Withdrawal of Life-Sustaining Treatment: Patients\u27 Rights—Privacy Rights

As medical expertise and technologies improve, many patients who would otherwise die of their illnesses or injuries survive. For many of these patients and their families, the knowledge and therapies that save their lives are a blessing. Unfortunately for some, survival means not recovery, but rather a severely limited existence dependent on some form of life-sustaining treatment, such as a ventilator or feeding tube. For some of these patients, such an existence is not a blessing, but a curse, not a triumph over death, but rather a cruel prolonging of their dying. These patients, or their families, seek to have their life-supporting therapies withdrawn, allowing them to complete the process of dying which their bodies have already begun. Many patients are successful in having such treatments withdrawn. Success comes to others, though, only as the result of lengthy legal battles, which add to the grief of the patients and families involved. Most state courts confronted with withdrawal-of-support problems have found that patients do indeed have the right to demand the termination of life-supporting therapies, and most state courts have found that right to be derived from the federal constitutional right of privacy. The Supreme Court of Missouri, however, in its 1988 decision Cruzan v. Harmon, came to the opposite conclusion.Nancy Cruzan is a young woman in a persistent vegetative state as the result of an automobile accident. Her parents and co-guardians sought an order allowing them to authorize the removal of the feeding tube through which Ms. Cruzan receives the necessary nutrition and hydration to remain alive. The Missouri court noted over four dozen withdrawal-of-support cases from other states that had nearly unanimously respected the patients\u27 requests to have treatment halted. Despite that, the court found that Ms. Cruzan has no right of privacy or self-determination that can outweigh the immense, clear fact of life in which the state maintains a vital interest. The most troublesome aspect of the Cruzan decision was the court\u27s assertion that because Ms. Cruzan feels no pain, the treatments she receives are not burdensome to her. The court reached this conclusion despite evidence that Ms. Cruzan had said she would not want to be maintained in such a condition and that she would not want her family to suffer the pain of seeing her in such straits. The court\u27s statement shows a stunning lack of sensitivity to Ms. Cruzan\u27s human dignity, a dignity that is given meaning by, among other things, individual rights of self-determination, the right to be let alone. Ms. Cruzan\u27s parents and co-guardians appealed the Missouri decision to the United States Supreme Court. The Court heard arguments in Cruzan, its first withdrawal-of-support case, in December, 1989. This case gives the Court a chance to conclusively resolve the issue of how and by whom withdrawal-of-support decisions are made. A patient\u27s decision to order the cessation of treatment is a personal medical decision and should be made, like any other personal medical decision, in the privacy of the doctor-patient relationship, not in a courtroom. A clear and definitive ruling by the Court that every patient has a right, guaranteed by the federal Constitution, to order treatment discontinued will return these treatment decisions to their proper place, the patient\u27s bedside. This Comment will discuss the problems created by the current state of affairs, which all too frequently forces patients and their families into the courts to have fundamental questions of medical treatment decided. It will then discuss the foundation of a patient\u27s federal constitutional right to order the withdrawal of life-sustaining therapies. It is imperative that the Court clearly enunciate this right for many reasons; these will be discussed in the final section of this Comment

Cytokine CXCL2 concentration in the cerebrospinal fluid of patients with aneurysmal subarachnoid hemorrhage is associated with patient-reported headache pain

Subarachnoid hemorrhage (SAH) is a severe type of stroke categorized by a sharp, sudden, and persistent headache. The mechanism of headache after SAH is currently poorly understood but the neuro-inflammatory response has been identified as a target in understanding the causes of headache after SAH. A better understanding of this mechanism may lead to identification of molecular targets for therapeutic reduction of headache pain and improving outcomes after SAH. In this study, we collected cerebrospinal fluid (CSF) from patients hospitalized with SAH and conducted a cytokine array to screen for soluble factors involved in SAH-associated headache Introductionhttps://knowledgeconnection.mainehealth.org/lambrew-retreat-2022/1012/thumbnail.jp

Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database.

OBJECTIVE: Retrospective analyses of several trials suggest etomidate may be unsafe for intubation in patients with sepsis. We evaluated the association of etomidate and mortality in a large cohort of septic patients to determine if single-dose etomidate was associated with increased in-hospital mortality. DESIGN AND SETTING: Retrospective cohort study at the Philips eICU Research Institute ICU clinical database. INTERVENTIONS: None. PATIENTS: Among 741,036 patients monitored from 2008 through 2010, we identified 2,014 adults intubated in the ICU 4-96 hrs after admission, having clinical criteria consistent with sepsis, severe sepsis, or septic shock. In all, 1,102 patients received etomidate and 912 received other induction agents for intubation. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was in-hospital mortality, but we also evaluated demographic and clinical factors, severity of illness, ICU mortality, ICU length of stay, hospital length of stay, ventilator days, and vasopressor days. Competing risk Cox proportional hazard regression models were used for primary outcomes. Demographics and illness severity were similar between the groups. Hospital mortality was similar between the groups (37.2% vs. 37.8%, p = 0.77), as were ICU mortality (30.1% vs. 30.2%, p = 0.99), ICU length of stay (8.7 days vs. 8.9 days, p = 0.66), and hospital length of stay (15.2 vs. 14.6 days, p = 0.31). More patients in the etomidate group received steroids before and after intubation (52.9% vs. 44.5%, p \u3c 0.001), but vasopressor use and duration of mechanical ventilation were similar. No regression model showed an independent association of etomidate with mortality, shock, duration of mechanical ventilation, ICU or hospital length of stay, or vasopressor use. A hospital mortality model limited to only patients with septic shock (n = 650) also showed no association of etomidate and hospital mortality. CONCLUSION: In a mixed-diagnosis group of critically ill patients with sepsis, severe sepsis, and septic shock, single-dose etomidate administration for intubation in the ICU was not associated with higher mortality or other adverse clinical outcomes

Valproate for agitation in critically ill patients: a retrospective study.

