Denying Death: The Terminally Critically Ill.

We describe a subgroup of the Chronically Critically Ill (CCI) we call the Terminally Critically Ill as demonstrated by terminally ill cancer patients. These cancer patients, though clearly terminally ill and with relatively short prognoses, can be kept alive for extended periods with medical interventions aimed at treating the complications of the cancer and cancer treatment. Such interventions can be painful, exhausting, costly and may interfere with attending to end of life concerns. We present a typical (composite) case and discuss ethical concerns regarding this growing subgroup of the chronically critically ill patients for whom death is routinely denied and delayed for extended periods.

Developing a Standardized Ethics Consultation Note Template Based on the Formatting Preferences of Stakeholders.

Effective documentation is considered a core competency for clinical ethics consultation. Ethics consultants within the Cleveland Clinic in Cleveland, Ohio, observed variation in the formatting of ethics chart notes across consultants and realized that this formatting was based on their own views of effectiveness. To minimize variation and optimize the readability and understandability of ethics chart notes for end users, a team undertook a quality improvement project to assess the formatting preferences of healthcare professionals who rely on ethics consultation notes. The team developed three sample templates and conducted interviews with stakeholders to understand their preferences. A single standardized template was developed based on the preferences that emerged, which all consultants on the ethics consultation service then utilized. In the first five months of implementation, the percentage of end user respondents marking the highest Likert scale option on a post-consultation survey regarding whether the ethics consultation service provided helpful documentation increased from 60 percent to 72 percent compared to the same five-month period in the year prior.

Medical and Ethical Concerns Regarding Pacemaker Implantation in a Patient with Substance Use Disorder.

Medical and ethical dilemmas surrounding endocarditis and cardiac valve replacements related to intravenous drug use have been described often. Less well-described are dilemmas associated with pacemaker implantation in such patients. We describe a patient with a substance use disorder for whom a pacemaker was medically indicated.

In My Best Interest.

BACKGROUND: Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration's Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. OBJECTIVE: To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. DESIGN/SETTING: A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. MEASUREMENTS: Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. RESULTS: Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. CONCLUSION: Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.

Family members' requests to extend physiologic support after declaration of brain death: a case series analysis and proposed guidelines for clinical management.

We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients' ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS's advice and recommendations generally promoted "reasonable accommodation" of the requests, balancing compassion for grieving families with other ethical and moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finite-goal accommodation, a "reasonable accommodation" strategy proved effective in balancing stakeholders' interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the "reasonable accommodation" approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases.