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1
Childress, James F. An ethical analysis of withdrawal from life-sustaining technologies and assisted death: A report for the Office of Technology Assessment. [Washington, D.C.?: The Office, 1985.
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2
Fogelman, Patricia Maani, and Janine A. Gerringer. Withdrawal of Cardiology Technology. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190204709.003.0011.
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The care of the cardiac patient requires exquisite assessment including history, physical examinations, and diagnostic data in order to make differential diagnoses and formulate individualized treatment plans. Interventions include education about lifestyle modifications, the introduction and titration of cardiac medications, and referral for more advanced treatments such as vasoactive or inotropic medications, cardiovascular implantable electronic devices, and ventricular assist devices. Often, patients decide to discontinue these therapies. Standardized protocols for withdrawal of life-sustaining respiratory therapies provide structured guidance, reduce variation in practice, and improve satisfaction of families and healthcare providers. This chapter reviews such therapies and the process for cessation while simultaneously attending to symptom management.
3
1919-, Zucker Marjorie B., and Zucker Howard D, eds. Medical futility and the evaluation of life-sustaining interventions. Cambridge: Cambridge University Press, 1997.
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4
Olson, Lori, and Christian T. Sinclair. A Communication Intervention in the Intensive Care Unit (DRAFT). Edited by Nathan A. Gray and Thomas W. LeBlanc. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190658618.003.0038.
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Caregiver outcomes of anxiety, depression, and posttaumatic stress disorder are modifiable based on care received while a patient is in the intensive care unit (ICU) setting. When compared to usual ICU care (which did include family meetings), the intervention added a structured end-of-life conference according to VALUE-based guidelines and a 15-page bereavement informational booklet. Patients in the intervention arm also had longer conferences, more time with family speaking, and more life-sustaining treatments withdrawn. The chapter describes the basics of the study, briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case.
5
Elective withdrawal of life-sustaining treatments in neonatal intensive care: Ethical implications. Ottawa: National Library of Canada, 1993.
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6
Rady, Mohamed Y., and Ari R. Joffe. Non-heart-beating organ donation. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0390.
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The transplantation community endorses controlled and uncontrolled non-heart-beating organ donation (NHBD) to increase the supply of transplantable organs at end of life. Cardiac arrest must occur within 1–2 hours after the withdrawal of life-support in controlled NHBD. Uncontrolled NHBD is performed after failed cardiopulmonary resuscitation in an unexpected witnessed cardiac arrest. Donor management aims to protect transplantable organs against warm ischaemic injury through the optimization of haemodynamics and mechanical ventilation. This also requires antemortem instrumentation and systemic anticoagulation for organ perseveration in controlled NHBD. Interval support with extracorporeal membrane oxygenation or cardiopulmonary bypass is generally required for optimal organ perfusion and oxygenation in uncontrolled NHBD, which remains a controversial medical practice. There are several unresolved ethical challenges. The circulatory criterion of 2–10 minutes of absent arterial pulse does not comply with the uniform determination of death criterion of the irreversible cessation of functions of the cardiovascular or central nervous systems. There are no robust safeguards in clinical practice that can prevent faulty prognostication, and premature withdrawal of treatment or termination of cardiopulmonary resuscitation. Unmanaged conflicting interests of increasing the supply of transplantable organs can have serious consequences on the medical care of potentially salvageable patients. Perimortem interventions can interfere with the delivery of an optimal quality of end-of-life care. The lack of disclosure of these NHBD ethical controversies does not uphold the moral obligation for an informed consent.
7
Wagner, Beth. Withdrawal of Respiratory Technology. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190204709.003.0012.
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Respiratory failure can be defined as the inability of the lungs to provide adequate oxygenation or ventilation to sustain life. Respiratory failure can lead to abrupt clinical deterioration and is extremely distressing for patients and families. Advances in technology over the past decade have produced many life-sustaining therapies for patients with respiratory failure. Examples include high-flow oxygen therapy, invasive and noninvasive mechanically assisted breathing ventilation, prostacyclin therapy, and extracorporeal membrane oxygenation (ECMO). The care of these complex patients necessitates policies and procedures to assure quality care in withdrawal. Standardized protocols for withdrawal of life-sustaining respiratory therapies provide structured guidance, reduce variation in practice, and improve family and healthcare provider satisfaction.
8
Wise, Matt, and Paul Frost. Terminal care in the intensive care unit. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0153.
