scholarly journals Ethical Issues at the Beginning of Life

2021 ◽  
Vol 28 (4) ◽  
pp. 143-148
Author(s):  
In Gyu Song
Keyword(s):  
High Risk ◽  
Medical Staff ◽  
Ethical Issues ◽  
Medical Condition ◽  
Neonatal Resuscitation ◽  
Treatment Decision ◽  
Heart Association ◽  
Best Interest ◽  
Treatment Plans ◽  
Life Sustaining Treatment

With improvements in the survival rate of high-risk newborns, the need for ethical considerations is increasing. In the event of a conflict of opinion between the parents and the medical staff about the treatment decision, often there are concerns about who needs to make the decision that would be in the best interest of the baby. In this article, focusing on the guidelines for neonatal resuscitation revised in 2020, ethical issues that may arise before and soon after birth are reviewed. In addition, the considerations in determining the treatment direction for neonates with poor prognosis and the care required for babies and their families during the neonatal period have been investigated. Decisions about withholding or discontinuing neonatal resuscitation are often time-pressed since they are often made when labor is imminent or are needed shortly after the baby’s birth. The recommendations put forth by the American Heart Association in 2020 may be referred toward decision making. Since the medical condition of high-risk newborns also often change rapidly following admission, it becomes necessary to review the treatment goals periodically. Though principles suggested by the American Academy of Pediatrics regarding the treatment decision of high-risk newborns are available, in Korea, it is also essential to consider the country’s law while discussing life-sustaining treatment. Improving the patient's quality of life is equally important as deciding treatment plans and approaches for sustaining life. Toward this, it becomes necessary that the medical staff treating high-risk newborns be educated on palliative care and build a support system.

Fostering medical staff reflection on the technological alienation of parents in the NICU

2021 ◽  
pp. 147775092110618
Author(s):  
Abram Brummett ◽  
Annie B. Friedrich
Keyword(s):  
Medical Staff ◽  
Moral Distress ◽  
Ethical Issues ◽  
Treatment Refusal ◽  
Healthy Newborn ◽  
Incurable Condition ◽  
Life Sustaining Treatment ◽  
Terminal Diagnosis ◽  
The Relationship

We describe a case of parents refusing a tracheostomy for an otherwise healthy newborn. The refusal was not honored because permitting the refusal would have violated state law, which required a child to have a qualifying condition (e.g. a terminal diagnosis, permanent unconsciousness, incurable condition with severe suffering) to remove or withhold life-sustaining treatment. However, this case strained the relationship between the parents and medical staff, who worried about sending the newborn home with a tracheostomy where she was not wanted. While many ethical issues arise in treatment refusal cases like this, we focus on the opportunity for ethicists to help the medical staff reflect on the technological alienation of the parents, which may help foster empathy, reduce moral distress, and strengthen the quality of the doctor-parent-patient triad.

scholarly journals Inter-Physician Variability in Strategies Linked to Treatment Limitations After Severe Traumatic Brain Injury: Proactivity or wait-and-see

2020 ◽  
Author(s):  
Annette Robertsen ◽  
Eirik Helseth ◽  
Reidun Førde
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Ethical Issues ◽  
Ethical Reasoning ◽  
Best Interest ◽  
Worst Case ◽  
Life Sustaining Treatment ◽  
Wait And See ◽  
Prognostic Uncertainty

Abstract BackgroundPrognostic uncertainty is a major challenge for physicians working in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interest arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making in patients with severe traumatic brain injury in the later trauma hospital phase. ResultsA divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team – family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to considering limitations of life-sustaining treatment when the prognosis was grim. They were often the ones who initiated ethical discussions and took leadership in clarification and deliberation processes. They saw themselves as guides for the families and believed both preparation for best-case and worst-case scenarios to be of value. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios. ConclusionsDepending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.Trial registration: Not applicable

scholarly journals Forgoing life sustaining treatment decision-making in critically ill children: Parental views and factor’s influence

