20 research outputs found
Quality of life in elderly ICU survivors before the COVID-19 pandemic: a systematic review and meta-analysis of cohort studies
Objectives The influence of age on intensive care unit
(ICU) decision-making
is complex, and it is unclear if
it is based on expected subjective or objective patient
outcomes. To address recent concerns over age-based
ICU
decision-making,
we explored patient-assessed
quality of
life (QoL) in ICU survivors before the COVID-19
pandemic.
Design A systematic review and meta-analysis
of cohort
studies published between January 2000 and April 2020,
of elderly patients admitted to ICUs.
Primary and secondary outcome measures We
extracted data on self-reported
QoL (EQ-5D
composite
score), demographic and clinical variables. Using a
random-effect
meta-analysis,
we then compared QoL
scores at follow-up
to scores either before admission, age-matched
population controls or younger ICU survivors. We
conducted sensitivity analyses to study heterogeneity and
bias and a qualitative synthesis of subscores.
Results We identified 2536 studies and included 22 for
qualitative synthesis and 18 for meta-analysis
(n=2326
elderly survivors). Elderly survivorsâ QoL was significantly
worse than younger ICU survivors, with a small-to-
medium
effect size (d=0.35 (â0.53 and â0.16)). Elderly survivorsâ
QoL was also significantly greater when measured slightly
before ICU, compared with follow-up,
with a small effect
size (d=0.26 (â0.44 and â0.08)). Finally, their QoL was
also marginally significantly worse than age-matched
community controls, also with a small effect size (d=0.21
(â0.43 and 0.00)). Mortality rates and length of follow-up
partly explained heterogeneity. Reductions in QoL seemed
primarily due to physical health, rather than mental health
items.
Conclusions The results suggest that the proportionality
of age as a determinant of ICU resource allocation should
be kept under close review and that subjective QoL
outcomes should inform person-centred
decision -aking in
elderly ICU patients.
PROSPERO registration number CRD42020181181
Aide memoire for a balancing act? Critiquing the 'Balance Sheet' approach to best interest decision-making
The balance sheet is commonly used as a deliberative approach to decide best interests in Court of
Protection and family cases in England and Wales, since Thorpe LJ in Re A (Male Sterilisation)
described the balance sheet as a tool to enable judges and best interests decision-makers to quantify,
compare, and calculate the different options at play. Recent judgments have critically reflected on the
substance and practical function of the balance sheet approach, highlighting the practical stakes of its
implicit conceptual assumptions and normative commitments. Using parallel debates in
proportionality, we show that the balance sheet imports problematic assumptions of commensurability
and aggregation, which can both overdetermine the outcome of best interests decisions and obfuscate
the actual process of judicial deliberation. This means that the decision-making of judges and best
interests assessors more generally could fail to properly reflect the nature of values at stake, as well as
the skills of practical judgment needed to compare such values with sensitivity and nuance. The paper
argues that critical reflection of the balance sheet makes vital space for a more contextualised,
substantive mode of deliberation which emphasises skills of qualitative evaluation towards enhancing
conditions of articulation around the range of values involved in best interests decision-making
Recommended from our members
Implementing advance care plans in the peri-operative period, including plans for cardiopulmonary resuscitation: Association of Anaesthetists clinical practice guideline.
Contemporary guidance takes a patient-centred approach and recommends discussing and planning treatments that should be considered, not just those that should be withheld. Although some organisations and communities still use specific DNACPR (do not attempt cardiopulmonary resuscitation) forms to recommend that cardiopulmonary resuscitation is not attempted, this approach has been shown to have disadvantages and is no longer regarded as best practice. The following guidelines have been produced in response to this change. They are designed to help anaesthetists, as part of the wider healthcare team, to implement and respond to advance care planning documents before and during procedures. The guidelines apply to all procedures, however minor and low risk they are considered to be, and the same ethical and legal principles apply to procedures carried out under local or regional anaesthesia and/or conscious sedation, as well as to those under general anaesthesia
Dialogue and materiality/embodiment in science|arts creative pedagogy: their role and manifestation
This is the final version. Available on open access from Elsevier via the DOI in this record.This paper responds to recent calls to explore the nuances of the interaction between the sciences, the arts and their inherent creativity to better understand their potential within teaching and learning. Building on previous arguments that the science-arts-creativity relationship is dialogic and relational, this research focuses on the question: How are dialogue and material/embodied activity manifested within creative pedagogy? We begin with a fusion of Bakhtinian-inspired and New-Materialist understandings of dialogue drawing out the importance of embodiment in order to revitalize how we articulate dialogue within creative educational practice. We then take on the challenge of a materialist diffractive analysis to conduct research which complements the theoretical framing and offers our outcomes in a way that appropriately makes the phenomena tangible. We present the outcomes of the diffractive analysis including the constitution of matter as well as meaning in the dialogic space; and the emergence of new assemblages of embodied teachers, students, ideas, and objects within transdisciplinary educational practice. We conclude by arguing for the benefits of diffractive analysis: that we have fore-fronted the entangled relationality of trans-disciplinary creative pedagogy; avoided bracketing out aspects of education that are often side-lined; opened out the space of pedagogical
approaches that might be attempted; and begun to challenge what education is for. In so doing, the article aims to open up new ways for teachers, students and researchers to experience seeing, doing, feeling and researching science|arts creative pedagogy and provoke conversations about how this might develop in the future.European Commissio
Considerations for legal, ethical, and effective practice in dementia research