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In the UK, around 10%–20% of all patients admitted to the intensive care unit (ICU) do not survive while, in the United States, it has been estimated that 22% of all deaths occur in an ICU. Therefore, terminal or palliative care is as important as any of the life-saving interventions that occur in the ICU. The goal of palliative care is to achieve a good death. In the ICU, the switch from care with curative intent to palliation occurs when it becomes obvious that the patient is not responding to treatment. Typically, this is manifest by deteriorating physiology and escalating organ support in the setting of overwhelming disease or injury. It is predominantly expert opinion (consensus amongst treating medical and nursing teams) that determines the point at which the patient is recognized as not responding to treatment and, in fact, dying. This chapter covers the ethical considerations, communication, family disagreement, organ donation, withdrawal of therapies, care after death, and diagnosing death.
9
Sullivan, Maria A., and Frances R. Levin. Introduction. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199392063.003.0001.
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Alcohol and substance-use disorders in late life have been under-studied. Alcohol and prescription drugs are frequently abused by older Americans, yet addictive disorders are often difficult to identify in this population because of screening instruments adapted to younger adults, stigma and shame that limit help-seeking in older adults, and co-occurring medical and psychiatric conditions that mimic or mask both acute effects and withdrawal syndromes associated with alcohol or substance-use disorders. We will review the evidence for the effectiveness of motivational brief interventions in this population, the need to modify certain pharmacotherapies, including standard detoxification regimens, as well as how to develop age-specific treatment services which tailor the content and pace of presentation toward older adults. Older patients can demonstrate equally or more successful outcomes than younger individuals. This text is intended as a practical handbook to enhance clinical skills in identifying and treating addiction in older adults.
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Wakeman, Sarah E., and Josiah D. Rich. Pharmacotherapy for substance use disorders within correctional facilities. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199360574.003.0046.
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Drug addiction treatment is increasingly complex. Only 5% of prisons and 34% of jails offer any detoxification services, and only 1% of jails offer methadone for opioid withdrawal. Even fewer facilities offer medication assisted therapy (MAT) for alcohol or substance use disorders despite the tremendous evidence base supporting the use of medications to treat addiction. Untreated opioid dependence both within corrections and in the community is associated with HIV, Hepatitis C, crime, and death by overdose. Substantial evidence argues that these risks are reduced through long-term treatment with agonist medications such as methadone and buprenorphine. Only a minority of prisoners receive any addiction treatment while incarcerated. Those that do are usually offered behavioral interventions, which when used alone have extremely poor outcomes. Although there are limited studies on the outcomes of drug treatment during incarceration, there are nearly 50 years of evidence documenting the efficacy of methadone given in the community in reducing opioid use, drug-related health complications, overdose, death, criminal activity, and recidivism. Buprenorphine is similarly an effective, safe, and cost-effective long-term treatment for opioid dependence that reduces other opioid use and improves health and quality of life outcomes. There is a growing role for MAT in jails, and to a lesser degree in prisons for the treatment of alcohol and opiate dependence. This chapter presents the current state of evidence based practice in correctional MAT models.
11
Wakeman, Sarah E., and Josiah D. Rich. Pharmacotherapy for substance use disorders within correctional facilities. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199360574.003.0046_update_001.
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Drug addiction treatment is increasingly complex. Only 5% of prisons and 34% of jails offer any detoxification services, and only 1% of jails offer methadone for opioid withdrawal. Even fewer facilities offer medication assisted therapy (MAT) for alcohol or substance use disorders despite the tremendous evidence base supporting the use of medications to treat addiction. Untreated opioid dependence both within corrections and in the community is associated with HIV, Hepatitis C, crime, and death by overdose. Substantial evidence argues that these risks are reduced through long-term treatment with agonist medications such as methadone and buprenorphine. Only a minority of prisoners receive any addiction treatment while incarcerated. Those that do are usually offered behavioral interventions, which when used alone have extremely poor outcomes. Although there are limited studies on the outcomes of drug treatment during incarceration, there are nearly 50 years of evidence documenting the efficacy of methadone given in the community in reducing opioid use, drug-related health complications, overdose, death, criminal activity, and recidivism. Buprenorphine is similarly an effective, safe, and cost-effective long-term treatment for opioid dependence that reduces other opioid use and improves health and quality of life outcomes. There is a growing role for MAT in jails, and to a lesser degree in prisons for the treatment of alcohol and opiate dependence. This chapter presents the current state of evidence based practice in correctional MAT models.
12
Michelson, Kelly N., and Joel E. Frader. Supportive and End-of-Life Care in the Pediatric Intensive Care Unit. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199918027.003.0020.
