Respecting an autonomous decision to refuse life-saving treatment: a case study

2020 ◽  
Vol 12 (8) ◽  
pp. 304-309
Author(s):  
Emma Moore
Keyword(s):  
Treatment Options ◽  
Respiratory Arrest ◽  
Professional Autonomy ◽  
Prehospital Setting ◽  
Fundamental Aspect ◽  
Duty Of Care ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Life Saving ◽  
Ambulance Crew

Background: Autonomy is a key ethical principle in healthcare, giving patients the right to be involved in their own care. Allowing patients to make decisions based on their own values and beliefs is a fundamental aspect of evidence-based practice. Professional autonomy allows paramedics to make critical decisions around patient care in an emergency, enabling them to provide life-saving treatment. A patient's autonomy can conflict with that of a paramedic, leading to complex ethical situations which can affect the way a paramedic performs their duty of care. Decision-making is a fundamental skill for paramedics and often in the prehospital setting, paramedics have to manage situations with a certain degree of risk if they are to manage patients effectively and safely, while respecting patients' legal and ethical rights. Case presentation: An ambulance crew were called to attend a 62-year-old woman with a history of chronic obstructive pulmonary disease, respiratory arrest and stage 2 respiratory failure, who had breathing difficulties. She was deemed to have capacity by the ambulance crew under the Mental Capacity Act. The patient refused to be taken to hospital for treatment against paramedic recommendation, as she wished to receive no further treatment or hospital admission and wanted to die at home. The ambulance crew referred her to her GP. Conclusions: Paramedics experience great difficulties in making decisions, as information and alternative treatment options are often limited in the prehospital setting. One major limitation to autonomy is where an autonomous patient is refusing life-saving treatment. This can create ethical dilemmas for paramedics, leaving them to feel a sense of vulnerability and anxiety around performing their duty of care. The law is clear: an autonomous patient's decision to refuse treatment, even if it may seem unwise, must be respected in accordance with the Human Rights Act 1998.

scholarly journals Cell therapy for lung disease

2017 ◽  
Vol 26 (144) ◽  
pp. 170044 ◽  
Author(s):  
Sabine Geiger ◽  
Daniela Hirsch ◽  
Felix G. Hermann
Keyword(s):  
Clinical Studies ◽  
Therapeutic Approach ◽  
Lung Diseases ◽  
Distress Syndrome ◽  
Treatment Options ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Cell Therapies ◽  
Promising Therapeutic Approach ◽  
Preclinical And Clinical Studies

Besides cancer and cardiovascular diseases, lung disorders are a leading cause of morbidity and death worldwide. For many disease conditions no effective and curative treatment options are available. Cell therapies offer a novel therapeutic approach due to their inherent anti-inflammatory and anti-fibrotic properties. Mesenchymal stem/stromal cells (MSC) are the most studied cell product. Numerous preclinical studies demonstrate an improvement of disease-associated parameters after MSC administration in several lung disorders, including chronic obstructive pulmonary disease, acute respiratory distress syndrome and idiopathic pulmonary fibrosis. Furthermore, results from clinical studies using MSCs for the treatment of various lung diseases indicate that MSC treatment in these patients is safe. In this review we summarise the results of preclinical and clinical studies that indicate that MSCs are a promising therapeutic approach for the treatment of lung diseases. Nevertheless, further investigations are required.

scholarly journals A Systematic Review of Risk Factors Associated with Near-Fatal and Fatal Asthma

2005 ◽  
Vol 12 (5) ◽  
pp. 265-270 ◽  
Author(s):  
GG Alvarez ◽  
M Schulzer ◽  
D Jung ◽  
JM FitzGerald
Keyword(s):  
Risk Factors ◽  
Mechanical Ventilation ◽  
Inhaled Corticosteroids ◽  
Respiratory Arrest ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Mortality And Morbidity ◽  
Factors Associated ◽  
Fatal Asthma ◽  
The Impact

