IMPORTANCE: Incarcerated patients admitted to the hospital face threats to their rights to privacy and self-determination in medical decision-making. Little is known about medical decision-making ...processes for hospitalized incarcerated persons who lack decisional capacity. OBJECTIVE: To characterize the prevalence of incapacity among hospitalized incarcerated patients and describe the decision-making processes, including who served as surrogate decision-makers, involvement of prison employees in medical decisions, and ethical concerns emerging from the patients’ care. DESIGN, SETTING, AND PARTICIPANTS: Retrospective descriptive and qualitative study of medical records for all patients admitted from prison for at least 24 hours between January 1, 1999, and September 1, 2019, at a large Midwestern academic medical center. Data analysis was performed from March 15, 2021, to December 14, 2022. MAIN OUTCOMES AND MEASURES: Prevalence of prison-to-hospital admissions for patients with a loss of capacity and characteristics of medical decision-making. RESULTS: During the 20-year study period, 462 patients from the prison were admitted to the hospital, totaling 967 unique admissions. Of these, 131 admissions (14%) involved patients with a loss of capacity and 43 admissions (4%, representing 34 unique patients) required surrogate decision-making. Ten of these patients had advance directives. Surrogate decision-makers often faced decisions about end-of-life care (n = 17) or procedural consent (n = 23). A family member was identified as surrogate decision-maker in 23 admissions. In 6 cases with a kindred surrogate, additional consent was requested from a prison employee. In total, prison employees were documented as being present during or participating in major medical decisions for half of the admissions. Five themes emerged from thematic analysis: uncertainty and misinformation about patient rights and the role of prison employees in medical decision-making with respect to these two themes, privacy violations, deference to prison officials, and estrangement from family and friends outside of the prison. CONCLUSIONS AND RELEVANCE: In this first in-depth description, to date, of decision-making practices for hospitalized incarcerated patients lacking decisional capacity, admissions of these patients generated uncertainty about their rights, sometimes infringing on patients’ privacy and autonomy. Clinicians will encounter incarcerated patients in both hospital and clinic settings and should receive education on how to support ethically and legally sound decision-making practices for this medically vulnerable population.
U.S. states vary in their procedures for appointing and challenging default surrogates, the attributes they require of them, priority ranking of possible decision makers, and dispute resolution — ...with important implications for clinicians, patients, and public health.
BACKGROUNDPulmonary hypertension (PH) exists when mean pulmonary artery pressure (mPAP) is 25 mm Hg or greater. mPAP of 35 mm Hg or greater, with increased pulmonary vascular resistance from ...portopulmonary hypertension, has been associated with increased post-liver transplant (LT) mortality. However, mPAP of 35 mm Hg or greater can also occur in the setting of normal pulmonary vascular resistance from a high flow state and/or increased pulmonary venous volume. We describe the frequency of patients with mPAP of 35 mm Hg or greater at LT and correlate their clinical outcomes with hemodynamic characteristics.
METHODSWe reviewed hemodynamics of 300 consecutive adult patients undergoing LT. Primary and secondary outcomes were transplant hospitalization mortality and 1-year mortality.
RESULTSOverall, PH was documented in 117 (39%) of 300 transplant recipients. Five patients were receiving ongoing treatment for portopulmonary hypertension at the time of transplant. mPAP of 35 mm Hg or greater was seen in 31 of 300 patients (10.3%; median, 38 mm Hg; range, 35-46 mm Hg). No intraoperative deaths occurred. Transplant hospitalization mortality was 0% for those with mPAP of 35 mm Hg or greater (vs 2.2% if mPAP < 35 mm Hg, P = 1.0). One-year mortality was similar for patients with and without mPAP of 35 mm Hg or greater (3.2% vs 6.0%, P = 1.0). No deaths were associated with right heart failure.
CONCLUSIONSAt the time of LT, 39% of recipients had PH (mPAP ≥ 25 mm Hg) and 10.3% had mPAP ≥ 35 mm Hg. When associated with a high flow state and/or increased volume, transplant hospitalization and 1-year posttransplant outcomes were not adversely affected.
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