2020 ◽  
pp. 147775092095856
Author(s):  
Nurnaningsih Nurnaningsih ◽  
Sri Setiyarini ◽  
Syafa’atun Al Mirzanah ◽  
Retna Siwi Padmawati ◽  
Mohammad Juffrie
Keyword(s):  
Decision Making ◽  
Critically Ill ◽  
Pediatric Intensive Care ◽  
Treatment Decision ◽  
Point Of View ◽  
Critically Ill Children ◽  
Mechanical Support ◽  
Best Interest ◽  
Value Of Children ◽  
Life Sustaining Treatment

Objective Explore parents’ point of view about forgoing life sustaining treatment (LST) in terminal critically ill children and factors affecting their decisions. Method This was a qualitative study using in-depth interviews with parents whose child died between 6–12 months old in pediatric intensive care unit (PICU) of a university-affiliated teaching hospital. Interviews were audiotaped and transcribed. Data were analyzed using interpretive description method. Result A total of 7 parents of 5 children decided to withhold or withdraw LST. Five parents from 4 children decided to sign the do not attempt resuscitation (DNAR), and none choose to withdrew the LST, including mechanical support. Factors influenced their decision were communication, value of children, child best interest, intuition, religious belief, and emotions. Economic factors did not influence the decision-making. Conclusion Most parents decided to sign the DNAR, none choose to withdrew mechanical support. Communication was the most important factor that influenced parents to make a forgoing LST decision.

A review study of nasal endoscopy protocol during the COVID-19 pandemic

2020 ◽  
Vol 2 (CSI) ◽  
pp. 38-41
Author(s):  
Rafid Jabbar
Keyword(s):  
High Risk ◽  
Health Services ◽  
Paranasal Sinus ◽  
Medical Staff ◽  
Nasal Endoscopy ◽  
Paranasal Sinus Diseases ◽  
The World ◽  
Major Procedure ◽  
Risk Of Exposure ◽  
Review Study

During ENT practice, we have to examine the nose and perform several nasal procedures in our clinics. Otolaryngologists are at a high risk of exposure to the COVID-19 virus. Nasal endoscopy is a major procedure for the diagnosis of the nasal and paranasal sinus diseases and introducing proper health services for our patients. In addition, the world is living the era of the COVID-19 pandemic, for which we have to protect ourselves, educate our medical staff, and work together against the spread of this severely contagious disease within our communities. The main purpose of this study is to review the protocol of nasal endoscopy in the ENT clinic and enhance the safest way to deal with patients during this pandemic.(1)

scholarly journals 2021 Update on the Clinical Management and Diagnosis of Kawasaki Disease

2021 ◽  
Vol 23 (3) ◽  
Author(s):  
Frank Zhu ◽  
Jocelyn Y. Ang
Keyword(s):  
High Risk ◽  
Kawasaki Disease ◽  
Corticosteroid Therapy ◽  
Clinical Management ◽  
Treatment Guidelines ◽  
Day Treatment ◽  
Significant Proportion ◽  
Clinical Manifestations ◽  
Heart Association ◽  
Ivig Resistance

Abstract Purpose of Review Provide an updated review of the clinical management and diagnosis of Kawasaki disease with inclusion of potential diagnostic difficulties with multisystem inflammatory syndrome in children (MIS-C) given the ongoing COVID-19 pandemic. Recent Findings Adjunctive corticosteroid therapy has been shown to reduce the rate of coronary artery dilation in children at high risk for IVIG resistance in multiple Japanese clinical studies (most notably RAISE study group). Additional adjunctive therapies (etanercept, infliximab, cyclosporin) may also provide limited benefit, but data is limited to single studies and subgroups of patients with cardiac abnormalities. The efficacy of other agents (atorvastatin, doxycycline) is currently being investigated. MIS-C is a clinically distinct entity from KD with broad clinical manifestations and multiorgan involvement (cardiac, GI, hematologic, dermatologic, respiratory, renal). MIS-C with Kawasaki manifestations is more commonly seen in children < 5 years of age. Summary The 2017 American Heart Association (AHA) treatment guidelines have included changes in aspirin dosing (including both 80–100 mg/kg/day and 30–50 mg/kg/day treatment options), consideration of the use of adjuvant corticosteroid therapy in patients at high risk of IVIG resistance, and the change in steroid regimen for refractory KD to include both pulse-dose IVMP and longer course of prednisolone with an oral taper. A significant proportion of children diagnosed with MIS-C, a post-infectious syndrome of SARS-CoV-2 infection, meet criteria for Kawasaki disease. Further investigation is warranted to further delineate these conditions and optimize treatment of these conditions given the ongoing COVID-19 pandemic.

