Eric L. Krakauer

Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status

IN US HOSPITALS, CARDIOPULMONARY RESUSCITATION (CPR) is the de facto default option—patients must “opt out” by requesting or consenting to a do-not-attemptresuscitation order. Despite its worthy intent, requiring all patients or their surrogates to consent to a do-notattempt-resuscitation order to avoid CPR has resulted in an ethically unjustifiable practice that exposes many patients to substantial harms. Whenever there is a plausible risk of cardiac arrest, the standard approach is to ask patients or their surrogates about their preferences regarding CPR. However, the very act of asking can suggest to the patient and family that CPR may be beneficial, even when the clinician believes otherwise. Additionally, research in cognitive psychology has revealed that default options are often interpreted as recommendations or guidelines, or as the path of least resistance, and that such default options significantly affect decision making. For these reasons, patients or their surrogates may be biased toward choosing full resuscitation status, even when CPR likely would bring little or no benefit and would risk considerable harm. Therefore, the standard approach of neutrally seeking consent to withhold CPR may inadvertently diminish patients’ and families’ comprehension of the clinical situation and lead to decisions that are grounded neither in patients’ values nor in their best interest. Instead of assuming that CPR must always be offered, we suggest 3 distinct approaches based on the likelihood and degree of potential benefits and harms of resuscitation. In all 3 approaches, physicians must take the time to fully explain the patient’s prognosis and likely disease trajectory, clarify any misconceptions, and elicit the patient’s values and goals, which should form the basis for all CPR discussions. However, the options offered by the physician should change as the likely proportion of burdens to benefits increases.

On Patient Autonomy and Physician Responsibility in End-of-Life Care

In current medical practice, excessive or reflexive deference to an unreflective concept of patient autonomy may inadvertently compromise patient autonomy by placing unwanted and unreasonable responsibility for technical medical decisions on patients or their surrogate decision makers rather than on their physicians. Such practices can harm patients by depriving them of the expert, professional advice they both need and deserve to make important decisions about their health care. We describe herein how the patient-physician relationship has evolved in recent decades as more life-sustaining and life-saving treatments, such as cardiopulmonary resuscitation, have become available. We then examine respect for patient autonomy and describe how patient autonomy can be promoted while the physicians responsibility for technical medical decisions is simultaneously affirmed. The patient is the expert on his or her values, goals, and preferences, while the physician is the expert on the medical means for honoring the patients perspective. We conclude that an intervention, such as cardiopulmonary resuscitation, should not be offered when, based on the patients own criteria, it promises no physical or psychosocial benefit or would be far more harmful than beneficial.

Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report

Felicia Marie Knaul, Paul E Farmer*, Eric L Krakauer*, Liliana De Lima, Afsan Bhadelia, Xiaoxiao Jiang Kwete, Héctor Arreola-Ornelas, Octavio Gómez-Dantés, Natalia M Rodriguez, George A O Alleyne, Stephen R Connor, David J Hunter, Diederik Lohman, Lukas Radbruch, María del Rocío Sáenz Madrigal, Rifat Atun†, Kathleen M Foley†, Julio Frenk†, Dean T Jamison†, M R Rajagopal†, on behalf of the Lancet Commission on Palliative Care and Pain Relief Study Group‡

Differences in the quality of the patient-physician relationship among terminally ill African-American and white patients: impact on advance care planning and treatment preferences.

Little is known about the quality of the patient–physician relationship for terminally ill African Americans. To compare the quality of the patient–physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST). Cross sectional survey of 803 terminally ill African-American and white patients. Patient-reported quality of the patient–physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis). The quality of the patient–physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52–0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03–1.58; aRR = 1.25, 95%CI = 1.07–1.47, respectively). Additional adjustment for the quality of the patient–physician relationship had no impact on the differences in ACP and treatment preferences. Lower reported patient–physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.

Opioid Inaccessibility and Its Human Consequences: Reports From the Field

ABSTRACT Strong opioids such as morphine are rarely accessible in low- and middle-income countries, even for patients with the most severe pain. The three cases reported here from three diverse countries provide examples of the terrible and unnecessary suffering that occurs everyday when this essential, inexpensive, and safe medication is not adequately accessible by patients in pain. The reasons for this lack of accessibility are explored, and ways to resolve the problem are proposed.

Just palliative care: responding responsibly to the suffering of the poor.

The disproportionate suffering of the worlds poor from AIDS and cancer has generated efforts to promote palliative care as an affordable alternative to expensive disease-modifying therapies. These well-intentioned efforts stem from a wish to respond to the suffering of the poor as quickly and widely as possible and from the view that only inexpensive interventions are feasible in poor settings. Such efforts also may be informed by the cautious attitude of palliative care in rich countries toward disease-modifying treatments for patients with advanced life-threatening illnesses. Yet, acceptance of unequal access for the poor to life-saving medical services that are badly needed and potentially feasible is unjust. Although palliative interventions to relieve the disproportionate physical, psychological, and social suffering of the poor are essential, they should be integrated with preventive and disease-modifying interventions for major killers, such as acquired immunodeficiency syndrome and cancer.

Experience with a hospital policy on not offering cardiopulmonary resuscitation when believed more harmful than beneficial

PURPOSE This study investigated the impact of age, race, and functional status on decisions not to offer cardiopulmonary resuscitation (CPR) despite patient or surrogate requests that CPR be performed. METHODS This was a retrospective cohort study of all ethics committee consultations between 2007 and 2013 at a large academic hospital with a not offering CPR policy. RESULTS There were 134 cases of disagreement over whether to provide CPR. In 45 cases (33.6%), the patient or surrogate agreed to a do-not-resuscitate (DNR) order after initial ethics consultation. In 67 (75.3%) of the remaining 89 cases, the ethics committee recommended not offering CPR. In the other 22 (24.7%) cases, the ethics committee recommended offering CPR. There was no significant relationship between age, race, or functional status and the recommendation not to offer CPR. Patients who were not offered CPR were more likely to be critically ill (61.2% vs 18.2%, P < .001). The 90-day mortality rate among patients who were not offered CPR was 90.2%. CONCLUSIONS There was no association between age, race, or functional status and the decision not to offer CPR made in consultation with an ethics committee. Orders to withhold CPR were more common among critically ill patients.

Assessing and Responding to Palliative Care Needs in Rural Sub-Saharan Africa: Results from a Model Intervention and Situation Analysis in Malawi

Introduction Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences. Methods Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP’s first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders. Results The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available. Conclusions We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.

Vietnam's Palliative Care Initiative: Successes and Challenges in the First Five Years

In 2005, Vietnams Ministry of Health (MoH) launched a palliative care initiative that uses the World Health Organization (WHO) public health strategy for national palliative care program development. With international financial and technical support, the initiative has made significant early progress. A rapid situation analysis in 2005 led to national Guidelines on Palliative Care in 2006, radically improved opioid prescribing regulations in 2008, the training of more than 400 physicians in palliative care by early 2010 using three curricula written especially for Vietnam, and the initiation of palliative care services in some hospitals and in the community. Yet, access to palliative care services remains very limited. Many challenges must be overcome to reach the goal of access for all to essential palliative care services that are integrated into the systems of cancer care, HIV/AIDS care, and primary care. Going forward, crucial aspects of the initiative will be continued commitment to palliative care by the MoH, careful planning and targeted funding that address each part of the WHO public health strategy, ongoing expert technical support, and collaboration among international technical and financial supporters.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.