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Providing supportive end-of-life care is an essential component of critical care. Intensivists require excellent communication skills to convey painful information in a compassionate manner and to assist families in making difficult decisions. Both aggressive life-supporting treatment and care following a decision to withdraw or withhold life-support require attention to providing adequate comfort care, including relief of pain, anxiety, delirium, agitation, nausea, and other gastrointestinal complaints. Understanding the use of a variety of drugs, including their interactions and side effects, as well as nonpharmacological therapies, is essential. Following a decision to withdraw life support, intensivists should develop a plan that is clear to other care providers and families, minimizes further interventions, and provides as much privacy as possible. After a child dies, numerous tasks must be completed; most important among them are offering parents an opportunity for follow-up support and giving involved staff members time to gather their thoughts and feelings.
13
Ourada, Jason D., and Kenneth L. Appelbaum. Intoxication and drugs in facilities. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199360574.003.0024.
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Active abuse of substances by inmates poses a challenge for correctional psychiatrists. Substance use disorders (SUD) are common among inmates, with higher prevalence usually found in those with general psychiatric conditions. Knowledge about substance use in correctional facilities fosters competent clinical intervention and enhances management at all levels. Psychiatrists working in jails and prisons have the challenging task of maintaining therapeutic alliances with patients who have co-occurring SUDs and also may be actively using substances. Patients might not spontaneously report use during incarceration because they fear retribution by correctional staff or not receiving needed treatment for medical and mental health problems. Psychiatrists need to remain aware of this and to screen for SUD and active substance use as part of comprehensive treatment planning. The clinical challenges in jails and prisons differ, and the substances found in facilities vary geographically. Active substance abuse by inmates presents clinical and systemic challenges for correctional psychiatrists. The interplay among mental health, medical, and custody staff regarding screening, detection, triage, management, and treatment lies at the heart of these challenges. Correctional psychiatrists make important contributions by providing direct assessment and treatment to inmates, and by offering educational, clinical, and policy consultations to other staff. These contributions help prevent potentially life-threatening complications of intoxication and withdrawal, ensure integrated and evidence-based care, and avoid misguided or ill-informed disciplinary or other institutional practices. This chapter highlights these differences, outlines clinical management, and describes an interdisciplinary approach to intervention.
14
Dwyer, Michael. Strangling Angel. Liverpool University Press, 2018. http://dx.doi.org/10.5949/liverpool/9781786940469.001.0001.
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This book is the first comprehensive history of the anti-diphtheria campaign and the factors which facilitated or hindered the rollout of the national childhood immunization programme in Ireland. It is easy to forget the context in which Irish society opted to embrace mass childhood immunization. Dwyer shows us how we got where we are. He restores Diphtheria’s reputation as one of the most prolific child-killers of nineteenth and early twentieth-century Ireland and explores the factors which allowed the disease to take a heavy toll on child health and life-expectancy. Public health officials in the fledgling Irish Free State set the eradication of diphtheria among their first national goals, and eschewing the reticence of their British counterparts, adopted anti-diphtheria immunization as their weapon of choice. An unofficial alliance between Irish medical officers and the British pharmaceutical company Burroughs Wellcome placed Ireland on the European frontline of the bacteriological revolution, however, Wellcome sponsored vaccine trials in Ireland side-lined the human rights of Ireland’s most vulnerable citizens: institutional children in state care. An immunization accident in County Waterford, and the death of a young girl, raised serious questions regarding the safety of the immunization process itself, resulting in a landmark High Court case and the Irish Medical Union’s twelve-year long withdrawal of immunization services. As childhood immunization is increasingly considered a lifestyle choice, rather than a lifesaving intervention, this book brings historical context to bear on current debate.
15
Macauley, Robert C. Neuropalliative Care (DRAFT). Edited by Robert C. Macauley. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199313945.003.0015.
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Neuropalliative care encompasses disorders of consciousness, cognitive impairment, trauma, and other conditions. Each prompts specific ethical considerations, such as the often shifting values (and even personalities) of patients with dementia, forcing one to determine whether previously expressed wishes are determinative. Patients with amyotrophic lateral sclerosis maintain cognition long after motor failure, and the predicable trajectory makes possible specific advance care planning. Patients who have suffered acute spinal cord injury may initially demand withdrawal of life sustaining medical treatment, yet studies have shown a significant proportion eventually achieve a quality of life acceptable to them. And patients who have suffered a stroke often recover significant function, thus making early limitation of treatment a potential “self-fulfilling prophecy.”
16
Hain, Richard D. W. Ethics in paediatric palliative care. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656097.003.0105.
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Professional competence is a necessary but insufficient representation of how an individual health-care professional should properly behave in relation to a patient. Medical ethics addresses the further question of the basis on which actions taken by professionals in the context of that relationship are morally right. Children are distinct from adults in ethically relevant ways. They lack autonomy, both in practice and in principle, and their interests are easily ignored or annexed to others. In practice, ethical questions in children are currently addressed using the ‘four-principles’ or by appealing to rights-based arguments. Behind both are ethical theories (particularly deontology, utilitarian consequentialism, and virtue ethics) that are important, but problematic, in children. This chapter reviews existing ways of looking at ethics in end-of-life care for children, considering three specific contemporary debates in medical ethics in children’s palliative care: the principle of double effect, euthanasia, and withholding or withdrawal of life-sustaining treatment.
