Withdrawing life support and resolution of conflict with families.
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ABSTRACT:
SUBMITTER: Way J
PROVIDER: S-EPMC1124803 | biostudies-literature | 2002 Dec
REPOSITORIES: biostudies-literature
Publications
Withdrawing life support and resolution of conflict with families.
Way Jenny J Back Anthony L AL Curtis J Randall JR
BMJ (Clinical research ed.) 20021201 7376
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Project description:ObjectiveTo describe a series of patients with heart failure supported with a ventricular assist device (VAD) who requested (or whose surrogates requested) withdrawal of VAD support and the legal and ethical aspects pertaining to these requests.Patients and methodsWe retrospectively reviewed the medical records of patients at Mayo Clinic, Rochester, MN, from March 1, 2003, through January 31, 2009, who requested (or whose surrogates requested) withdrawal of VAD support and for whom the requests were fulfilled. We then explored the legal and ethical permissibility of carrying out such requests.ResultsThe median age of the 14 patients identified (13 men, 1 woman) was 57 years. Requests were made by 2 patients and 12 surrogates. None of the patients' available advance directives mentioned the VAD. For 11 patients, multidisciplinary care conferences were held before withdrawal of VAD support. Only 1 patient had an ethics consultation. All 14 patients died within 1 day of withdrawal of VAD support.ConclusionPatients have the right to refuse or request the withdrawal of any unwanted treatment, and we argue that this right extends to VAD support. We also argue that the cause of death in these cases is the underlying heart disease, not assisted suicide or euthanasia. Therefore, patients with heart failure supported with VADs or their surrogates may request withdrawal of this treatment. In our view, carrying out such requests is permissible in accordance with the principles that apply to withdrawing other life-sustaining treatments.
| S-EPMC2931614 | biostudies-literature
Project description:Study aimPsychosocial stress can complicate the first phase of life for young families. One group that has received little attention so far are families with increased parental stress and conflict potential. This paper aims to 1) classify knowledge and use of support services for families with increased parental stress and conflict potential and 2) describe the psychosocial characteristics and parenting behaviours of these families.MethodsFor this purpose, data from a representative cross-sectional study in 2015 with n=7 549 families as well as the follow-up study with n=905 families were analyzed. Parents who took their child to a pediatrician's office for a screening examination (U3-U7a) completed a written questionnaire. Knowledge and use of services were assessed using four pre-defined stress groups (unstressed, socioeconomically stressed, with parental stress and conflict potential, and highly burdened).ResultsFamilies with increased parental stress and conflict potential are less likely to receive support offers. Despite high knowledge of selective prevention services, they use these offers less frequently than socioeconomically or highly stressed families. They are more likely to report dysfunctional parenting behaviors.ConclusionThis raises the question of whether families with increased parental stress and conflict potential receive too little support because they have no clearly visible need for help or whether they are adequately provided for due to the high socioeconomic resources, service knowledge, and use of universal medical and family education services. The results provide important information for the care of families in various stressful situations and contribute to the assessment of the need for support.
| S-EPMC11248269 | biostudies-literature
Project description:To evaluate the effect of 1) patient values as expressed by family members and 2) a requirement to document patients' functional prognosis on intensivists' intention to discuss withdrawal of life support in a hypothetical family meeting.A three-armed, randomized trial.One hundred seventy-nine U.S. hospitals with training programs in critical care accredited by the Accreditation Council for Graduate Medical Education.Six hundred thirty intensivists recruited via e-mail invitation from a database of 1,850 eligible academic intensivists.Each intensivist was randomized to review 10, online, clinical scenarios with a range of illness severities involving a hypothetical patient (Mrs. X). In control-group scenarios, the patient did not want continued life support without a reasonable chance of independent living. In the first experimental arm, the patient wanted life support regardless of functional outcome. In the second experimental arm, patient values were identical to the control group, but intensivists were required to record the patient's estimated 3-month functional prognosis.Response to the question: "Would you bring up the possibility of withdrawing life support with Mrs. X's family?" answered using a five-point Likert scale. There was no effect of patient values on whether intensivists intended to discuss withdrawal of life support (p = 0.81), but intensivists randomized to record functional prognosis were 49% more likely (95% CI, 20-85%) to discuss withdrawal.In this national, scenario-based, randomized trial, patient values had no effect on intensivists' decisions to discuss withdrawal of life support with family. However, requiring intensivists to record patients' estimated 3-month functional outcome substantially increased their intention to discuss withdrawal.
| S-EPMC4128685 | biostudies-literature
Project description:Past attempts to characterize the neural mechanisms of affective priming have conceptualized it in terms of classic cognitive conflict, but have not examined the neural oscillatory mechanisms of subliminal affective priming. Using behavioral and electroencephalogram (EEG) time frequency (TF) analysis, the current study examines the oscillatory dynamics of unconsciously triggered conflict in an emotional facial expressions version of the masked affective priming task. The results demonstrate that the power dynamics of conflict are characterized by increased midfrontal theta activity and suppressed parieto-occipital alpha activity. Across-subject and within-trial correlation analyses further confirmed this pattern. Phase synchrony and Granger causality analyses (GCAs) revealed that the fronto-parietal network was involved in unconscious conflict detection and resolution. Our findings support a response conflict account of affective priming, and reveal the role of the fronto-parietal network in unconscious conflict control.
