Legal and Medical Aspects of the End of Human Life from the Perspective of Palliative Medicine Related to Cardiac Surgery

Despite the impressive developments in modern medicine, the healthcare system is still associated with human death. Medicine has made great strides in the treatment of many diseases. The procedures are particularly advanced in, e.g., cardiac surgery, vascular surgery, and other fields. However, despite these efforts, not all patients are cured, and the use of aggressive treatment often contributes to their suffering. This does not mean that patients should be left unattended at the end of their lives.. Palliative medicine deals with patients coming to the end of their lives, concentrating on alleviating suffering and improving quality of life. It is a medical speciality focused on a wide range of interventions, including symptom management, communication, and psychosocial and spiritual support for patients. Patients undergoing highly qualified procedures, for whom causal treatment is not possible, should have the right to such care before death. However, according to medical practice and national legal regulations, it is not always possible to provide this care, despite the anticipated death. This article presents the legal and medical aspects of the end of life from the point of view of the European and Polish healthcare systems.Piotr Jakubów: [email protected] Niedźwiecka: [email protected] Kondracka: [email protected] Turczynowicz: [email protected] Kocańda: [email protected] Malarewicz-Jakubów: [email protected] Jakubów - Medical University of Białystok, PolandKarolina Niedźwiecka - Medical University of Białystok, PolandJulia Kondracka - Medical University of Gdańsk, PolandAleksander Turczynowicz - Medical University of Białystok, PolandSzymon Kocańda - Medical University of Białystok, PolandAgnieszka Malarewicz-Jakubów - University of Bialystok, PolandAszyk P. et al., Deklaracja medycznego środowiska kardiologicznego, paliatywnego i internistycznego wskazująca na znaczenie opieki paliatywnej w kompleksowej opiece nad chorymi z niewydolnością serca, ‘Palliative Medicine in Practice’ 2018; vol. 12, no. 1, pp. 64–66.Avaaz.org, The Prague Charter, https://secure.avaaz.org/community_petitions/en/The_Prague_Charter_Relieving_suffering/.Bartko A., Pawlikowski J., Ewolucja opieki paliatywno-hospicyjnej: od terminalnie do prenatalnie, ‘Archiwum historii i filozofii medycyny’ 2016, vol. 79, pp.8–15.Boerner K., Rodriguez J., Quach E., Hendricksen M., Implementing the MOLST (Medical Orders for Life-Sustaining Treatments): Challenges Faced by Nursing Home Staff, ‘Geriatric Nursing’ 2018, vol. 39, no. 4, pp. 465–470.Bogusz H., Hospicjum – drzewo życia, Poznań 2017.Ciałkowska-Rysz A., De Walden-Gałuszko K., Medycyna Paliatywna, Warsaw 2022.Crespo-Leiro M. et al. Advanced Heart Failure: A Position Statement of the Heart Failure Association of the European Society of Cardiology. ‘European Journal of Heart Failure’ 2018, vol. 20, no. 11, pp. 1505–1535.European Commission (2022), Access to Affordable and High-Quality Long-Term Care, https://ec.europa.eu/info/law/better-regulation/have-your-say/initiatives/13190-Access-to-affordable-and-high-quality-long-term-care_en.Goldstein N.E., Morrison R.S., Evidence-Based Practice of Palliative Medicine, Philadelphia 2013.Goodlin S.J., Rich M.W. (eds.), End-of-Life Care in Cardiovascular Disease, New York 2015.Hentsch L. et al., Palliative Care Provision for People Living with Heart Failure: The Geneva Model, ‘Frontiers in Cardiovascular Medicine’ 2022, vol. 9/933977.House S.A., Schoo C., Ogilvie W.A., Advance Directives. StatPearls, https://www.statpearls.com/ArticleLibrary/viewarticle/17247.Huenchuan S., The Right to End-of-Life Palliative Care and a Dignified Death’, https://www.un.org/development/desa/ageing/wp-content/uploads/sites/24/2017/11/ECLAC-contribution.pdfKearney M., Mortally Wounded: Stories of Soul Pain, Death and Healing (3rd ed.), California 2021.Kovacs A.H., Dipchand A.I., Greutmann M., Tobler D., End-of-Life Care in Pediatric and Congenital Heart Disease, (in:) S. Goodlin, M. Rich (eds.), End-of-Life Care in Cardiovascular Disease, London 