Dementia represents a potentially overwhelming health burden, both for the UK and worldwide. Addressing this fast-growing issue is a key priority for the government, health service and the public. Advances in care including the development of efficacious disease-modifying, and eventually curative, treatments can only be achieved through effective dementia research. Specifically, research directly involving participants with dementia is essential to further understanding. However, working with cognitively impaired participants with and without capacity to consent to research presents unique ethical and legal challenges. For clinicians and scientists on the frontline of dementia research, scenarios frequently arise that pose such challenges. A lack of guidance for a consistent approach in navigating these scenarios limits researchersâ ability to proceed with confidence. This represents a threat to the rights and wishes of research participants as well as the field at large, as it may lead to studies being unnecessarily terminated or, worse, poor practice. In this article, we take a multiprofessional approach, informed by carer input, to these issues. We review the relevant ethical and legal literature relating to the conduct of non-interventional research studies in patients with dementia. This includes a thorough recap of the Mental Capacity Act (2005), which provides a legal framework in England and Wales for conducting research with participants who lack capacity to consent. We also discuss the important, but sometimes incomplete, role of research ethics committees in guiding researchers. We then present and discuss a series of case vignettes designed to highlight areas of incomplete coverage by existing governance. These vignettes describe theoretical scenarios informed by our own real-word experiences of encountering ethical issues when conducting dementia research. They include scenarios in which participants demonstrate varying degrees of understanding of the research they are involved in and ability to communicate their wishes and feelings. Building on these vignettes, we then provide a checklist for researchers to work through when presented with similar scenarios. This checklist covers the key ethical, legal and practical considerations that we have argued for. Taken together, this article can act as a guide, previously lacking in the literature, for colleagues in the field to enable much needed ethical, legal and effective research
The social underpinnings of mental distress in the time of COVID-19 â time for urgent action
We argue that predictions of a âtsunamiâ of mental health problems as a consequence of the pandemic of coronavirus disease 2019 (COVID-19) and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health. Some people will need specialised mental health support, especially those already leading tough lives; we need immediate reversal of years of underfunding of community mental health services. However, the disproportionate effects of COVID-19 on the most disadvantaged, especially BAME people placed at risk by their social and economic conditions, were entirely predictable. Mental health is best ensured by urgently rebuilding the social and economic supports stripped away over the last decade. Governments must pump funds into local authorities to rebuild community services, peer support, mutual aid and local community and voluntary sector organisations. Health care organisations must tackle racism and discrimination to ensure genuine equal access to universal health care. Government must replace highly conditional benefit systems by something like a universal basic income. All economic and social policies must be subjected to a legally binding mental health audit. This may sound unfeasibly expensive, but the social and economic costs, not to mention the costs in personal and community suffering, though often invisible, are far greater
No Weight for âDue Weightâ? A Childrenâs Autonomy Principle in Best Interest Proceedings
Article 12 of the un Convention on the Rights of the Child (crc) stipulates that children should have their views accorded due weight in accordance with age and maturity, including in proceedings affecting them. Yet there is no accepted understanding as to how to weigh childrenâs views, and it is associated strongly with the indeterminate notion of âcompetenceâ. In this article, case law and empirical research is drawn upon to argue that the concept of weighing their views has been an obstacle to childrenâs rights, preventing influence on outcomes for children in proceedings in which their best interests are determined. Younger children and those whose wishes incline against the prevailing orthodoxy (they may resist contact with a parent, for example) particularly lose out. Childrenâs views appear only to be given âsignificant weightâ if the judge agrees with them anyway. As it is the notion of autonomy which is prioritised in areas such as medical and disability law and parentsâ rights, it is proposed in this article that a childrenâs autonomy principle is adopted in proceedings â in legal decisions in which the best interest of the child is the primary consideration, children should get to choose, if they wish, how they are involved and the outcome, unless it is likely that significant harm will arise from their wishes. They should also have âautonomy supportâ to assist them in proceedings. This would likely ensure greater influence for children and require more transparent decision-making by adults.</jats:p
More presumptions please? Wishes, feelings and best interests decision-making
Examines by reference to case law the extent to which the Court of Protection's application of the Mental Capacity Act 2005 is compliant with the tenets of the UN Convention on the Rights of Persons with Disabilities, in particular the requirement in art.12(4) for states to ensure measures relating to exercise of legal capacity respect the rights, will and preference of the person
Overcoming challenges in the Mental Capacity Act 2005: Practical guidance for working with complex issues
This book provides mental capacity practitioners with accessible ethical guidance and applicable tools for applying the Mental Capacity Act (MCA) 2005. It shows how clients' relationships can impact their capacity in positive and negative ways, and which communication skills practitioners can use to enable and empower those with impairment. It also covers how to engage in self-reflection and transparent debate about values to improve the quality of assessments.
Helping practitioners interpret complex issues of mental capacity in the most beneficial way for clients, this book is essential reading for students and practitioners of law, medicine, mental health services and social care