Kenneth Prager

The Critical Role of Religion: Caring for the Dying Patient from an Orthodox Jewish Perspective

BACKGROUND AND OBJECTIVE Culturally competent medical care for the dying patient by families and health care professionals is a challenging task especially when religious values, practices, and beliefs influence treatment decisions for patients at the end of life. This article describes end-of-life guidelines for hospital health care professionals caring for Orthodox Jewish patients and their families. Religious perspectives on advance directives, comfort care and pain control, nutrition and hydration, do not resuscitate/do not intubate (DNR/DNI), and extubation are often unfamiliar to the American medical community. DESIGN The guidelines for the care of the dying Orthodox Jewish patient were mutually agreed upon by the authors, recognized authorities in medicine, ethics, and Jewish law, who presented their perspectives during a 1-day symposium and who participated in an active working-group session. CONCLUSIONS Care of the religious patient close to death is enormously complex especially when balancing religious obligations, the role of the rabbi, medical procedures, and personal preferences. These guidelines address from a religious perspective profound issues such as the definition of death, organ donation, and caring for the patient at lifes end. The guidelines can be useful for any hospital that serves an Orthodox Jewish population.

Determination of Brain Death by Apnea Test Adapted to Extracorporeal Cardiopulmonary Resuscitation

d b WHEN CARDIOPULMONARY RESUSCITATION (CPR) has to be prolonged for more than 10 to 30 minutes, survival and neurologic outcomes are dismal.1 This has spurred the institution of rescue extracorporeal membrane oxygenation (ECMO), known as extracorporeal cardiopulmonary resuscitation (ECPR). In this situation, ECMO provides both circulatory and oxygenation support via a system called venoarterial ECMO (VA-ECMO). Vascular access is achieved via the jugular and/or femoral route, and venous blood is drained into the ECMO device, oxygenated, warmed, and pumped back into the arterial system (Fig 1). An added benefit is that ECPR can facilitate therapeutic interventions that potentially could reverse the cause of the cardiac arrest or collapse (eg, emergent coronary revascularization or relief of cardiac tamponade). ECPR also allows the provision of therapeutic hypothermia by precise blood temperature control. There is some evidence, most of it from Taiwan, that ECPR in patients suffering from in-hospital cardiac arrest improves both shortand long-term survival when compared with conventional CPR,2,3 although this finding has not been consistent.1 The Extraorporeal Life Support Organization, a worldwide registry of more han 170 centers,4 has reported a steady increase in the number of atients receiving ECPR over the last 2 decades (Table 1).5 Although ECPR potentially may enhance survival and neurologic outcome, a substantial proportion of patients will nonetheless sustain severe neurologic complications, and there is a 1 in 5 hance of brain death.5 The 3 clinical findings necessary to confirm brain death include coma with a known cause, the absence of brainstem reflexes, and apnea (Table 2). The definitive diagnosis of brain death during ECPR is technically and logistically challenging. Conventional apnea testing is not feasible because oxygenation and carbon dioxide elimination are accomplished by ECMO. The transportation of a patient to the radiology suite for

Medical care for the elderly: should limits be set?

The current Medicare operation—reimbursing medical goods and services to a growing number of people without basing the reimbursement benefit on the actual cost of the services—is unsustainable, but there are some possible remedies. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

The appropriate use of increasingly sophisticated life-sustaining technology.

The medical community should formulate guidelines for appropriate use of organ-replacement therapies, taking into consideration the resources involved and the clinical expectation that the therapy can serve as a bridge to recovery or transplantation or can be a destination therapy.

When Physicians and Surrogates Disagree about Futility

Situations in which the patients family seems not to be acting in good faith or the patients suffering is uncontrollable are relatively rare and do not warrant giving physicians unilateral power to withhold or withdraw treatment in all cases of perceived medical futility.