2015, pp. 136–154.Kowalik G., Idea opieki paliatywno-hospicyjnej – rys historyczny, ‘Studia Medyczne’ 2013, vol. 29, no. 2, pp. 188–194.Leeds H., Smith D., Palliative Care Involvement in Patients with Operative Mortality after Cardiac Surgery, ‘The Heart Surgery Forum’ 2020, vol. 23, no. 6, pp. E789–E792.MacDonald S., Herx L., Boyle A. (eds.), Palliative Medicine: A Case-Based Manual (4th ed.), Oxford 2022.Maciver J., Ross H.J., A Palliative Approach for Heart Failure End-of-Life Care, ‘Current Opinion in Cardiology’ 2018, vol. 33, no. 2, pp. 202–207.Maetens A., Cohen J., Harding R., A Public Health Approach to Integrate Palliative Care into a Country’s Health-Care System: Guidance as Provided by the WHO, (in:) R.D. MacLeod, L. van den Block (eds.), Textbook of Palliative Care, Cham 2020, pp. 1749–1768.Manalo M.F.C., End-of-Life Decisions about Withholding or Withdrawing Therapy: Medical, Ethical, and Religio-Cultural Considerations, ‘Palliative Care’ 2013, vol. 10, no. 7, pp. 1–5.Mullen R., The Provision of Palliative Care in Europe, https://pace.coe.int/en/files/25057.Najwyższa Izba Kontroli, Zdążyć z pomocą, https://www.nik.gov.pl/aktualnosci/opieka-paliatywna-i-hospicyjna.html.Penders Y.W.H., Bopp M., Zellweger U., Bosshard G., Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: A Mortality Follow-back Study, ‘Journal of General Internal Medicine’ 2020, vol. 35, no. 1, pp. 126–132.Sobański P.Z. et al., Stanowisko Grupy Ekspertów Polskiego, ‘Kardiologia Polska’ 2020, vol. 3, pp. 104–117.Radbruch L., de Lima L., Lohmann D., Gwyther E., Payne S., The Prague Charter: Urging Governments to Relieve Suffering and Ensure the Right to Palliative Care, ‘Palliative Medicine’ 2013, vol. 27, no. 2, pp. 101–102.Radbruch L., Payne S., White Paper on Standards and Norms for Hpspice and Palliative Care in Europe: Part 1. Recommendations from the European Association for Palliative Care, ‘Journal of Palliative Care’ 2009, vol. 16, no. 6, pp. 278–289.Roberts N.F., The History of Hospice: A Different Kind of Health ‘Care’, ‘Forbes’ 22.06.2018, https://www.forbes.com/sites/nicolefisher/2018/06/22/the-history-of-hospice-a-different-kind-of-health-care.Schmidlin E., Palliative Care as a Human Right: What Has the Prague Charter Achieved? ‘European Journal of Palliative Care’ 2015, vol. 22, no. 3, pp. 141–143, https://www.academia.edu/12245063/Palliative_care_as_a_human_right-_what_has_the_Prague_Charter_achieved.Singh G.K., Davidson P.M., Macdonald P.S., Newton P.J., The Perspectives of Health Care Professionals on Providing End of Life Care and Palliative Care for Patients with Chronic Heart Failure: An Integrative Review, ‘Heart, Lung & Circulation’ 2019, vol. 28, no. 4, pp. 539–552.Sobanski P.Z. et al., Palliative Care for People Living with Heart Failure: European Association for Palliative Care Task Force Expert Position Statement ‘Cardiovascular Research’ 2020, vol. 116, no. 1, pp. 12–27.Sobanski P.Z., Krajnik M., Goodlin S.J., Palliative Care for People Living With Heart Disease: Does Sex Make a Difference? ‘Frontiers in Cardiovascular Medicine’ 2021, vol. 8/629752.Truby L.K., Rogers J.G., Advanced Heart Failure: Epidemiology, Diagnosis, and Therapeutic Approaches, ‘JACC Heart Failure’ 2020 vol. 8, no. 7, pp. 523–536.Vitas Healthcare, What Are the Differences and Commonalities Between Hospice and Palliative Care?, https://www.vitas.com/hospice-and-palliative-care-basics/about-palliative-care/hospice-vs-palliative-care-whats-the-difference.Vranick J., Sanghavi D.K., Torp K.D., Stanton M., Do Not Resuscitate, ‘National Library of Medicine’, https://www.ncbi.nlm.nih.gov/books/NBK470163/.Waligórska D., Opieka paliatywna i hospicyjna. Rozporządzenie Ministra Zdrowia z dnia 29 października 2013 r. w sprawie świadczeń gwarantowanych z zakresu opieki paliatywnej i hospicyjnej Dz.U. z 2013 r., poz. 1347, https://www.gov.pl/web/zdrowie/opieka-paliatywna-i-hospicyjna-w-warunkach-stacjonarnych.Zehnder A.R., Pedrosa Carrasco A.J., Etkind S.N., Factors Associated with Hospitalisations of Patients with Chronic Heart Failure Approaching the End of Life: A Systematic Review ‘Palliative Medicine’ 2022, vol. 36, no. 10, pp. 1452–1468.283537

