A application of mind OF PROACTIVE...

A application of mind OF PROACTIVE ETHICS CONSULTATION FOR CRITICALLY AND TERMINALLY ILL PATIENTS WITH expanded LENGTHS OF STAY

M D Dowdy, C Robertson, J A Bander Critical Care M Vol 26 (February 1998) 252-259

End-of-life decisions have become more difficult with the advancement of medical technology. The ability to sustain life brings questions involving extended suffering, emotional stress, financial debilitation, and resource allocation. Ethics consultation oftentimes is used to facilitate decision making in similar complex cases. This study sought to assess the efficiency of proactive ethics consultation upon documented patient care communications and upon decisions regarding high-risk patients in the intensive care unit (ICU). The authors hypothesized that proactive ethics consultation could be used as a process-oriented intervention for improving communication and decision making among physicians, patients, and health care team members.

courses This prospective, controlled study analyzed the charts and documentation of 99 patients in the ICU treated with more than 96 hours of continuous mechanical ventilation. After discharge, data regarding patient age, form relative to sex primary and secondary diagnoses, system of payment, admission and following code status, patient acuity, amplification of stay, decisional capacity, advance directives, do-not-resuscitate orders, formal ethics consultation, and consultation with other health care professionals were accumulateed by chart review.

Three assemblages compared were

* a baseline form into groups enrolled in the study before establishment of the hospital's ethics consultation service,

* a superintendence group in which ethics consultation was the option of health care team members, and

* a treatment cluster in which the ethics consultants intervened proactively after patients had received more than 96 hours of mechanical ventilation.

Physicians and care team members reviewed patient care planning for treatment cluster members using a standardized place of prompting questions designed to focus forward key issues of decision making and communication. make anxiouss were identified, and action strategies were indicateed Formal ethics consultation was made available forward request.

Consultants informally met with give suck tos chaplains, social workers, and other allied health care professionals involved in patient care to inform them of the consultants' character and to encourage sharing of information and team communication. An observational tool was exhibited to gather patients' medical record documentation. These medical record items were used as a quality of communication index. The interest in communication was restricted intentionally to documented information relevant to end-of-life decisions. make easy validity was reviewed by the hospital's medical executive committee members and accepted for the intentions of this study.

Analysis of variance was used to determine the multivariate relationships of quality of communication and longitudinal dimensions of stay between survivors and nonsurvivors. A chi-square criterion was used separately to compare do-not-resuscitate orders and other life-sustaining treatment decisions. Step-wise regression analysis was used to determine variables that best predicted hospital charges.

accrues Postoperative chart reviews of the three assign places tos indicated no statistically significant differences of important demographic variables, including age, inflection for sex and acuity. Comparisons of survivors and nonsurvivors for the three clusters indicated -- at statistically significant of the same heights -- more frequent and documented communication, more attend much [i]or[/i] regularly decisions to forgo life-sustaining treatment, and reduc extent of stay in the ICU for the treatment cluster members. Additionally, differences in patient charges among the collections were not statistically significant and, thus, too small to raise expectations of proactive ethics consultation as a reliable order for reducing hospital costs.

Limitations of this cogitation derive from the small and actual specific sample size. Additionally, the standardization of a process-oriented intervention is difficult to reign over The range of variables may be expanded in the hereafter to focus on communication, advance directives, or decision-making skills. Proactive ethics consultation for high-risk patient populations put forwards a promising approach to improving decision making and communication and reducing duration of ICU stay for patients who are terminally ill.

Discussion. sum of two units characteristics of proactive ethics consultation emerg from the thought First, consultation in the application of mind was provided before an identified ethical riddle or conflict occurred. A next to the first characteristic involved the shift in the initial focus from ethical question s to clinical communication essential to quality patient care and to hardy ethical dialogue. Additionally, staff members perceived a shift in attitude to common that placed greater value forward collaboration among all members of the team.

Physicians and supply with nourishments expressed greater conviction that patients and their surrogates should be kept informed and involved in decision making, and that patients could be approached about difficult situations without stimulating defensiveness, fear, or hopelessnes The authors conclud that the bare mention of ethical issues no longer implied wrongdoing.