The Right to Information—A First Step Toward Improving End-of-Life Care

To the Editor: New York recently became the second state in the nation to enact legislation that requires physicians to offer terminally ill patients an opportunity to discuss end-of-life options. The PalliativeCare InformationAct, whichwent into effect on February 9, 2011, mandates that New York attending doctors and nurse practitioners offer terminally ill patients information and counseling on palliative care and appropriate end-of-life options. The law expects that patients will be provided with information about their prognosis, the risks and benefits of the various treatment options, and the right to comprehensive pain and symptom management, including palliative sedation for refractory suffering. Advocates of the legislation see this as a progressive step to enhance patient and family decision making by providing information about choices at the end of life. Opponents of the legislation, like the Medical Society of the State of New York, worry that it will interfere with the physician-patient relationship, and that each physician should decide how much information to disclose. That we need a law in the first place to instruct clinicians to provide what most people say they would want if faced with a life-limiting illnessdhonest and accurate information about their disease and its treatmentdis disconcerting. However, as New York teaching hospitals are ranked near the bottom nationally in usage of hospice care for cancer patients at the end of life, a state mandate seemed appropriate.

Guide to Considering Nonpsychiatric Medical Intervention Over Objection for the Patient Without Decisional Capacity

A considerable percentage of medical inpatients are communicative but lack decisional capacity. These patients also often lack surrogates, particularly when they are homeless, elderly, mentally ill, or substance users. Caring for such patients often raises ethical dilemmas, particularly when the patient refuses a proposed medical intervention. Legal and ethical guidelines regarding patients without capacity focus on treating for psychiatric illnesses, do-not-resuscitate orders, and withdrawal of life-sustaining therapies. Even with these guidelines, one study found that more than 80% of decisions for patients lacking decisional capacity and without surrogates were made, often inappropriately, by physicians without hospital oversight. These unilateral decisions can raise multiple ethical problems, including physician bias, conflict of interest, and violation of autonomy. Beyond suggesting ethics committee consultation, nearly no guidance is available to the physician, or the ethics committee itself, when considering nonpsychiatric medical intervention over objection. In addition, even when a surrogate is present, he or she would likely benefit from physician guidance to help make a sound decision. Therefore, a structured approach delineating the core questions to address in these situations can be a helpful tool for physicians and surrogates alike, even if only as preparation for an ethics consult or committee meeting, or for the ethics committee itself. We propose here a 7-question approach, and we apply this approach to 3 real cases. Comprehensive psychiatric consultations determined that each of these 3 patients lacked capacity to decide on the proposed interventions using previously described criteria. Patients were probed and engaged to the fullest, but they could not or would not provide more insight than we present below. Rigorous

Consent for organ donation after circulatory death at U.S. transplant centers

ABSTRACT Background: Despite calls for a controlled organ donation after circulatory death (cDCD) consent process that is more rigorous, consistent, and transparent, little is known about the cDCD consent processes utilized by U.S. hospitals. The objective of this research was to describe the cDCD consent policies of U.S. transplant hospitals, including consent for antemortem interventions (AMI), in order to inform the development of a more rigorous and sound consent process. Methods: Cross-sectional study data of cDCD policies of U.S. transplant hospitals were collected between July 2013 and October 2014. Respondents submitted their policies for investigator review and/or completed a 25-item Web-based survey describing their hospitals cDCD and AMI policies. There were 209 U.S. adult transplant hospitals identified through the Organ Procurement and Transplantation Network (OPTN). Results: One hundred responses were received, representing 48% of all 209 U.S. transplant hospitals and 60% of the 168 transplant centers with an identified knowledgeable informant. In 79 policies (79%), organ procurement organization representatives (OPOs) are given sole responsibility for obtaining signed cDCD consent. Thirty-four policies (34%) give OPOs the responsibility for obtaining written AMI consent, 13 policies give it to treating physicians, and 6 policies state that AMI consent must be obtained collaboratively. Treating physicians have no delineated responsibilities in the cDCD and AMI consent process in 70 (70%) and 58 (58%) policies, respectively. We observed wide variability in the acceptability of first-person authorization (FPA) for cDCD and AMI; FPA was rejected as evidence of consent for cDCD and AMI in 7 and 11 policies, respectively. Conclusions: The cDCD consent policies of U.S. transplant hospitals are highly variable and inconsistent in addressing key aspects of the consent process. The major policy differences observed raise questions about what constitutes a sound and comprehensive cDCD consent policy.

Reply to Drs Rady and Verheijde

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