Abstract
Scheunemann LP, Cunningham TV, Arnold RM, et al.: How clinicians discuss critically ill patients' preferences and values with surrogates: An empirical analysis. Crit Care Med 2015. (E-pub ahead of print.)
Although shared decision making requires clinicians to discuss the patient's values and preferences, little is known about the extent to which this occurs with surrogates in ICUs. In this prospective, cross-sectional study in five ICUs in two hospitals, the authors sought to assess whether and how clinicians talk with surrogates about incapacitated patients' preferences and values. Fifty-four physicians and 159 surrogates for 71 patients were involved in the study. The authors audiorecorded 71 conferences in which clinicians and surrogates discussed life-sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient's previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatments recommendations by clinicians that incorporated the patient's preferences or values.
Results demonstrated that in 30% of conferences there was no discussion about the patient's previously expressed preferences or values. In 37% of conferences, clinicians and surrogates discussed both the patient's treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient's treatment preferences or values, but not both. In more than 88% of conferences there was no conversation about the patient's values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD 4.3; range 0%–16%) of words spoken pertained to patient preferences or values. The authors conclude that in roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients' preferences or values about end-of-life decision making. In less than 12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients' values and preferences are elicited and integrated into end-of-life decisions in ICUs.
Padela A, Mohiuddin A: Ethical obligations and clinical goals in end-of-life care: Deriving a quality-of-life construct based on the Islamic Concept of Accountability Before God (Taklīf). Am J Bioeth 2015. (E-pub ahead of print.)
End-of-life medical decision making presents a major challenge to patients and physicians alike. In order to determine whether it is ethically justifiable to forgo medical treatment in such scenarios, clinical data must be interpreted alongside patient values, as well as in light of the physician's ethical commitments. Though much has been written about this ethical issue from religious perspectives (especially Christian and Jewish), little work has been done from an Islamic point of view. To fill the gap in the literature around Islamic bioethical perspectives on this matter, the authors derive a theologically rooted rubric for goals of care. They use the Islamic obligation for Muslims to seek medical treatment as the foundation for determining the clinical conditions under which Muslim physicians have a duty to treat. They link the theological concept of accountability before God (taklīf) to quality-of-life assessment. Using this construct, they suggest that a Muslim physician is not obligated to maintain or continue clinical treatment when patients who were formerly of, or had the potential to be, mukallaf (the term for a person who has taklīf), are now not expected to regain that status by means of continued clinical treatment.
De Vos MA, Bos AP, Plotz FB, et al.: Talking with parents about end-of-life decisions for their children. Pediatrics 2015. (E-pub ahead of print.)
Retrospective studies show that most parents prefer to share in decisions to forgo life-sustaining treatment (LST) of their children. We do not yet know how physicians and parents communicate about these decisions and to what extent parents share in the decision making process. The authors conducted a prospective exploratory study in two Dutch university medical centers. Results demonstrated that overall, 27 physicians participated, along with 37 parents of 19 children for whom a decision to withhold or withdraw LST was being considered. Forty-seven conversations were audiorecorded, ranging from one to eight meetings per patient. By means of a coding instrument researchers quantitatively and qualitatively analyzed physicians' and parents' communicative behaviors. On average, physicians spoke 67% of the time, parents 30%, and nurses 3%. All physicians focused primarily on providing medical information, explaining their preferred course of action, and informing parents about the decision being reached by the team. Only in two cases were parents asked to share in the decision making. Despite their intense emotions, most parents made a great effort to actively participate in the conversation. They did this by asking for clarifications; offering their preferences; and reacting to the decision being proposed, mostly by expressing their assent. In the few cases where parents strongly preferred LST to be continued, the physicians either gave parents more time or revised the decision. The authors conclude that parents are able to handle a more active role than they are currently being given, and that parents' greatest concern is that their child might suffer.
Committee opinion no. 617: End-of-life decision making. Obstet Gynecol 2015;125:261–267.
Obstetrician-gynecologists care for women throughout their lifespans and are in an ideal position to have ongoing discussions with patients about their values and wishes regarding future care and to encourage them to complete an advance directive for health care. In addition, situations may arise in which obstetrician-gynecologists need to participate in end-of-life care. When end-of-life decisions need to be made while a woman is pregnant, the level of ethical complexity often is increased. The purpose of this Committee Opinion is to discuss ethical issues related to end-of-life care, historical and legal constructs, patient-physician communication, intradisciplinary and interdisciplinary collaboration, and educational opportunities pertinent to obstetrician-gynecologists and other providers of women's health care.
Stevenson DG, Dalton JB, Grabowski DC, Huskamp HA: Nearly half of all Medicare hospice enrollees received care from agencies owned by regional or national chains. Health Aff 2015;34:30–38.
Analyses of ownership in the U.S. hospice sector have focused on the growth of for-profit hospice care and on aggregate differences in patient populations and service use patterns between for-profit and not-for-profit agencies. Such comparisons, although useful, do not offer insights about the types of organizations within the hospice sector, including the emergence of multiagency chains. Using Medicare cost report data for the period 2000–2011, the authors tracked the evolution of the U.S. hospice industry. They not only describe the market's composition by profit status but also provide new information about the roles of regional and national chains. Almost half of all Medicare hospice enrollees in 2011 received hospice services from a multiagency chain. A handful of companies play a prominent role, although the presence of smaller for-profit and not-for-profit hospice chains also has grown in recent years. By focusing on the role of the diverse organizations that provide hospice care, these analyses can help inform efforts to monitor and assure quality of care, to assess payment adequacy and options for reform, and to facilitate greater transparency and accountability within the hospice marketplace.