Saturday, January 24, 2015

5th International Conference on Advance Care Planning and End-of-Life Care (ACPEL)

The 5th International Conference on Advance Care Planning and End-of-Life Care (ACPEL) will be held from 9 to 12 September 2015 in Munich, Germany.  The Call for Abstracts is open until 15 Feb 2015.

Already booked sessions include:
  • Does the plan actually represent what the patient wanted? - Susan Hickman, Respecting Choices
  • ACP in Palliative Care Evaluation of implementation - Rebecca Sudore, UCSF School of Medicine, San Francisco
  • Setting the agenda for the next two years - Sara Davison, Dpt of Nephrology, University of Alberta
  • What do we know about the economic case? - Josie Dixon, LSE London, GB
  • Nationwide adoption of an ACP program by a large U.S. health provider (HMO) - Daniel Johnson, Kaiser Permanente
  • Facilitator Training and (Re-)Certification - Bud Hammes, Respecting Choices, La Crosse

Friday, January 23, 2015

Death Test: Criteria for Screening and Triaging to Appropriate ALternative Care (CRISTAL)

Australian critical care physician Ken Hillman and health services researcher Magnolia Cardona-Morrell have just published a new checklist in BMJ Supportive and Palliative Care:  "Development of a Tool for Defining and Identifying the Dying Patient in Hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL)."

The goal is to develop an evidence-based screening tool to identify elderly patients at the end of life and quantify the risk of death in hospital or soon after discharge.  The Telegraph calls it a "death test."


This should minimize prognostic uncertainty and avoid potentially harmful and futile treatments.  After all, an unambiguous checklist may assist clinicians in reducing uncertainty patients who are likely to die within the next 3 months and help initiate transparent conversations with families and patients about end-of-life care. 


Thursday, January 22, 2015

A Better Death: End of Life Care: Doctors, Machines and Technology Can Keep Us Alive, but Why?

The Vancouver Sun has just published the first of a significant 3-part series on "A Better Death": "End of Life Care: Doctors, Machines and Technology Can Keep Us Alive, but Why?"

Wednesday, January 21, 2015

Managing Conscientious Objections in Intensive Care Medicine

I was delighted to be a part of this ad hoc subcommittee of this American Thoracic Society Ethics and Conflict of Interest Committee that developed An Official Policy Statement: "Managing Conscientious Objections in Intensive Care Medicine."  It was just published in the American Journal of Respiratory and Critical Care Medicine 191(2): 219–227.

"Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs."

"The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients."


"The committee recommends that: 

  1. COs in ICUs be managed through institutional mechanisms
  2. Institutions accommodate COs,  provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution
  3. A clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate
  4. Institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting."

Tuesday, January 20, 2015

VSED & Complexities of Choosing an End Game for Dementia

On the front page of today's Science section of the New York Times, Paula Span has an important story, " Complexities of Choosing an End Game for Dementia."

Can you specify in advance of severe dementia, "triggering conditions" to ensure that nobody tries to keep you alive by spoon feeding or offering liquids?

Can people who develop dementia use VSED (“voluntarily stopping eating and drinking”) to end their lives by including such instructions in an advance directive?

Monday, January 19, 2015

Involvement of ICU Families in Decisions: Fine-tuning the Partnership

Elie Azoulay and colleagues in Paris has just published "Involvement of ICU Families in Decisions: Fine-tuning the Partnership" in the Annals of Intensive Care.



















I have written a lot about the resolution of intractable end-of-life conflicts.  If the lessons and strategies in this article were followed, there would be far fewer such conflicts.

Here is the abstract:

"Families of patients are not simple visitors to the ICU. They have just been separated from a loved one, often someone they live with, either abruptly or, in nearly half the cases, because a chronic condition has suddenly worsened. They must cope with a serious illness of a loved one, while having to adapt to the unfamiliar and intimidating ICU environment. In many cases, the outcome of the critical illness is uncertain, a situation that causes considerable distress to the relatives. 

"As shown by our research group and others, families exhibit symptoms of anxiety (70%) and depression (35%) in the first few days after admission, as well as symptoms of stress (33%) and difficulty understanding the information delivered by the healthcare staff (50%). Furthermore, relatives of patients who die in the ICU are at risk for psychiatric syndromes such as generalized anxiety, panic attacks, depression, and posttraumatic stress syndrome. In this setting of psychological distress, families are asked to consider sharing in healthcare decisions about their loved one in the ICU."

"This article aims to foster the debate about the shared decision-making process. We have three objectives: to transcend the overly simplistic position that opposes paternalism and autonomy, to build a view founded only on an evaluation of actual practice and experience in the field, and to keep the focus squarely on the patient. Families want information and communication time from the staff. Nurses and physicians need to understand that families can share in decisions only if the entire ICU staff actively promotes family involvement and, of course, if the family wants to participate in all or part of the decision-making process."

Saturday, January 17, 2015

"Being Mortal" - Atul Gawande on FRONTLINE

On February 10, FRONTLINE follows renowned New Yorker writer and Boston surgeon Atul Gawande as he explores the relationships doctors have with patients who are nearing the end of life. 

In conjunction with Gawande's new book, Being Mortal, the film investigates the practice of caring for the dying, and shows how doctors -- himself included -- are often remarkably untrained, ill-suited and uncomfortable talking about chronic illness and death with their patients.

Friday, January 16, 2015

Virginia to Strengthen Futile Care Law

This week, Virginia introduced a new bill (S.B. 2153) that would strengthen and clarify that state's long-standing futile care law.

CURRENT VIRGINIA LAW

Current law provides that "Nothing in this article shall be construed to require a physician to prescribe or render health care to a patient that the physician determines to be medically or ethically inappropriate. . . .  If the conflict remains unresolved, the physician shall make a reasonable effort to transfer the patient to another physician who is willing to comply with the request . . . .  The physician shall provide . . . a reasonable time of not less than fourteen 14 days to effect such 27 transfer. During this period, the physician shall continue to provide any life-sustaining care . . . ." 

PROPOSED AMENDMENT
The bill would add the following language.  "If, at the end of the 14-day period, the physician has been unable to transfer the patient to another physician who is willing to comply with the request of the patient, the terms of the advance directive, the decision of the agent or person authorized to make decisions pursuant to § 54.1-2986, or the Durable Do Not Resuscitate Order despite reasonable efforts, the physician may cease to provide care that he has determined to be medically or ethically inappropriate."