Intensive care unit utilization among patients with cancer at the end of life

Over the last 2 decades, survival rates in critically ill cancer patients have improved. Despite the increase in survival, the intensive care unit (ICU) continues to be a location where end-of-life care takes place. More than 20% of deaths in the United States occur after admission to an ICU, and as baby boomers reach the seventh and eighth decades of their lives, the volume of patients in the ICU is predicted to rise. The aim of this study was to evaluate intensive care unit utilization among patients with cancer who were at the end of life. End of life was defined using decedent and high-risk cohort study designs. The decedent study evaluated characteristics and ICU utilization during the terminal hospital stay among patients who died at The University of Texas MD Anderson Cancer Center during 2003-2007. The high-risk cohort study evaluated characteristics and ICU utilization during the index hospital stay among patients admitted to MD Anderson during 2003-2007 with a high risk of in-hospital mortality. Factors associated with higher ICU utilization in the decedent study included non-local residence, hematologic and non-metastatic solid tumor malignancies, malignancy diagnosed within 2 months, and elective admission to surgical or pediatric services. Having a palliative care consultation on admission was associated with dying in the hospital without ICU services. In the cohort of patients with high risk of in-hospital mortality, patients who went to the ICU were more likely to be younger, male, with newly diagnosed non-metastatic solid tumor or hematologic malignancy, and admitted from the emergency center to one of the surgical services. A palliative care consultation on admission was associated with a decreased likelihood of having an ICU stay. There were no differences in ethnicity, marital status, comorbidities, or insurance status between patients who did and did not utilize ICU services. Inpatient mortality probability models developed for the general population are inadequate in predicting in-hospital mortality for patients with cancer. The following characteristics that differed between the decedent study and high-risk cohort study can be considered in future research to predict risk of in-hospital mortality for patients with cancer: ethnicity, type and stage of malignancy, time since diagnosis, and having advance directives. Identifying those at risk can precipitate discussions in advance to ensure care remains appropriate and in accordance with the wishes of the patient and family.^

“Dishonourable disobedience” – Why refusal to treat in reproductive healthcare is not conscientious objection

In medicine, the vast majority of conscientious objection (CO) is exercised within the reproductive healthcare field – particularly for abortion and contraception. Current laws and practices in various countries around CO in reproductive healthcare show that it is unworkable and frequently abused, with harmful impacts on women's healthcare and rights. CO in medicine is supposedly analogous to CO in the military, but in fact the two have little in common. This paper argues that CO in reproductive health is not actually Conscientious Objection, but Dishonourable Disobedience (DD) to laws and ethical codes. Healthcare professionals who exercise CO are using their position of trust and authority to impose their personal beliefs on patients, who are completely dependent on them for essential healthcare. Health systems and institutions that prohibit staff from providing abortion or contraception services are being discriminatory by systematically denying healthcare services to a vulnerable population and disregarding conscience rights for abortion providers. CO in reproductive healthcare should be dealt with like any other failure to perform one's professional duty, through enforcement and disciplinary measures. Counteracting institutional CO may require governmental or even international intervention.

Part of the global DOC versus AOU (dissolved organic carbon/apparent oxygen utilization) data compilation, Ross Sea

Dissolved and particulate organic matter was measured during six cruises to the southern Ross Sea. The cruises were conducted during late austral winter to autumn from 1994 to 1997 and included coverage of various stages of the seasonal phytoplankton bloom. The data from the various years are compiled into a representative seasonal cycle in order to assess general patterns of dissolved organic matter (DOM) and particulate organic matter (POM) dynamics in the southern Ross Sea. Dissolved organic carbon (DOC) and particulate organic carbon (POC) were at background concentrations of approximately 42 and 3 µM C, respectively, during the late winter conditions in October. As the spring phytoplankton bloom progressed, organic matter increased, and by January DOC and POC reached as high as 30 and 107 µM C, respectively, in excess of initial wintertime conditions. Stocks and concentrations of DOC and POC returned to near background values by autumn (April). Approximately 90% of the accumulated organic matter was partitioned into POM, with modest net accumulation of DOM stocks despite large net organic matter production and the dominance of Phaeocystis antarctica. Changes in NO3 concentration from wintertime values were used to calculate the equivalent biological drawdown of dissolved inorganic carbon (DICequiv). The fraction of DICequiv drawdown resulting in net DOC production was relatively constant (ca. 11%), despite large temporal and spatial variability in DICequiv drawdown. The C : N (molar ratio) of the seasonally produced DOM had a geometric mean of 6.2 and was nitrogen-rich compared to background DOM. The DOM stocks that accumulate in excess of deep refractory background stocks are often referred to as "semi-labile" DOM. The "semi-labile" pool in the Ross Sea turns over on timescales of about 6 months. As a result of the modest net DOM production and its lability, the role DOM plays in export to the deep sea is small in this region.

Part of the global DOC versus AOU (dissolved organic carbon/apparent oxygen utilization) data compilation, Arabian Sea

Concentrations of total organic carbon (TOC) were determined on samples collected during six cruises in the northern Arabian Sea during the 1995 US JGOFS Arabian Sea Process Study. Total organic carbon concentrations and integrated stocks in the upper ocean varied both spatially and seasonally. Highest mixed-layer TOC concentrations (80-100 µM C) were observed near the coast when upwelling was not active, while upwelling tended to reduce local concentrations. In the open ocean, highest mixed-layer TOC concentrations (80-95 µM C) developed in winter (period of the NE Monsoon) and remained through mid summer (early to mid-SW Monsoon). Lowest open ocean mixed-layer concentrations (65-75 µM C) occurred late in the summer (late SW Monsoon) and during the Fall Intermonsoon period. The changes in TOC concentrations resulted in seasonal variations in mean TOC stocks (upper 150 m) of 1.5-2 mole C/m**2, with the lowest stocks found late in the summer during the SW Monsoon-Fall Intermonsoon transition. The seasonal accumulation of TOC north of 15°N was 31-41 x 10**12 g C, mostly taking place over the period of the NE Monsoon, and equivalent to 6-8% of annual primary production estimated for that region in the mid-1970s. A net TOC production rate of 12 mmole C/m**2/d over the period of the NE Monsoon represented ~80% of net community production. Net TOC production was nil during the SW Monsoon, so vertical export would have dominated the export terms over that period. Total organic carbon concentrations varied in vertical profiles with the vertical layering of the water masses, with the Persian Gulf Water TOC concentrations showing a clear signal. Deep water (>2000 m) TOC concentrations were uniform across the basin and over the period of the cruises, averaging 42.3±1.4 µM C.

Part of the global DOC versus AOU (dissolved organic carbon/apparent oxygen utilization) data compilation, Pacific Ocean

Total organic carbon (TOC) was analyzed on four transects along 140°W in 1992 using a high temperature combustion/discrete injection (HTC/DI) analyzer. For two of the transects, the analyses were conducted on-board ship. Mixed-layer concentrations of organic carbon varied from about 80 µM C at either end of the transect (12°N and 12°S) to about 60 µM C at the equator. Total organic carbon concentrations decreased rapidly below the mixed-layer to about 38-40 µM C at 1000 m across the transect. Little variation was observed below this depth; deep water concentrations below 2000 m were virtually monotonic at about 36 µM C. Repeat measurements made on subsequent cruises consistently found the same concentrations at 1000 m or deeper, but substantial variations were observed in the mixed-layer and the upper water column above 400 m depth. Linear mixing models of total organic carbon versus sigmaT exhibited zones of organic carbon formation and consumption. TOC was found to be inversely correlated with apparent oxygen utilization (AOU) in the region between the mixed-layer and the oxygen minimum. In the mixed-layer, TOC concentrations varied seasonally. Part of the variations in TOC at the equator was driven by changes in the upwelling rate in response to variations in physical forcing related to an El Niño and to the passage of tropical instability waves. TOC export fluxes, calculated from simple box models, averaged 8±4 mmol C/m**2/day at the equator and also varied seasonally. These export fluxes account for 50-75% of the total carbon deficit and are consistent with other estimates and model predictions.

Part of the global DOC versus AOU (dissolved organic carbon/apparent oxygen utilization) data compilation, WOCE14

Total organic carbon (TOC) samples were collected at 6 stations spaced ~800 km apart in the eastern South Atlantic, from the Equator to 45°S along 9°W. Analyses were performed by high temperature catalytic oxidation (HTCO) in the base laboratory. Despite the complex advection and mixing patterns of North Atlantic and Antarctic waters with extremely different degrees of ventilation, TOC levels below 500 m are quasi-constant at 55±3 µmol C/l, pointing to the refractory nature of deep-water TOC. On the other hand, a TOC excess from 25 to 38 g C/m**2 is observed in the upper 100 m of the permanently stratified nutrient-depleted Equatorial, Subequatorial and Subtropical upper ocean, where vertical turbulent diffusion is largely prevented. Conversely, TOC levels in the nutrient-rich upper layer of the Subantarctic Front only exceeds 9 g C/m**2 the deep-water baseline. As much as 70% of the TOC variability in the upper 500 m is due to simple mixing of reactive TOC formed in the surface layer and refractory TOC in deep ocean waters, with a minor contribution (13%) to oxygen consumption in the prominent subsurface AOU maximum at 200-400 m depth.