scholarly journals The effects of a preoperative multidisciplinary conference on outcomes for high-risk patients with challenging surgical treatment options: a retrospective study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Masayoshi Koike ◽  
Mie Yoshimura ◽  
Yasushi Mio ◽  
Shoichi Uezono
Keyword(s):  
Patient Safety ◽  
Retrospective Study ◽  
High Risk ◽  
Treatment Plan ◽  
Treatment Options ◽  
High Risk Patients ◽  
Appropriate Treatment ◽  
Risk Patients ◽  
Treatment Plans ◽  
Multidisciplinary Conference

Abstract Background Surgical options for patients vary with age and comorbidities, advances in medical technology and patients’ wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee. Methods In this retrospective study, we assessed the reasons for convening High-Risk Conferences, the final decisions made and treatment outcomes using conference records and patient medical records for conferences conducted at our institution from April 2010 to March 2018. Results A total of 410 High-Risk Conferences were conducted for 406 patients during the study period. The department with the most conferences was cardiovascular surgery (24%), and the reasons for convening conferences included the presence of severe comorbidities (51%), highly difficult surgeries (41%) and nonmedical/personal issues (8%). Treatment changes were made for 49 patients (12%), including surgical modifications for 20 patients and surgery cancellation for 29. The most common surgical modification was procedure reduction (16 patients); 4 deaths were reported. Follow-up was available for 21 patients for whom surgery was cancelled, with 11 deaths reported. Conclusions Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.

scholarly journals The Indices of Cardiovascular Magnetic Resonance Derived Atrial Dynamics May Improve the Contemporary Risk Stratification Algorithms in Children with Hypertrophic Cardiomyopathy

2021 ◽  
Vol 10 (4) ◽  
pp. 650
Author(s):  
Lidia Ziółkowska ◽  
Łukasz Mazurkiewicz ◽  
Joanna Petryka ◽  
Monika Kowalczyk-Domagała ◽  
Agnieszka Boruc ◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
High Risk ◽  
Risk Stratification ◽  
Heart Association ◽  
The Novel ◽  
Identification Performance ◽  
Strong Trend ◽  
Prognostic Utility ◽  
Conduit Function ◽  
High Risk Children

Introduction: The most efficient risk stratification algorithms are expected to deliver robust and indefectible identification of high-risk children with hypertrophic cardiomyopathy (HCM). Here we compare algorithms for risk stratification in primary prevention in HCM children and investigate whether novel indices of biatrial performance improve these algorithms. Methods and Results: The endpoints were defined as sudden cardiac death, resuscitated cardiac arrest, or appropriate implantable cardioverter-defibrillator discharge. We examined the prognostic utility of classic American College of Cardiology/American Heart Association (ACC/AHA) risk factors, the novel HCM Risk-Kids score and the combination of these with indices of biatrial dynamics. The study consisted of 55 HCM children (mean age 12.5 ± 4.6 years, 69.1% males); seven had endpoints (four deaths, three appropriate ICD discharges). A strong trend (DeLong p = 0.08) was observed towards better endpoint identification performance of the HCM Risk-Kids Model compared to the ACC/AHA strategy. Adding the atrial conduit function component significantly improved the prediction capabilities of the AHA/ACC Model (DeLong p = 0.01) and HCM Risk-Kids algorithm (DeLong p = 0.04). Conclusions: The new HCM Risk-Kids individualised algorithm and score was capable of identifying high-risk children with very good accuracy. The inclusion of one of the atrial dynamic indices improved both risk stratification strategies.

scholarly journals Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Annette Robertsen ◽  
Eirik Helseth ◽  
Reidun Førde
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Severe Traumatic Brain Injury ◽  
Ethical Issues ◽  
Ethical Reasoning ◽  
Depth Information ◽  
Worst Case ◽  
Life Sustaining Treatment ◽  
Wait And See ◽  
Prognostic Uncertainty

Abstract Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.

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