Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians.

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.

Medical students' knowledge about end-of-life decision-making

The influence of medical students' knowledge concerning end-of-life care, considering ethical theories and clinical practice, remains controversial. We aimed to investigate medical students' knowledge of bioethical concepts related to moral kinds of death (euthanasia, disthanasia, and orthothanasia) and to analyze the influence of their clinical experience on practicing such approaches in a tertiary hospital in the state of São Paulo, Brazil. We interviewed 180 medical students [distributed in Group 1 (G1) - first to third- year students, and Group 2 (G2) - fourth to sixth-year students] to evaluate the influence of the course on "medical ethics" on ethical theories and clinical practice, using a closed questionnaire. The course on "medical ethics" did not distinguish the groups (P=0.704) in relation to bioethical concepts. Neologisms such as "cacothanasia" and "idiothanasia" were incorrectly viewed as bioethical concepts by 28% of the interviewees. Moreover, 45.3% of the sample considered health care professionals incapable of managing terminally ill patients, especially G2 (29%) as compared to G1 (16.5%, P=0.031). The concept of euthanasia was accepted by 41% of sample, as compared to 98.2% for orthothanasia. Among medical students that accepted ways to abbreviate life (22.9%), 30.1% belonged to G1, and only 16.1% to G2 (P=0.049). These medical students were unfamiliar with common bioethical concepts. Moreover, they considered healthcare professionals incapable of managing terminally ill patients. The ethical ideal of the "good death" reflects better acceptance of orthothanasia by medical students, suggesting a tendency to apply it in their future clinical practice.

Attitudes toward end-of-life decision making in South Texas

Advance care planning has the potential to create positive outcomes in the realm of end-of-life health care. The completion of advance directives and living wills are vital in equipping patients with autonomy and ensuring that their end-of-life wishes are respected. However, there remains a lack of knowledge and low completion rates of advance directives despite their possible improvements and ramifications on health care at the end of life. This study seeks to determine the knowledge of and attitudes towards end-of-life decision-making in South Texas. The study is designed as a cross-sectional, exploratory survey using a descriptive survey instrument to query 71 subjects in South Texas. The setting for the study includes three distinct groups, two in San Antonio, Texas and one in Brownsville, Texas. Unique differences in demographics between the three groups, such as variability in age, ethnicity, language and religious affiliation allowed for preliminary associations to be concluded in describing the results of the survey instrument. Ultimately, this study describes the attitudes and perceptions of advance care planning in South Texas and reveals the need for further education and awareness of the topic, perhaps indicating the need for a public health initiative in this regard.^

No second chance: the experiences of junior neonatal nurses in providing end-of-life care for babies and families in the NNU

Background

An infant’s death is acutely stressful for parents and professionals. Little is known about junior nurses’ experiences providing end-of-life care in Neonatal Units (NNU).

Objectives

To better understand junior nurses’ experiences providing end-of-life care in NNU, the study explored the challenges and opportunities inherent in their practice relating to providing such care to babies and their families.

Methods

Neonatal nurses (n=12) with less than 3 years’ experience who were undergoing a neonatal education programme participated. Two focus groups were convened each with 6 nurses. The Ethics Committee at the relevant University approved the study. Nominal Group Technique (NGT) was used in the focus groups to build consensus around the challenges faced by junior nurses, alongside suggested developments in improving future care provision. Primary analysis involved successive rounds of ranking and decision making whilst secondary analysis involved thematic analysis.

Results

The study identified the pressures these nurses felt in having only one chance to ‘get it right’ for the infants and their families. They perceived the need for further ‘education and training’ highlighting that improved education provision would include both additional courses and internal training sessions. Greater ‘support’ from mentors themselves more experienced in this aspect of care within the NNU was identified as important in addressing issues around confidence building and skill development.

Conclusions

The results highlight junior nurses’ need for specific education and mentorship around end-of-life care for babies. This presentation will outline the implications for practice, education and further research.

The impact of life stage and societal culture on subordinate influence ethics: A study of Brazil, China, Germany, and the US

In this paper, we investigate the effects of societal values and life stage on subordinate influence ethics. Based on the evolving crossvergence theory of macro-level predictors of values evolution, we demonstrate the applicability of crossvergence theory in the micro-level context. Furthermore, our study provides the first empirical multi-level analysis of influence ethics utilizing a multi pie-country sample. Thus, we illustrate how the breath of crossvergence can be expanded to provide a multi-level theoretical foundation of values and behavior evolution across cultures. Specifically, we integrate micro-level life stage theory and macro-level societal culture theory to concurrently assess the contributions of each theory in explaining subordinate influence ethics across the diverse societies of Brazil. China, Germany and the U.S. Consistent with previous research, we found significant societal differences in influence ethics. However, we also found that life stage theory played a significant role in understanding influence ethics. Thus, our findings expand the crossvergence perspective on societal change, indicating that key micro-level predictors (e.g., life stage) should be included in cross-cultural research. (C) 2009 Elsevier Inc. All rights reserved.

IPH response to Palliative and End of Life Care Strategy Consultation

Palliative care and end of life care is the active, holistic care of patients with advanced and progressive illness.  It is an integral part of the care delivered by all health and social care professionals, and indeed by families and carers, to those living with, and dying from any advanced, progressive and incurable conditions.  The Department of Health, Social Services and Public Safety (NI) issued a consultation document on a 5 year Strategy in December 2009.

Änderung des Therapieziels am Lebensende: Effekte einer Klinik-Leitlinie [Changing the treatment goal at the end of life: effects of a guideline at a hospital].

BACKGROUND AND OBJECTIVE: Deciding about treatment goals at the end of life is a frequent and difficult challenge to medical staff. As more health care institutions issue ethico-legal guidelines to their staff the effects of such a guideline should be investigated in a pilot project.¦PARTICIPANTS AND METHODS: Prospective evaluation study using the pre-post method. Physicians and nurses working in ten intensive care units of a university medical center in Germany answered a specially designed questionnaire before and one year after issuance of the guideline.¦RESULTS: 197 analyzable answers were obtained from the first (pre-guideline) and 251 from the second (post-guideline) survey (54 % and 58 % response rate, respectively). Initially the clinicians expressed their need for guidelines, advice on ethical problems, and continuing education. One year after introduction of the guideline one third of the clinicians was familiar with the guideline's content and another third was aware of its existence. 90% of those who knew the document welcomed it. Explanation of the legal aspects was seen as its most useful element. The pre- and post-guideline comparison demonstrated that uncertainty in decision making and fear of legal consequences were reduced, while knowledge of legal aspects and the value given to advance directives increased. The residents had derived the greatest benefit.¦CONCLUSION: By promoting the knowledge of legal aspects and ethical considerations, guidelines given to medical staff can lead to more certainty when making in end of life decision.

End-of-Life Care for Older People in Acute and Long-Stay Care Settings in Ireland

The National Council on Ageing and Older People (NCAOP) and the Irish Hospice Foundation (IHF) are pleased to present this report, End-of-Life Care for Older People in Acute and Long-Stay Care Settings in Ireland. The report details the results of research that focuses, for the first time in Ireland, on the quality oflife and quality of care at the end-of-life for older people in various care settings including acute hospitals, public extended care units, private nursing homes, voluntary nursing homes and welfare homes. The report provides a new model for care at the end-of-life which goes beyond specialist palliative care provision to embrace a compassionate approach that supports older people who are living with, or dying from, progressive, chronic and life-threatening conditions, and attends to all their needs: physical, psychological,social and spiritual. Download document here

End-of-Life Care for Older People - Conference Proceedings

The purpose of this report on seminar proceedings is to provide a focused andaccurate summary of the deliberations of the seminar.The main aim of the seminar was to provide a forum in which to consider the determinants of quality of life of older people at the end-of-life and to identify priority measures and policies to ensure the highest standards of end-of-life care for older people in acute and long-stay settings in Ireland. Download document here

End of life trajectories across conditions

The findings of Pinnock and colleagues’ study on the longitudinal perspectives of people with severe chronic obstructive pulmonary disease (COPD) have implications for other non-malignant conditions.To read the 'BMJ' news article in full.

End of life care standards for people with dementia

End of life care standards for people with dementiaThis project, funded under Call 1 of CARDI’s Grants Programme and led by Dr Suzanne Cahill, School of Social Work and Social Policy, Trinity College Dublin, highlights the need for guaranteed standards of care for older people with dementia at the end of their lives.The research recommends the introduction of standards as a matter of urgency because of the huge increases in the number of people affected, and the number likely to be affected in the future. It is estimated that the number of people with dementia in the Republic of Ireland will rise from 44,000 to 104,000 by 2036 and in Northern Ireland from 16,000 to 47,000 in 2051.The research draws attention to the importance of agreeing new standards in Ireland, North and South, by proposing guidelines to develop policies and practices that can reflect the best available throughout the world.Research Team:•������ Dr Suzanne Cahill, School of Social Work and Social Policy, Trinity College Dublin•������ Ms Daphne Doran, Quality Initiatives, Belfast•������ Dr Max Watson, University of Ulster and Northern Ireland HospiceResearch briefingFull report��