The role of policy and law in shaping the ethics and quality of end-of-life care in intensive care

Dzeng, Elizabeth; Bein, Thomas; Curtis, J. Randall

doi:10.1007/s00134-022-06623-2

Cited by 14 publications

(5 citation statements)

References 8 publications

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“…Furthermore, even clinicians who were familiar with the relevant laws stated that their decisions were largely driven by patient factors and not by a desire to be compliant with the law. Together, these studies suggest that while palliative care laws have the potential to affect clinical care and outcomes, the extent is questionable when implemented in an intertwined system where national and institutional culture, institutional policies, clinicians, and patients are all mutually influenced . Indeed, in individual state-year analyses, we observed heterogeneity with regard to the magnitude of the association between palliative care laws with place of death, suggesting that the extent of outcomes from a palliative care law may be highly dependent on differences in its implementation or environmental factors.…”

Section: Discussionmentioning

confidence: 86%

Place of Death From Cancer in US States With vs Without Palliative Care Laws

et al. 2023

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ImportanceIn the US, improving end-of-life care has become increasingly urgent. Some states have enacted legislation intended to facilitate palliative care delivery for seriously ill patients, but it is unknown whether these laws have any measurable consequences for patient outcomes.ObjectiveTo determine whether US state palliative care legislation is associated with place of death from cancer.Design, Setting, and ParticipantsThis cohort study with a difference-in-differences analysis used information about state legislation combined with death certificate data for 50 US states (from January 1, 2005, to December 31, 2017) for all decedents who had any type of cancer listed as the underlying cause of death. Data analysis for this study occurred between September 1, 2021, and August 31, 2022.ExposuresPresence of a nonprescriptive (relating to palliative and end-of-life care without prescribing particular clinician actions) or prescriptive (requiring clinicians to offer patients information about care options) palliative care law in the state-year where death occurred.Main Outcomes and MeasuresMultilevel relative risk regression with state modeled as a random effect was used to estimate the likelihood of dying at home or hospice for decedents dying in state-years with a palliative care law compared with decedents dying in state-years without such laws.ResultsThis study included 7 547 907 individuals with cancer as the underlying cause of death. Their mean (SD) age was 71 (14) years, and 3 609 146 were women (47.8%). In terms of race and ethnicity, the majority of decedents were White (85.6%) and non-Hispanic (94.1%). During the study period, 553 state-years (85.1%) had no palliative care law, 60 state-years (9.2%) had a nonprescriptive palliative care law, and 37 state-years (5.7%) had a prescriptive palliative care law. A total of 3 780 918 individuals (50.1%) died at home or in hospice. Most decedents (70.8%) died in state-years without a palliative care law, while 15.7% died in state-years with a nonprescriptive law and 13.5% died in state-years with a prescriptive law. Compared with state-years without a palliative care law, the likelihood of dying at home or in hospice was 12% higher for decedents in state-years with a nonprescriptive palliative care law (relative risk, 1.12 [95% CI 1.08-1.16]) and 18% higher for decedents in state-years with a prescriptive palliative care law (relative risk, 1.18 [95% CI, 1.11-1.26]).Conclusions and RelevanceIn this cohort study of decedents from cancer, state palliative care laws were associated with an increased likelihood of dying at home or in hospice. Passage of state palliative care legislation may be an effective policy intervention to increase the number of seriously ill patients who experience their death in such locations.

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Section: Discussionmentioning

confidence: 86%

Place of Death From Cancer in US States With vs Without Palliative Care Laws

et al. 2023

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“…Firstly, this was a survey of physicians’ reported practices and beliefs in France, and therefore, may not generalizable to other countries or cultures. However, the French experience is often cited as a model for reflection on the ethics and quality of end-of-life care in intensive care [ 53 ]. Secondly, we cannot exclude selection bias, in particular related to the dissemination of the study information through the RESC network.…”

Section: Discussionmentioning

confidence: 99%

Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians’ beliefs

Giabicani

Arditty²,

Mamzer

et al. 2023

PLoS ONE

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Introduction Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. Methods Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. Results Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient’s wishes would help avoid these conflicts. Conclusion Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.

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“…Illustrative examples from the data were included. Adapted with permission from Dzeng et al DNR indicates do not resuscitate; ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit.…”

Section: Methodsmentioning

confidence: 99%

“…We interviewed clinicians and administrators with different clinical backgrounds and organizational responsibilities. This project was guided by a conceptual framework based on a literature review and prior work by the authors (Figure 1 44 ). 31,36,44,45 This conceptual framework was continuously refined throughout the project as more data were collected and analyzed.…”

Section: Designmentioning

confidence: 99%

Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers

Dzeng

Batten

Dohan³

et al. 2023

JAMA Intern Med

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ImportanceThere is substantial institutional variability in the intensity of end-of-life care that is not explained by patient preferences. Hospital culture and institutional structures (eg, policies, practices, protocols, resources) might contribute to potentially nonbeneficial high-intensity life-sustaining treatments near the end of life.ObjectiveTo understand the role of hospital culture in the everyday dynamics of high-intensity end-of-life care.Design, Setting, and ParticipantsThis comparative ethnographic study was conducted at 3 academic hospitals in California and Washington that differed in end-of-life care intensity based on measures in the Dartmouth Atlas and included hospital-based clinicians, administrators, and leaders. Data were deductively and inductively analyzed using thematic analysis through an iterative coding process.Main Outcome and MeasureInstitution-specific policies, practices, protocols, and resources and their role in the everyday dynamics of potentially nonbeneficial, high-intensity life-sustaining treatments.ResultsA total of 113 semistructured, in-depth interviews (66 women [58.4%]; 23 [20.4%] Asian, 1 [0.9%] Black, 5 [4.4%] Hispanic, 7 [6.2%] multiracial, and 70 [61.9%] White individuals) were conducted with inpatient-based clinicians and administrators between December 2018 and June 2022. Respondents at all hospitals described default tendencies to provide high-intensity treatments that they believed were universal in US hospitals. They also reported that proactive, concerted efforts among multiple care teams were required to deescalate high-intensity treatments. Efforts to deescalate were vulnerable to being undermined at multiple points during a patient’s care trajectory by any individual or entity. Respondents described institution-specific policies, practices, protocols, and resources that engendered broadly held understandings of the importance of deescalating nonbeneficial life-sustaining treatments. Respondents at different hospitals reported different policies and practices that encouraged or discouraged deescalation. They described how these institutional structures contributed to the culture and everyday dynamics of end-of-life care at their institution.Conclusions and RelevanceIn this qualitative study, clinicians, administrators, and leaders at the hospitals studied reported that they work in a hospital culture in which high-intensity end-of-life care constitutes a default trajectory. Institutional structures and hospital cultures shape the everyday dynamics by which clinicians may deescalate end-of-life patients from this trajectory. Individual behaviors or interactions may fail to mitigate potentially nonbeneficial high-intensity life-sustaining treatments if extant hospital culture or a lack of supportive policies and practices undermine individual efforts. Hospital cultures need to be considered when developing policies and interventions to decrease potentially nonbeneficial, high-intensity life-sustaining treatments.

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The role of policy and law in shaping the ethics and quality of end-of-life care in intensive care

Cited by 14 publications

References 8 publications

Place of Death From Cancer in US States With vs Without Palliative Care Laws

Place of Death From Cancer in US States With vs Without Palliative Care Laws

Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians’ beliefs

Hospital Culture and Intensity of End-of-Life Care at 3 Academic Medical Centers

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