month period. MAIN OUTCOME MEASURES: Case mix and process of care measures derived from the intercollegiate stroke audit package. Thirty day and one year mortality. RESULTS: About one-third (34%, 238/702) of stroke patients had DNR orders. The thirty-day mortality for DNR patients was 67% (160/238) versus 10% (46/449) for patients without DNR orders. DNR patients had significantly worse case-mix profile than non-DNR patients - median age 81 y vs 75y; fully conscious 36% vs 79%, able to walk 1% vs 21% and no loss of power in either arm 5% vs 24% (all p < 0.0001). DNR patients were more likely to be assessed early by a speech and language therapist (77% vs 59%, p < 0.001), but less likely to receive the majority of their care in a stroke/rehabilitation unit (20% vs 57%, p < 0.0001), or be cared for on a stroke unit or by a stroke team (42% vs 70%, p <0.0001), or had a description of the site of the cerebral lesion (31% vs 38%, p = 0.05) or be given aspirin (30% vs 42%, p = 0.007). CONCLUSIONS: Stroke patients with a DNR order are not receiving optimum care in that they are not being cared for on stroke units or by specialist teams. This may reflect the inadequate provision of specialist stroke services in the UK. (+info)