Implantacja protezy mechanicznej w pozycję trójdzielną (systemową) u chorego ze skorygowanym przełożeniem wielkich pni naczyniowych

The authors report a case of a 55 year-old male with corrected transposition of the great arteries and severe tricuspid (systemic) regurgitation treated with anatomical mechanical tricuspid valve replacement. Kardiol Pol 2011; 69, 5: 468–46

Wydzielanie endogennej erytropoetyny u chorych poddawanych pomostowaniu naczyń wieńcowych bez użycia krążenia pozaustrojowego

Background: Erythropoietin (EPO) deficiency or inadequate EPO secretion in response to bleeding may result in profound or prolonged anaemia after cardiac surgery. Aim: The aim of the study was to evaluate the changes in EPO secretion in patients undergoing off-pump coronary artery bypass grafting (OPCAB). Methods: Blood samples from 43 patients (mean age 65.1 ± 7.6 years) were obtained before surgery and on the 1st, 2nd, and 6th day post isolated OPCAB. EPO levels ≥ 4.3 mIU/mL were considered normal. Results: Thirteen (30%) patients had the preoperative EPO level below normal range even though their preoperative haemoglobin was ≥ 13 g/dL. In patients with basal EPO deficiency lower peak EPO levels were observed compared to the group with normal basal EPO levels, even though reduction in haemoglobin concentrations was comparable in both groups. Moreover, lower reticulocytosis was noted on day 1 (8.5 ± 4.0‰ vs. 11.7 ± 4.4‰; p = 0.04) and a tendency toward lower values was seen on day 2 (9.6 ± 4.3‰ vs. 13.0 ± 5.8‰; p = 0.07) among patients with preoperative EPO deficiency. Conclusions: Erythropoietin deficiency is common in patients scheduled for OPCAB, and it results in diminished increase in EPO secretion in response to bleeding. Consequently, in patients with EPO deficiency, reticulocytosis is lower than it could be predicted based on the observation of patients with normal EPO levels and similar blood loss.Wstęp: Niedobór erytropoetyny (EPO) czy też nieadekwatny wzrost jej wydzielania w odpowiedzi na krwawienie może skutkować nasiloną i/lub dłużej utrzymującą się niedokrwistością po zabiegach kardiochirurgicznych. Cel: Celem niniejszego badania była ocena zmian w wydzielaniu endogennej EPO u chorych poddawanych operacjom pomostowania naczyń wieńcowych bez użycia krążenia pozaustrojowego (OPCAB). Metody: Do badania włączono 43 chorych (w średnim wieku 65,1 ± 7,6 roku), u których wykonano izolowany zabieg OPCAB. Przed zabiegiem, a następnie w 1., 2. i 6. dobie po operacji wykonano oznaczenia EPO, hemoglobiny i liczby retikulocytów. Wyniki: U 13 (30%) chorych poziom EPO przed operacją znajdował się poniżej dolnej granicy normy laboratoryjnej, przy czym u wszystkich tych pacjentów stężenie hemoglobiny było ≥ 13 g/dl. U chorych z wyjściowym niedoborem EPO zaob­serwowano w okresie pooperacyjnym niższe szczytowe stężenia niż w grupie z wyjściowo prawidłowymi stężeniami EPO mimo porównywalnego spadku stężenia hemoglobiny. Ponadto, w tej grupie chorych stwierdzono niższą retikulocytozę w 1. dobie po zabiegu (8,5 ± 4,0‰ vs. 11,7 ± 4,4‰; p = 0,04) oraz tendencję do niższych wartości w 2. dobie (9,6 ± 4,3‰ vs. 13,0 ± 5,8‰; p = 0,07). Wnioski: Niedobór EPO jest częstym zjawiskiem w populacji chorych zakwalifikowanych do pomostowania naczyń wieńcowych i skutkuje mniejszym wzrostem wydzielania endogennej EPO w odpowiedzi na krwawienie. W konsekwencji u osób z niedoborem EPO obserwuje się mniejszy przyrost liczby retikulocytów niż u pacjentów z prawidłowymi stężeniami EPO i podobną utratą krwi