17
Veatch, Robert M., Amy Haddad, and E. J. Last. Death and Dying. Edited by Robert M. Veatch, Amy Haddad, and E. J. Last. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780190277000.003.0018.
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Many of the critical moral decisions related to the care of terminally and critically ill patients actually involve the ethical issues of informed consent or the refusal and withdrawal of consent. Legal as well as most ethical theories consider the moral principle of autonomy to take priority over paternalism. If this is true, then it is acceptable for the substantially autonomous patient, even if treatment is life-sustaining, to decline or to withdraw consent. This chapter begins with the problems associated with definitions of death. In succeeding sections, the cases deal with decisions by surrogates for terminally or critically ill patients who are not competent to make their own choices, looking first at formerly competent patients and then at those who have never been competent. In the final section, the issue is new controversies over limiting the amount of care that is provided to terminally ill patients in order to conserve scarce medical resources.
18
Field, John. Therapeutic strategies in managing cardiac arrest. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0064.
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Emergency and critical care specialists are important interdisciplinary physicians who often impact on the long-term survival of patients sustaining cardiac arrest, as well as immediate outcomes. These specialists are often at the crossroads of survival for patients achieving return of spontaneous circulation, and it is important to appreciate that out-of-hospital and in-hospital cardiac arrest patients represent different pathophysiological subgroups with respect to aetiology and pathophysiology. Important time-dependent triage and therapy are crucial, and efforts to identify and treat pathophysiological triggers share priority with the initiation of hypothermia protocols and other targeted interventions, such as coronary angiography and percutaneous coronary intervention. Updated basic life support (BLS) and advanced life support (ACLS) protocols emphasize the importance of high quality chest compressions as central to achieving return of spontaneous circulation and emphasize that airway interventions should not detract from this objective. No specific ACLS intervention including intubation, vasopressor therapy or use of anti-arrhythmic agents has been found to improve outcome. The goal of both BLS and ACLS protocols is the achievement of return of spontaneous circulation, the prevention of re-arrest and the initiation of immediate post-resuscitation interventions associated with improved outcome. These include targeted temperature management (induced hypothermia) and coronary angiography for appropriate patients and ‘bundled’ critical care for all recognizing that the post-arrest state is a systemic inflammatory condition requiring multidisciplinary care beyond hypothermia and cardiovascular support.
19
White, Douglas, and Thaddeus Pope. Medical Futility and Potentially Inappropriate Treatment. Edited by Stuart J. Youngner and Robert M. Arnold. Oxford University Press, 2015. http://dx.doi.org/10.1093/oxfordhb/9780199974412.013.12.
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This article provides a historical, ethical, and conceptual review of medical futility disputes in the intensive care unit (ICU). Particular emphasis is placed on the role that physician power plays in these disputes. Specifically, the article analyzes the circumstances and arguments proposed to justify when physicians may stop life-sustaining treatment without the consent of either the patient or surrogate. The article begins by reviewing the history of the medical futility movement and the causes of medical futility disputes. Second, the major positions and policy statements addressing how such disputes should be resolved are summarized. Third, the article turns from an objective, descriptive approach to a more normative approach by highlighting the value-laden nature of most “futility” judgments regarding potentially inappropriate treatment. Finally, an outline of how clinicians should respond to requests for ICU interventions that they deem medically or ethically inappropriate is provided.
20
Davis, Mary C., Chung Jung Mun, Dhwani Kothari, Shannon Moore, Crys Rivers, Kirti Thummala, and Giulia Weyrich. The Nature and Adaptive Implications of Pain-Affect Dynamics. Oxford University Press, 2018. http://dx.doi.org/10.1093/oso/9780190627898.003.0013.
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Because pain is in part an affective experience, investigators over the past several decades have sought to elaborate the nature of pain-affect connections. Our evolving understanding of the intersection of pain and affect is especially relevant to intervention efforts designed to enhance the quality of life and functional health of individuals managing chronic pain. This chapter describes how pain influences arousal of the vigilance/defensive and appetitive/approach motivational systems and thus the affective health of chronic pain patients. The focus then moves to the dynamic relations between changes in pain and other stressors and changes in positive and negative affect as observed in daily life and laboratory-based experiments. A consensus emerges that sustaining positive affect during pain and stress flares may limit their detrimental effects and promote better functional health. The authors consider the implications of increased understanding of the dynamic interplay between pain and affective experience for enhancing existing interventions.