Nephrologists' changing practices in reported end-of-life decision-making.
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Because the dialysis patient population is increasingly composed of older patients with high symptom burden, shortened life expectancy, and multiple comorbid conditions, nephrologists often engage in end-of-life decision-making with their patients. In the 1990s, reported practices of nephrologists' end-of-life decision-making showed much variability. In part as a reaction to that variability, the Renal Physicians Association (RPA) and the American Society of Nephrology (ASN) developed a clinical practice guideline on end-of-life decision-making. To determine whether nephrologists' attitudes and reported practices had changed over time, survey responses from 296 nephrologists completing an online survey in 2005 were compared with 318 nephrologists who completed a similar mailed survey in 1990. In 2005, less variability was noted in reported practices to withhold dialysis from a permanently unconscious patient (90% would withhold in 2005 versus 83% who would withhold in 1990, P < 0.001) and to stop dialysis in a severely demented patient (53% in 2005 would stop versus 39% in 1990, P < 0.00001). In 2005, significantly more dialysis units were reported to have written policies on cardiopulmonary resuscitation (86% in 2005 versus 31% in 1990, P < 0.0001) and withdrawal of dialysis (30% in 2005 versus 15% in 1990, P < 0.0002); nephrologists were also more likely to honor a dialysis patient's do-not-resuscitate order (83% in 2005 versus 66%, P < 0.0002) and to consider consulting a Network ethics committee (52% in 2005 versus 39%, P < 0.001). Nephrologists' reported practices in end-of-life care have changed significantly over the 15 years separating the two surveys, suggesting that the development of the clinical practice guideline was worthwhile. (+info)
Survey of "do not resuscitate" orders in a district general hospital.
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OBJECTIVE: To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN: Point prevalence questionnaire survey of inpatients' medical and nursing records. SETTING: 10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS: Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES: Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS: Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS: In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients' suitability for resuscitation between doctors, nurses, patients, and patients' relatives. Suitability for resuscitation should be reviewed on every consultant ward round. (+info)
Audit of deaths less than a week after admission through an emergency department: how accurate was the ED diagnosis and were any deaths preventable?
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AIM: To review the causes of death in patients admitted via the emergency department (ED) who died within 7 days of admission and to identify any ways in which ED care could have been better. The study also aims to compare the diagnosis made in the ED and the mortality diagnosis. METHODS: A retrospective study; subjects were all patients who attended the ED over 4 months and died within 7 days of admission. The paramedics' notes, ED case cards, inpatient medical notes and details of postmortem findings were examined to identify the time and date of arrival in the ED, presenting complaint, provisional diagnosis made by the ED, treatment plan devised by the ED, diagnosis made in wards, and the cause of death as issued on death certificates or from postmortem findings. Summary sheets of cases where the care provided by the emergency department could have been improved were reviewed, errors were identified and deaths were classified as preventable or unpreventable. RESULTS: Database revealed 3521 admissions via the ED over 4 months, of which 95 cases (2.69%) died within 7 days of admission. 78 patients (82.1% of cases) were appropriately diagnosed and managed whereas 17 (17.87% of cases) were identified with deficiencies in either the diagnosis or the management provided in the ED. We reviewed the quality of care provided in the ED for these cases and rated deaths according to our preventability criteria: 5 (5.26%) deaths were unpreventable despite the deficiency in care provided in the ED; 3 (3.15%) deaths were definitely preventable; 3 (3.15%) were probably preventable; and 6 (6.31%) were possibly preventable deaths. CONCLUSION: The ED is playing a good role in the management of critically ill patients, with appropriate diagnosis and management in 82% of cases. Training of junior doctors is required to prevent occurrence of errors and thus preventable deaths, but all deaths are not preventable. New guidelines for sepsis management and management of undifferentiated clinical presentations are being introduced and we intend to audit the implications of new guidelines. (+info)
Seeking remedy, abstaining from therapy and resuscitation: an islamic perspective.
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This paper discusses the Islamic viewpoint on seeking remedy. It is imperative to seek remedy in life threatening situations or in case of highly infectious diseases. In such circumstances, the Muslim government can impose quarantine and enforcement of treatment to protect the community. In case of minors, the guardian could be appointed by the Qhadi (magistrate), to give consent to the necessary management. Otherwise, an adult competent male or female should give his free consent in order to start any medical or surgical procedure. He can abstain from treatment at any time. When treatment benefit is doubted, seeking remedy becomes facultative and if it seems that the side effects and inconvenience of treatment is more than the expected benefits, it becomes Makrooh (disliked). If the treatment is futile, then there is no need to continue such treatment. If treatment involves amulets, divination, talismans or sorcery, then it should be prohibited. Usage of prohibited materials e.g. pork or alcohol is not allowed except in certain limited situations, where there is no alternative medicine and it should be prescribed by a competent Muslim physician where it is considered as a necessity (necessity knows no law). Fatwas from the permanent committee of Religious Sciences, Research and Ifta of the Kingdom of Saudi Arabia regarding "do not resuscitate" policy will be fully discussed. (+info)
To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support.
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Advance directives and the concept of competence: are they a moral barrier to resuscitation?
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The ethical reflection on the principle of respect for autonomy has evolved from protecting the patients' right to direct health care decisions affecting them, to describing essential conditions necessary to recognize the patients' consent as being really informed. Some specific problems arise with patients who are not autonomous or whose autonomy is doubtful at the time of undertaking medical treatments. The advance directives are seen as a means which permits to respect the patient's autonomy even in such difficult situations. Such directives are understood as the declarations made by patients in which they express the will concerning treatment preferences, in particular, resuscitation recommendations, in case of their potential future lack of ability to act autonomously. This paper attempts to answer to the question of whether the advance directives fulfill (and if so, on what basis) the standards established by the concept of competence. (+info)
'Do not resuscitate order' in neonatology: authority rules.
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Ethical dilemmas in medicine should be resolved in light of four essential principles. To specify and guide concrete actions, it is necessary to 'supplement' these principles by certain other (substantive, authority and procedural) rules. The purpose of this paper is to establish and justify the authority rules regarding the order not to resuscitate newborns. The authority rules are intended to indicate who should decide, but they do not determine what should be chosen. Decision regarding newborn's treatment/letting die depends on medical and quality-of-life judgments. Parents, doctors, and society are considered to possess decisional authority in the matter. However, who in a given case should decide ought to be inferred from the reasoning which assumes, as its premises, the medical and quality-of-life judgments. The 'logical' syntax of this reasoning is presented in this paper. (+info)
Do-not-resuscitate orders and/or hospice care, psychological health, and quality of life among children/adolescents with acquired immune deficiency syndrome.
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