BACKGROUND: Asthma mortality and morbidity continue to be a serious global problem. Systematic reviews provide an opportunity to review risk factors in detail.OBJECTIVE: To review all of the literature for risk factors associated with near-fatal asthma (NFA) and fatal asthma (FA).METHODS: A literature search from 1960 to January 2004 in MEDLINE and EMBASE was conducted. Studies were included based on the following criteria: NFA was defined as an asthma exacerbation resulting in respiratory arrest requiring mechanical ventilation or a partial pressure of CO2of at least 45 mmHg or asthma resulting in death (FA); the study reported the number of cases (NFA and/or FA) and asthmatic controls; there was explicit reporting of risk factors; cases that were adult and pediatric in nature; and all study types. Studies that included patients with chronic obstructive pulmonary disease were excluded.RESULTS: Four hundred and three articles were identified, of which 27 met the inclusion criteria. Increased use of medications such as beta-agonists via metered dose inhalers (OR=1.67, 95% CI 0.99 to 2.84, P=0.057) and nebulizers (OR=2.45, 95% CI 1.52 to 3.93, P=0.0002), oral steroids (OR=2.71, 95% CI 1.34 to 5.51, P=0.006) and oral theophylline (OR=2.02, 95% CI 1.03 to 3.98, P=0.04) and a history of hospital (OR=2.62, 95% CI 1.04 to 6.58, P=0.04) and/or intensive care unit (OR=5.14, 95% CI 1.91 to 13.86, P=0.001) admissions and mechanical ventilation (OR=6.69, 95% CI 2.80 to 15.97, P=0.0001) due to asthma were predictors of NFA and FA. Prior emergency department assessment did not confer a greater risk of NFA and FA (OR=1.13, 95% CI 0.43 to 2.92, P=0.810).The use of inhaled corticosteroids (ICS) measured in a dose-independent fashion (did the patient take ICS previously; yes or no) inferred equivocal risk of NFA and FA (OR=1.31, 95% CI 0.83 to 2.05, P=0.25). However, two studies measured the use of ICS in a dose-dependent fashion (ie, measured the number of prescriptions filled within the previous six to 12 months). Both studies showed a trend toward a protective effect against FA. One study showed that the premature cessation of ICS can hasten death.CONCLUSIONS: In the present study, risk factors of NFA and FA have been more accurately defined. Clinicians should identify patients with these characteristics to reduce their risk of NFA and FA. Further research should focus on quantifying the impact of risk factors on asthma deaths.

scholarly journals Glycopyrrolate/eFlow CS: The First Nebulized Long-Acting Muscarinic Antagonist Approved to Treat Chronic Obstructive Pulmonary Disease

2018 ◽  
Vol 53 (3) ◽  
pp. 285-293 ◽  
Author(s):  
Roy A. Pleasants
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Pulmonary Disease ◽  
Data Extraction ◽  
Treatment Options ◽  
Dose Finding ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Muscarinic Antagonist ◽  
Patient Reported ◽  
Long Acting

Objective: To review the pharmacology, efficacy, and safety of the first nebulized long-acting muscarinic antagonist (LAMA), glycopyrrolate (GLY)/eFlow closed system (CS) nebulizer, approved for maintenance treatment of chronic obstructive pulmonary disease (COPD). Data Sources: A PubMed search was conducted (January 2000 to July 2018) using the following terms/phrases: nebulized glycopyrrolate, inhalation devices in COPD, long-acting muscarinic antagonists COPD, and COPD survey. Retrieved articles were reviewed to identify additional references. Study Selection and Data Extraction: Primary and review articles on GLY/eFlow CS and other treatment options for patients with COPD were selected. Data Synthesis: Guidelines recommend the use of LAMAs, alone or in combination with long-acting β2-agonists, as maintenance therapy for the majority of patients with COPD. With the range of different devices and bronchodilators now available, treatment can be tailored based on individual needs. The eFlow CS nebulizer delivers GLY rapidly over a 2- to 3-minute period and provides bronchodilation within 30 minutes, lasting 12 hours. Phase 2 dose-finding and phase 3 studies demonstrated sustained statistically significant and clinically important improvements in pulmonary function and patient-reported outcomes with GLY/eFlow CS. Relevance to Patient Care and Clinical Practice: GLY/eFlow CS provides a novel, portable, efficient, and rapid drug delivery system. Conclusions: The recently approved GLY/eFlow CS drug-device combination provides a viable treatment option for patients with COPD, particularly those with conditions that may impair proper use of traditional handheld inhalers.