PURPOSE: The purpose was to describe the use of valproate therapy for agitation in critically ill patients, examine its safety, and describe its relationship with agitation and delirium. MATERIALS AND METHODS: This retrospective cohort study evaluated critically ill adults treated with valproate for agitation from December 2012 through February 2015. Information on valproate prescribing practices and safety was collected. Incidence of agitation, delirium, and concomitant psychoactive medication use was compared between valproate day 1 and valproate day 3. Concomitant psychoactive medication use was analyzed using mixed models. RESULTS: Fifty-three patients were evaluated. The median day of valproate therapy initiation was ICU day 7, and it was continued for a median of 7 days. The median maintenance dose was 1500 mg/d (23 mg/kg/d). The incidence of agitation (96% vs 61%, P \u3c .0001) and delirium (68% vs 49%, P = .012) significantly decreased by valproate day 3. Treatment with opioids (77% vs 65%, P = .02) and dexmedetomidine (47% vs 24%, P = .004) also decreased. In mixed models analyses, valproate therapy was associated with reduced fentanyl equivalents (-185 μg/d, P = .0003) and lorazepam equivalents (-2.1 mg/d, P = .0004). Hyperammonemia (19%) and thrombocytopenia (13%) were the most commonly observed adverse effects. CONCLUSIONS: Valproate therapy was associated with a reduction in agitation, delirium, and concomitant psychoactive medication use within 48 hours of initiation

Inadequacy of Headache Management After Subarachnoid Hemorrhage.

BACKGROUND: Headache profoundly affects management of spontaneous subarachnoid hemorrhage but is poorly characterized. OBJECTIVE: To characterize headache after spontaneous subarachnoid hemorrhage. METHODS: Medical records of patients with Hunt and Hess grades I-III subarachnoid hemorrhage admitted from 2011 to 2013 were reviewed. Demographics, clinical and radiographic features, medications, and pain scores were recorded through day 14 after hemorrhage. Headache pain was characterized on the basis of a numeric rating scale and analgesic use. Severe headache was defined as 2 or more days with maximum pain scores of 8 or greater or need for 3 or more different analgesics for 2 or more days. Univariate and multivariable models were used to analyze factors associated with severe headache. RESULTS: Of the 77 patients in the sample, 57% were women; median age was 57 years. Severe headache (73% overall) was associated nonlinearly with Hunt and Hess grade: grade I, 58%; grade II, 88%; and grade III, 56% (P = .01), and with Hijdra score: score 0-10, 56%; score 11-20, 86%; score 21-30, 76% (P = .03). By univariate analysis, patients with low Hijdra scores were less likely to have severe headache (27% vs 57%; P = .02). In a multivariable model, younger age and higher Hijdra score tended to be associated with severe headache. CONCLUSIONS: Headache after spontaneous subarachnoid hemorrhage was often severe, necessitating multiple opioid and nonopioid analgesics. Many patients reported persistent headache and inadequate pain control

Ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arresT (PROTECT): study protocol for a randomized, placebo-controlled trial

BACKGROUND: Pneumonia is the most common infection after out-of-hospital cardiac arrest (OHCA) occurring in up to 65% of patients who remain comatose after return of spontaneous circulation. Preventing infection after OHCA may (1) reduce exposure to broad-spectrum antibiotics, (2) prevent hemodynamic derangements due to local and systemic inflammation, and (3) prevent infection-associated morbidity and mortality. METHODS: The ceftriaxone to PRevent pneumOnia and inflammaTion aftEr Cardiac arrest (PROTECT) trial is a randomized, placebo-controlled, single-center, quadruple-blind (patient, treatment team, research team, outcome assessors), non-commercial, superiority trial to be conducted at Maine Medical Center in Portland, Maine, USA. Ceftriaxone 2 g intravenously every 12 h for 3 days will be compared with matching placebo. The primary efficacy outcome is incidence of early-onset pneumonia occurring \u3c 4 days after mechanical ventilation initiation. Concurrently, T cell-mediated inflammation bacterial resistomes will be examined. Safety outcomes include incidence of type-one immediate-type hypersensitivity reactions, gallbladder injury, and Clostridioides difficile-associated diarrhea. The trial will enroll 120 subjects over approximately 3 to 4 years. DISCUSSION: The PROTECT trial is novel in its (1) inclusion of OHCA survivors regardless of initial heart rhythm, (2) use of a low-risk antibiotic available in the USA that has not previously been tested after OHCA, (3) inclusion of anti-inflammatory effects of ceftriaxone as a novel mechanism for improved clinical outcomes, and (4) complete metagenomic assessment of bacterial resistomes pre- and post-ceftriaxone prophylaxis. The long-term goal is to develop a definitive phase III trial powered for mortality or functional outcome. TRIAL REGISTRATION: ClinicalTrials.gov NCT04999592 . Registered on August 10, 2021