IMPORTANCE: Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical ...information. OBJECTIVE: To determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs). DESIGN, SETTING, AND PARTICIPANTS: Mixed-methods study comprising quantitative surveys and qualitative interviews conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009. MAIN OUTCOMES AND MEASURES: Discordance about prognosis, defined as a difference between a physician’s and a surrogate’s prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician’s prognostic estimate and a surrogate’s best guess of that estimate); differences in belief (any difference between a surrogate’s actual estimate and their best guess of the physician’s estimate). RESULTS: Two hundred twenty-nine surrogate decision makers (median age, 47 interquartile range {IQR}, 35-56 years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 IQR, 47-74 years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient’s prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates’ prognostic estimates were much more accurate than chance alone, but physicians’ prognostic estimates were statistically significantly more accurate than surrogates’ (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19). CONCLUSIONS AND RELEVANCE: Among critically ill patients, discordant expectations about prognosis were common between patients’ physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians’ assessments of patients’ prognoses and differences in beliefs about patients’ prognoses.
Abstract A 13-year-old patient named Jahi McMath was determined to be dead by neurologic criteria following cardiopulmonary arrest and resuscitation at a hospital in Oakland, California. Her family ...did not agree that she was dead and refused to allow her ventilator to be removed. The family's attorney stated in the media that families, rather than physicians, should decide whether patients are dead and argued in the courts that the families' constitutional rights of religion and privacy would be violated otherwise. Ultimately, a judge agreed that the patient was dead in keeping with California law, but the constitutional issue was undecided. The patient was then transferred to a hospital in New Jersey, a state whose laws allow families to require on religious grounds that death be determined by cardiopulmonary criteria. Although cases such as this are uncommon, they demonstrate public confusion about the concept of neurologic death and the rejection of this concept by some families. The confusion may be caused in part by a lack of uniformity in state laws regarding the legal basis of death, as reflected in the differences between New Jersey and California statutes. Families who reject the determination of death by neurologic criteria on religious grounds should be given reasonable accommodation in all states, but society should not pay for costly treatments for patients who meet these criteria unless the state requires it, as only New Jersey does. Laws that give physicians the right to determine death by neurologic criteria in other states probably can survive a constitutional challenge. Physicians and hospitals faced with similar cases in the future should follow state laws and work through the courts if necessary.
Increasingly in the United States and other countries, medical decisions, including those at the end of life, are made using a shared decision-making model. Under this model, physicians and other ...clinicians help patients clarify their values and reach consensus about treatment courses consistent with them. Because most critically ill patients are decisionally impaired, family members and other surrogates must make end-of-life decisions for them, ideally in accord with a substituted judgment standard. Physicians generally make decisions for patients who lack families or other surrogates and have no advance directives, based on a best interests standard and occasionally in consultation with other physicians or with review by a hospital ethics committee. End-of-life decisions for patients with surrogates usually are made at family conferences, the functioning of which can be improved by several methods that have been demonstrated to improve communications. Facilitative ethics consultations can be helpful in resolving conflicts when physicians and families disagree in end-of-life decisions. Ethics committees actually are allowed to make such decisions in one state when disagreements cannot be resolved otherwise.
OBJECTIVES:To present a case of conflict over end-of-life care in the intensive care unit (ICU) and to describe how such conflicts have been resolved in the United States since the inception of ICUs.
...DATA SOURCES:A nonsystematically derived sample of published studies and professional and lay commentaries on end-of-life care, ethical principles, medical decision-making, medical futility, and especially conflict resolution in the ICU.
STUDY SELECTION:Some of those studies and commentaries dealing specifically with conflicts over end-of-life care in the ICU and their resolution.
DATA SYNTHESIS:An historical review of conflict resolution over end-of-life issues in U.S. ICUs.
RESULTS AND CONCLUSIONS:Conflict at the end of life in ICUs in the United States is relatively rare because most families and physicians agree about how patients should be treated. Nevertheless, conflict still exists over some patients whose families insist on care that physicians consider inappropriate and hence inadvisable, and over other patients whose families object to care that physicians prefer to provide. When such conflict occurs, mediation between families and physicians is usually successful in resolving it. Consultation from ethics committees also may be helpful in achieving resolution, and one state actually allows such committees to adjudicate disputes. Physicians who act unilaterally against family wishes run the risk of malpractice suits, although such suits usually are unsuccessful because the physicians are not shown to have violated standards of care.
BACKGROUND:These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and ...highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence.
PRINCIPAL FINDINGS:Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula.
CONCLUSIONS:End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.