scholarly journals Interstitial Lung Disease in Rheumatoid Arthritis Remains a Challenge for Clinicians

2019 ◽  
Vol 8 (12) ◽  
pp. 2038 ◽  
Author(s):  
Elisabeth Bendstrup ◽  
Janne Møller ◽  
Sissel Kronborg-White ◽  
Thomas Skovhus Prior ◽  
Charlotte Hyldgaard
Keyword(s):  
Rheumatoid Arthritis ◽  
Interstitial Lung Disease ◽  
Lung Disease ◽  
Treatment Options ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Antifibrotic Therapy ◽  
New Treatment ◽  
Diagnostic Work ◽  
Evidence Based Therapy

Interstitial lung disease (ILD) is a serious complication of rheumatoid arthritis (RA) contributing to significantly increased morbidity and mortality. Other respiratory complications, such as chronic obstructive pulmonary disease and bronchiectasis, are frequent in RA. Infections and drug toxicity are important differential diagnoses and should be considered in the diagnostic work-up of patients with RA presenting with respiratory symptoms. This review provides an overview of the epidemiology and pathogenesis of RA-ILD, the radiological and histopathological characteristics of the disease as well as the current and future treatment options. Currently, there is no available evidence-based therapy for RA-ILD, and immunosuppressants are the mainstay of therapy. Ongoing studies are exploring the role of antifibrotic therapy in patients with progressive fibrotic ILD, which may lead to a new treatment approach for subgroups of patients with RA-ILD.

scholarly journals Antiviral immunity is impaired in COPD patients with frequent exacerbations

2019 ◽  
Vol 317 (6) ◽  
pp. L893-L903 ◽  
Author(s):  
Aran Singanayagam ◽  
Su-Ling Loo ◽  
Maria Calderazzo ◽  
Lydia J. Finney ◽  
Maria-Belen Trujillo Torralbo ◽  
...  
Keyword(s):  
Epithelial Cells ◽  
Treatment Options ◽  
Stable State ◽  
Innate Immune ◽  
Chronic Obstructive ◽  
Type I ◽  
Obstructive Pulmonary Disease ◽  
Immune Mediators ◽  
Copd Patients

Patients with frequent exacerbations represent a chronic obstructive pulmonary disease (COPD) subgroup requiring better treatment options. The aim of this study was to determine the innate immune mechanisms that underlie susceptibility to frequent exacerbations in COPD. We measured sputum expression of immune mediators and bacterial loads in samples from patients with COPD at stable state and during virus-associated exacerbations. In vitro immune responses to rhinovirus infection in differentiated primary bronchial epithelial cells (BECs) sampled from patients with COPD were additionally evaluated. Patients were stratified as frequent exacerbators (≥2 exacerbations in the preceding year) or infrequent exacerbators (<2 exacerbations in the preceding year) with comparisons made between these groups. Frequent exacerbators had reduced sputum cell mRNA expression of the antiviral immune mediators type I and III interferons and reduced interferon-stimulated gene (ISG) expression when clinically stable and during virus-associated exacerbation. A role for epithelial cell-intrinsic innate immune dysregulation was identified: induction of interferons and ISGs during in vitro rhinovirus (RV) infection was also impaired in differentiated BECs from frequent exacerbators. Frequent exacerbators additionally had increased sputum bacterial loads at 2 wk following virus-associated exacerbation onset. These data implicate deficient airway innate immunity involving epithelial cells in the increased propensity to exacerbations observed in some patients with COPD. Therapeutic approaches to boost innate antimicrobial immunity in the lung could be a viable strategy for prevention and treatment of frequent exacerbations.