| S-EPMC5943601 | biostudies-literature
Project description:There are two main behavioral expressions of multisensory integration (MSI) in speech; the perceptual enhancement produced by the sight of the congruent lip movements of the speaker, and the illusory sound perceived when a speech syllable is dubbed with incongruent lip movements, in the McGurk effect. These two models have been used very often to study MSI. Here, we contend that, unlike congruent audiovisually (AV) speech, the McGurk effect involves brain areas related to conflict detection and resolution. To test this hypothesis, we used fMRI to measure blood oxygen level dependent responses to AV speech syllables. We analyzed brain activity as a function of the nature of the stimuli-McGurk or non-McGurk-and the perceptual outcome regarding MSI-integrated or not integrated response-in a 2 × 2 factorial design. The results showed that, regardless of perceptual outcome, AV mismatch activated general-purpose conflict areas (e.g., anterior cingulate cortex) as well as specific AV speech conflict areas (e.g., inferior frontal gyrus), compared with AV matching stimuli. Moreover, these conflict areas showed stronger activation on trials where the McGurk illusion was perceived compared with non-illusory trials, despite the stimuli where physically identical. We conclude that the AV incongruence in McGurk stimuli triggers the activation of conflict processing areas and that the process of resolving the cross-modal conflict is critical for the McGurk illusion to arise. Hum Brain Mapp 38:5691-5705, 2017. © 2017 Wiley Periodicals, Inc.
| S-EPMC6866806 | biostudies-literature
Project description:Conflicts are ubiquitous between individuals as well as between groups. Effective conflict resolution is essential for individual well-being and group functioning and often involves leadership dynamics. The evolutionary human sciences have suggested that conflict resolution is shaped by psychological heuristics, norms and ecology. There are limited empirical data, however, on conflict resolution across cultures. Using a cross-cultural database of 109 leadership dimensions coded from over 1200 text records from the eHRAF ethnographic database, exploratory analyses investigated correlates of conflict resolution. The results revealed greater evidence of conflict resolution among kin groups than political groups and greater evidence of within-group conflict resolution than between-group, which did not vary across subsistence strategies or group contexts, with two exceptions - military group conflicts were biased towards between-group contexts and religious groups biased towards within-group contexts. The strongest predictors of conflict-resolution services were other prosocial functions and included group representation and providing counsel, protection and punishment, as well as qualities of interpersonal skills and fairness. Followers received social service benefits and reduced risk of harm. For leaders who resolve conflicts, status and social benefits were potential negative predictors. These results provide a comparative view of the correlates of conflict resolution suggesting diversity across social contexts.
| S-EPMC10427275 | biostudies-literature
Project description:ObjectivesTo investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center.MethodsThree hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis.ResultsEighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support.ConclusionsWithdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.
| S-EPMC4037202 | biostudies-literature
Project description:ObjectiveTo identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates.DesignObservational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST.ResultsOf 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74).ConclusionsAmong infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST.
| S-EPMC8055718 | biostudies-literature
Project description:RationaleFamilies of critically ill patients are often asked to make difficult decisions to pursue, withhold, or withdraw aggressive care or resuscitative measures, exercising "substituted judgment" from the imagined standpoint of the patient. Conflict may arise between intensive care unit (ICU) physicians and family members regarding the optimal course of care.ObjectivesTo characterize how ICU physicians approach and manage conflict with surrogates regarding end-of-life decision-making.MethodsSemistructured interviews were conducted with 18 critical care physicians from four academically affiliated hospitals. Interview transcripts were analyzed using methods of grounded theory.ResultsPhysicians described strategies for engaging families to resolve conflict about end-of-life decision-making and tending to families' emotional health. Physicians commonly began by gauging family receptiveness to recommendations from the healthcare team. When faced with resistance to recommendations for less aggressive care, approaches ranged from deference to family wishes to various persuasive strategies designed to change families' minds, and some of those strategies may be counterproductive or harmful. The likelihood of deferring to family in the event of conflict was associated with the perceived sincerity of the family's "substituted judgment" and the ability to control patient pain and suffering. Physicians reported concern for the family's emotional needs and made efforts to alleviate the burden on families by assuming decision-making responsibility and expressing nonabandonment and commitment to the patient. Physicians were attentive to repairing damage to their relationship with the family in the aftermath of conflict. Finally, physicians described their own emotional responses to conflict, ranging from frustration and anxiety to satisfaction with successful resolution of conflict.ConclusionsCritical care physicians described a complex and multilayered approach to physician-family conflict. The reported strategies offer insight into pragmatic approaches to achieving resolution of conflict while attending to both family and physician emotional impact, and they also highlight some potentially unhelpful or harmful behaviors that should be avoided. Further research is needed to evaluate how these strategies are perceived by families and other ICU clinicians and how they affect patient, family, and clinician outcomes.
| S-EPMC5822405 | biostudies-literature
Project description:Palliative sedation (PS) is the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life. Although uncommon, some patients undergoing aggressive symptom control measures still have severe suffering from underlying disease or therapy-related adverse effects. In these circumstances, use of PS is considered. Although the goal is to provide relief in an ethically acceptable way to the patient, family, and health care team, health care professionals often voice concerns whether such treatment is necessary or whether such treatment equates to physician-assisted suicide or euthanasia. In this review, we frame clinical scenarios in which PS may be considered, summarize the ethical underpinnings of the practice, and further differentiate PS from other forms of end-of-life care, including withholding and/or withdrawing life-sustaining therapy and physician-assisted suicide and euthanasia.
| S-EPMC2947968 | biostudies-literature