Moral Distress Amongst American Physician Trainees Regarding Futile Treatments at the End of Life: A Qualitative Study.

BACKGROUND: Ethical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients. OBJECTIVE: We asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress. DESIGN: Semi-structured in-depth qualitative interviews. PARTICIPANTS: Twenty-two internal medicine residents and fellows across three American academic medical centers. APPROACH: This study uses systematic qualitative methods of data gathering, analysis and interpretation. KEY RESULTS: Physician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life. CONCLUSIONS: Moral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful.This study was funded by the Health Resources and Service Administration T32 HP10025-20 Training Grant, the Gates Cambridge Scholarship, Society of General Internal Medicine Founders Grant, and the Ho-Chiang Palliative Care Research Fellowship at the Johns Hopkins School of Medicine.This is the author accepted manuscript. The final version is available from Springer via http://dx.doi.org/10.1007/s11606-015-3505-

Three cases of feline panleukopenia associated to canine parvovirus variants

In this study, the results of haematological, virological and molecular analyses carried out on three cats with clinical signs of feline panleukopenia are reported. Parvovirus strains were detected in clinical samples of all cats by means of virus isolation and/or real-time PCR using a TaqMan probe. Unexpectedly, these feline strains were characterised as canine parvovirus variants 2a or 2c by MGB assays and/or sequence analysis of the VP2 gene. The detection of canine parvovirus strains in cats with overt disease poses some concerns about the efficacy of commercially-available feline panleukopenia vaccines against the canine viruses that have been repeatedly reported in cats

Canine parvovirus type 2c infection in a kitten associated with intracranial abscess and convulsions

A case of canine parvovirus type 2c (CPV-2c) infection in a 3-month-old feral kitten with a cerebral abscess and neurological disease is reported. The cat displayed ataxia and convulsions together with signs of gastroenteritis and profound alteration of the total and differential white blood cell counts. A parvovirus strain was detected by a TaqMan assay in the blood and faeces of the affected kitten, which was characterised as CPV by means of molecular assays but did not react with any of the CPV type-specific probes. By sequence and phylogenetic analyses of the VP2-protein gene, the CPV-2c strain displayed a non-coding mutation in the probe-binding region. Although the role of CPV-2c in this particular case is unclear, it is possible that it predisposed the kitten to the clinical signs seen. Continuous surveillance is needed to monitor future spreading of this CPV-2c mutant, and any associated clinical signs, in the dog and cat populatio

Detection of canine parvovirus type 2c by a commercially available in-house rapid test

Diagnosis of canine parvovirus (CPV) infection is usually carried out by means of rapid immunochromatographic assays, but the ability of these tests to detect all CPV variants, including the recently identified CPV-2c, is still debated. To determine if the assays detect the different CPV variants, 201 CPV PCR-positive faecal samples or rectal swabs were tested using a commercially available in-house test. Specimens (CPV-2a, n = 51; CPV-2b, n = 50; CPV-2c, n = 100), containing CPV DNA loads >10(5) DNA copies/mg faeces, as determined by real-time PCR, were selected from previous studies. The percentage of positive in-house tests was 80.4%, 78.0% and 77.0% for CPV types 2a, 2b and 2c, respectively, confirming the ability of the test to detect the new variant CPV-2c. However, considering the sensitivity limits of the in-house tests that have been observed previously, negative results from the in-house test kit should be confirmed by PCR-based methods

Experimental infection of dogs with a novel strain of canine coronavirus causing systemic disease and lymphopenia

A pantropic canine coronavirus (CCoV) strain (CB/05) has been recently associated to a fatal outbreak of systemic disease in young dogs. We report the clinical, virological and serological findings in dogs experimentally infected with strain CB/05. The dogs, three 2.5-month-old and two 6-month-old pups, were successfully infected, shedding viral RNA with their faeces for the entire observation period (21 days) and displaying systemic clinical signs resembling those observed during the course of natural infection. Leucopenia (acute lymphopenia) occurred in all infected dogs, with values dropping below 60% of the initial counts. Considering the severity of the CB/05-induced disease, two of the youngest pups were euthanized for ethical reasons at days 8-9 postinfection, whereas the other pups underwent a slow but progressive improvement of their clinical status with complete recovery. At postmortem examination, remarkable lesions were observed in the internal organs of the euthanized pups, that tested positive for CCoV by real-time RT-PCR and virus isolation on cell cultures. All pups seroconverted for CCoV, as shown by the high optical density values and antibody titres detected by ELISA and virusneutralisation tests, respectively. The present study confirms that strain CB/05 is highly pathogenic for dogs, being able to induce a severe disease (and in some cases the death) even in experimental conditions

Molecular characterization of Canine minute virus associated with neonatal mortality in a litter of Jack Russell terrier dogs

The molecular characterization of a strain of Canine minute virus (CnMV) associated with neonatal death is reported. Three newborn puppies of a litter of Jack Russell terrier dogs died after displaying systemic disease, whereas 2 surviving puppies showed no clinical signs with the exception of transient cardiac abnormalities that were evident by electrocardiography. Necropsy of 1 dead puppy revealed severe lesions in the internal organs. A strain of Canine minute virus was detected in tissue samples collected from the puppy, and virus circulation was demonstrated by molecular or serological testing in the dam, puppies of the same litter, and other puppies in the same kennel. By sequence and phylogenetic analysis of the gene encoding for the VP2 capsid protein, the strain circulating in the kennel was found to be related to recent Asian CnMV isolates. Continuous molecular surveillance for CnMV in kennels, shelters, and rescue centers would expand the knowledge base on the epidemiological and pathogenetic features of CnMV, which has been known for several decades but still poorly understoo

Long-term shedding of Canine alphaherpesvirus 1 in naturally infected newborn pups

The long-term shedding of Canine alphaherpesvirus 1 (CaHV-1) by neonatal pups with natural infection is reported. The pups belonged to a litter of 11 pointers of a breeding kennel in southern Italy, 9 of which developed a fatal form of systemic infection, as resulted by the detection of CaHV-1 in internal organs (kidney, liver, lung and brain) of one of this dogs and in the vaginal swab of their mother. The two remaining animals displayed a milder form of disease, with one pup showing ocular involvement, and underwent a progressive recovery. These pups were monitored from 11 to 36 days of age, showing a long-term shedding of the virus through the nasal and ocular secretions and the faeces. CaHV-1 shedding, as assessed by means of a specific and sensitive real-time PCR assay, occurred mainly through the nasal secretions, although the pup displaying ocular disease shed the virus at high titres and for a long period even in the ocular secretions