The delivery and transport of sediment through mountain rivers affects aquatic habitat and water resource infrastructure. While climate change is widely expected to produce significant changes in ...hydrology and stream temperature, the effects of climate change on sediment yield have received less attention. In the northern Rocky Mountains, we expect climate change to increase sediment yield primarily through changes in temperature and hydrology that promote vegetation disturbances (i.e., wildfire, insect/pathogen outbreak, drought-related die off). Here, we synthesize existing data from central Idaho to explore (1) how sediment yields are likely to respond to climate change in semi-arid basins influenced by wildfire, (2) the potential consequences for aquatic habitat and water resource infrastructure, and (3) prospects for mitigating sediment yields in forest basins. Recent climate-driven increases in the severity and extent of wildfire suggest that basin-scale sediment yields within the next few years to decades could be greater than the long-term average rate of 146
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observed for central Idaho. These elevated sediment yields will likely impact downstream reservoirs, which were designed under conditions of historically lower sediment yield. Episodic erosional events (massive debris flows) that dominate post-fire sediment yields are impractical to mitigate, leaving road restoration as the most viable management opportunity for offsetting climate-related increases in sediment yield. However, short-term sediment yields from experimental basins with roads are three orders of magnitude smaller than those from individual fire-related events (on the order of 10
1
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compared to 10
4
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, respectively, for similar contributing areas), suggesting that road restoration would provide a relatively minor reduction in sediment loads at the basin-scale. Nevertheless, the ecologically damaging effects of fine sediment (material
<
6
mm) chronically produced from roads will require continued management efforts.
► In response to changing climate, we expect sediment yields to increase. ► Increased vegetation disturbances, such as wildfire, are the expected mechanism. ► Elevated sediment yields in central Idaho will likely impact downstream reservoirs. ► Post-fire erosional events dominate sediment yields but are impractical to mitigate. ► Road restoration can provide limited reduction in sediment loads at the basin-scale.
A public health emergency, such as an influenza pandemic, will lead to shortages of mechanical ventilators, critical care beds, and other potentially life-saving treatments. Difficult decisions about ...who will and will not receive these scarce resources will have to be made. Existing recommendations reflect a narrow utilitarian perspective, in which allocation decisions are based primarily on patients' chances of survival to hospital discharge. Certain patient groups, such as the elderly and those with functional impairment, are denied access to potentially life-saving treatments on the basis of additional allocation criteria. We analyze the ethical principles that could guide allocation and propose an allocation strategy that incorporates and balances multiple morally relevant considerations, including saving the most lives, maximizing the number of "life-years" saved, and prioritizing patients who have had the least chance to live through life's stages. We also argue that these principles are relevant to all patients and therefore should be applied to all patients, rather than selectively to the elderly, those with functional impairment, and those with certain chronic conditions. We discuss strategies to engage the public in setting the priorities that will guide allocation of scarce life-sustaining treatments during a public health emergency.
OBJECTIVE:Rationing critical care beds occurs daily in the hospital setting. The objective of this systematic review was to examine the impact of rationing intensive care unit beds on the process and ...outcomes of care.
DATA SOURCE:We searched MEDLINE (1966–2003), CINAHL (1982–2003), Ovid Healthstar (1975–2003), EMBASE (1980–2003), Scisearch (1980–2003), the Cochrane Library, PUBMED related articles, personal files, abstract proceedings, and reference lists.
STUDY SELECTION:We included studies of seriously ill patients considered for admission to an intensive care unit bed during periods of reduced availability. We had no restriction on study design. Studies were excluded if rationing was performed using a scoring system or protocol and if cost-effectiveness was the only outcome.
DATA EXTRACTION:In duplicate and independently, we performed data abstraction and quality assessment.
DATA SYNTHESIS:We included ten observational studies. Hospital mortality rate was increased in patients refused intensive care unit admission vs. those admitted (odds ratio, 3.04; 95% confidence interval, 1.49–6.17). Factors associated with both intensive care unit bed refusal and increased mortality rate were increased age, severity of illness, and medical diagnosis. When intensive care unit beds were reduced, admitted patients were sicker, were less often admitted primarily for monitoring, and had a shorter intensive care unit length of stay, without other observed adverse effects.
CONCLUSIONS:These studies suggest that patients who are perceived not to benefit from critical care are more often refused intensive care unit admission; refusal is associated with an increased risk of hospital death. During times of decreased critical bed availability, several factors, including age, illness severity, and medical diagnosis, are used to triage patients, although their relative importance is uncertain. Critical care bed rationing requires further investigation.
Increasing numbers of patients survive traumatic brain injury and cardiopulmonary arrest and resuscitation and are admitted to the ICU while in coma. Some of these patients become brain dead; others ...regain consciousness. Still others become vegetative or minimally conscious, conditions called chronic disorders of consciousness and ultimately can be cared for outside the ICU. Whether these patients would want life-sustaining therapy is difficult to determine because most have not articulated their wishes before becoming comatose. Ethics and law recognize that patients with decision-making capacity have a right to refuse such therapy and that surrogates can exercise this right for them through the principle of substituted judgment as was established by the Supreme Court of New Jersey in the case of Karen Ann Quinlan. In its decision regarding Nancy Cruzan, the US Supreme Court determined that states may require clear and convincing evidence of a vegetative patient's prior wishes before life-sustaining therapy may be withdrawn; this standard has been applied to minimally conscious patients by state supreme courts in some cases. Nevertheless, cases such as these only come to the legal system because end-of-life decisions are contested, which is unusual, and most end-of-life decisions for specific patients with chronic disorders of consciousness are made by surrogates with recommendations from physicians without court involvement. Recent advances in neuroimaging may influence both end-of-life decision-making and legal deliberations. Targeting vegetative and minimally conscious patients in medical resource allocation remains ethically unacceptable and untested in the law.
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