scholarly journals The assessment of new drugs for asthma and COPD: a Delphi study examining the perspectives of Italian payers and clinicians

2016 ◽  
Vol 11 ◽  
Author(s):  
Silvia Sommariva ◽  
Aureliano P. Finch ◽  
Claudio Jommi
Keyword(s):  
Delphi Study ◽  
Treatment Options ◽  
Airflow Obstruction ◽  
Real Life ◽  
New Drugs ◽  
Chronic Obstructive ◽  
Obstructive Pulmonary Disease ◽  
Important Place ◽  
Consensus Document ◽  
Critical Issues

Background: Asthma and chronic obstructive pulmonary disease (COPD) are disorders of the lungs characterized by airflow obstruction, inflammation and tissue remodeling. Management of patients with these diseases is complex and the improvement of diagnostic-therapeutic strategies represents a critical challenge for the healthcare system. In this context, investigating the criteria and information needed for an appropriate and effective evaluation of incoming treatment options is crucial to ensure that clinicians and policy-makers are provided with the best available evidence to make decisions aimed at improving patient outcomes. Therefore, the objective of this study was to investigate the degree of agreement among Health Technology Assessment (HTA) experts on issues crucial to the evaluation of new drugs for asthma and COPD and to appropriately manage the clinical pathway for patients. Methods: This research was conducted using an e-Delphi technique organized in three subsequent rounds and involving a panel of ten experts (six regional and local payers and four clinicians). Panelists were asked to comment in written form on a set of statements, explaining qualitatively the extent to which they agreed or disagreed with the assertions. Statements were subsequently modified and resubmitted for assessment. Results: Panelists expressed their opinions during each round and, after round III, a consensus document was finalized. The degree of consensus was high among experts and concerned five main topics: (a) the need to address current unmet needs of patients with asthma or COPD, (b) the importance of further studies and real-life information in the evaluation of treatments, (c) existing evidence and evidence needed to assess drugs, (d) critical issues in obtaining a positive evaluation from regional and local authorities for new treatments to be included in regional formularies and to have an important place in therapeutic categories, and (e) the major obstacles to the appropriate administration of drugs and management of patients. Conclusion: The final document highlights that no proof of difference among drugs exists, that evidence on final endpoints (and particularly on mortality) should be strengthened and that actions regarding risk factors, appropriate diagnosis, patient staging and adherence to therapy are particularly important for a better clinical management.

scholarly journals The quandary of prehospital oxygen administration in chronic obstructive pulmonary disease - a review of the literature

2015 ◽  
Vol 6 (1) ◽  
Author(s):  
Elizabeth Perry ◽  
Brett Wiliams
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
Pulmonary Disease ◽  
Prehospital Setting ◽  
Chronic Obstructive ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
Obstructive Pulmonary Disease ◽  
Oxygen Administration ◽  
Mesh Terms ◽  
Copd Patients

Introduction Perpetual debate continues regarding the amount of oxygen that should delivered by paramedics to patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). A number of studies argue that providing excessive levels of oxygen in COPD patients results in hypercapnic respiratory failure. Despite the prevalence of COPD there continues to be a paucity of prehospital literature on this topic. To review and analyse the literature regarding prehospital administration of oxygen therapy in patients with COPD. Methods Literature review using a variety of medical databases including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL and PubMed. The following MeSH terms were used in the search: lung diseases, obstructive; emergency medical services; respiratory therapy Results Using exclusion and inclusion criteria a total of 9 papers were located. There is a lack of high quality evidence to adequately address the issue of oxygen prescription to COPD patients in the prehospital setting. It is recommended that oxygen flow is titrated in COPD patients to maintain SpO2 between 90-92%. Conclusion There is a need for randomised controlled trials in the prehospital setting to address the issue regarding oxygen prescription for COPD patients. Oxygen can be titrated using pulse oximetry to minimize complications of hypoxia and the risk of hypercapnia from excessively high oxygen concentration.

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