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 survivors’ QoL was significantly worse than younger ICU survivors, with a small-to- medium effect size (d=0.35 (−0.53 and −0.16)). Elderly survivors’ QoL was also significantly greater when measured slightly before ICU, compared with follow-up, with a small effect size (d=0.26 (−0.44 and −0.08)). Finally, their QoL was also marginally significantly worse than age-matched community controls, also with a small effect size (d=0.21 (−0.43 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

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

The social underpinnings of mental distress in the time of COVID-19 – time for urgent action

We argue that predictions of a ‘tsunami’ 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 “Due Weight”? A Children’s 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 children’s views, and it is associated strongly with the indeterminate notion of “competence”. 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 children’s 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. Children’s views appear only to be given “significant weight” 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 parents’ rights, it is proposed in this article that a children’s autonomy principle is adopted in proceedings – 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 “autonomy support” to assist them in proceedings. This would likely ensure greater influence for children and require more transparent decision-making by adults.</jats:p

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

Why have I not been told about this?:a survey of experiences of and attitudes to advance decision-making amongst people with bipolar

Background: The idea that people with severe mental illness should be able to plan in advance for periods of illness as a means of enhancing autonomy has been long debated and is increasingly being enshrined in codes of practice and mental health legislation. It has been argued that the ethical imperative for this is especially pronounced in bipolar (BP), a condition in which sufferers often experience episodic crises interspersed with periods of wellness. However, there is a paucity of published research investigating experiences of advance decision making (ADM) in people with BP or their attitudes towards it. Methods: An online survey of BPUK’s mailing list was conducted. 932 people with BP completed the survey (response rate 5.61%). Descriptive statistics and regression analysis were conducted to compare experience of with attitudes towards ADM and variables associated with interest in ADM. Results: A majority indicated a desire to plan care in advance of losing capacity (88%) but most had not done so (64%). High numbers of respondents expressed a wish to request as well as refuse treatment and most wanted to collaborate with psychiatrists, including on issues around self-binding. The most frequent motivation to utilise ADM was a desire to be more involved in mental health decisions. Interest in self-binding was associated with experience of compulsory treatment and trust in mental health services. Interest in refusals of all medication was associated with younger age and lack of trust in mental health services. Interest in ADM in general was associated with younger age but not educational level, ethnicity or gender. Conclusions: This study demonstrates an appetite for ADM amongst people with bipolar that is independent of educational status and ethnicity. As states reform their mental health laws, attention needs to be given to the distinctive attitudes toward ADM amongst people with bipolar