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Biomedical subjects

Robert D Truog

Publications and source records attributed to Robert D Truog.

At least 19 recordsLinked to original sources
PubMed2006

Sudden traumatic death in children: "we did everything, but your child didn't survive".

When caring for children who become suddenly and catastrophically ill, clinicians must simultaneously attend to a complex and rapidly evolving medical situation, as well as to the equally challenging demands of establishing compassionate relationships with family members and communicating well with colleagues. An 18-month-old toddler was brought to the hospital with severe head injury after being struck by a car. Over a period of hours, her condition evolved from prognostic uncertainty to the diagnosis of brain death and considerations of organ donation. Against this medical backdrop, the clinicians successfully established a trusting relationship with family members by careful attention to their emotional, informational, and care needs as they absorbed the devastating prognosis, took in the results of the brain death examination, and considered the option of organ donation. This case illustrates the importance of interdisciplinary communication, the vital role of social workers and other psychosocial providers with expertise in working with families, and the critical significance of mutual care and support for the clinicians who accompany families through these tragic life events.

Brain Death↗
PubMed2006

Rationing in the intensive care unit.

BACKGROUND: Critical care services represent a large and growing proportion of health care expenditures. Limiting the magnitude of these costs while maintaining a just allocation of these services will require rationing. We define rationing as "the allocation of healthcare resources in the face of limited availability, which necessarily means that beneficial interventions are withheld from some individuals." Although some have maintained that rationing of health care is unethical, we argue that rationing is not only unavoidable but essential to ensuring the ethical distribution of medical goods and services. PRINCIPAL FINDINGS: Intensivists have little to guide them in the rationing of critical care services. We have developed a taxonomy of the rationing choices faced by intensivists as a framework for ethical analysis. This taxonomy divides rationing decisions into three categories. First are those rationing decisions that may be justified by external constraints (such as not prescribing a potentially beneficial medication because it is not available on the hospital formulary). Second are those that may be justified by reference to clinical guidelines (as, for example, not prescribing a potentially beneficial medication because a valid guideline recommends treatment with a less expensive alternative). Third are those that are justified by individual clinical judgment (such as choosing which of two patients should be admitted into the last ICU bed, in the absence of any evidence-based guidance). Judgments made on the basis of clinical judgment deserve particular scrutiny, since they may mask unethical prejudices or bias. CONCLUSIONS: Although this taxonomy does not by itself determine which decisions are ethical, it does clarify the type of evidence that is appropriate to supporting the decision that is made. Additional work is needed to elucidate how both empirical evidence and ethical analysis can further inform the rationing decisions that arise in the taxonomy described here.

Health Care Rationing↗
PubMed2006

Toward interventions to improve end-of-life care in the pediatric intensive care unit.

Although children account for only about 3% of all deaths that occur in the United States each year, these patients and their families have needs that are uniquely different from those of adult patients. To date, however, no research on interventions to improve end-of-life care in the pediatric intensive care unit (PICU) has been performed. This review seeks to facilitate and inform future interventional studies by summarizing existing descriptive data about end-of-life care in this setting. These data are organized around six domains that have been identified as critical to high-quality, family-centered care: 1) support of the family unit; 2) communication with the child and family about treatment goals and plans; 3) ethics and shared decision making; 4) relief of pain and other symptoms; 5) continuity of care; and 6) grief and bereavement support. These data are integrated and used to develop evidence-based suggestions for a variety of interventions that could be implemented and then evaluated for their potential contribution to improving the care of children dying in the PICU.

Bereavement↗
PubMed2006

Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.

For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill. We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Association's Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care. Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.

Continuity of Patient Care↗
PubMed2006

Do differences in the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists positions on the ethics of maternal-fetal interventions reflect subtly divergent professional sensitivities to pregnant women and fetuses?

As therapeutic interventions that are designed for the direct benefit of the fetus have evolved, pediatric specialists along with obstetricians have become increasingly engaged in the management of pregnancies that are complicated by fetal disorders. Do the 2 groups of medical specialists hold differing "world views" on the nature of the maternal-fetal relationship that could have an impact on decision-making? A direct comparison of the positions of the ethics committees of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists concerning maternal-fetal conflicts and fetal therapy reveals subtle but telling differences. Compared with the American College of Obstetricians and Gynecologists policy, the American Academy of Pediatrics statement accords somewhat less weight to maternal decision-making and is more tolerant of overriding maternal refusal of interventions that are recommended for fetal benefit. In doing so, it may oblige pregnant patients to assume greater risk and tolerate diminished autonomy. We urge leaders from both disciplines to meet and seek consensus so that a common approach and language can guide treatment of the patients whom we share.

Attitude of Health Personnel↗
PubMed2006

Improving the quality of end-of-life care in the pediatric intensive care unit: parents' priorities and recommendations.

OBJECTIVE: Despite recognition that dying children and their families have unique palliative care needs, there has been little empirical inquiry of parent perspectives to improve the quality of end-of-life care and communication. The purpose of this study was to identify and describe the priorities and recommendations for end-of-life care and communication from the parents' perspective. METHODS: This was a qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires, conducted at 3 pediatric ICUs in Boston, Massachusetts. Fifty-six parents whose children had died in PICUs after withdrawal of life support participated in this study. We measured parent-identified priorities for end-of-life care and communication. RESULTS: Parents identified 6 priorities for pediatric end-of-life care including honest and complete information, ready access to staff, communication and care coordination, emotional expression and support by staff, preservation of the integrity of the parent-child relationship, and faith. CONCLUSIONS: Parental priorities and recommendations offer simple yet compelling guidance to improve pediatric end-of-life clinical practice and research.

Adolescent↗
PubMed2005

International differences in end-of-life attitudes in the intensive care unit: results of a survey.

BACKGROUND: Important international differences exist in attitudes toward end-of-life issues in the intensive care unit. METHODS: A simple questionnaire survey was sent by e-mail to participants at an international meeting on intensive care medicine. Respondents were asked to choose 1 of 3 to 5 possible answers for each of 4 questions related to the treatment of a hypothetical patient in a vegetative state due to anoxic encephalopathy after cardiac arrest with no family and no advance directives. RESULTS: From 3494 valid addresses, 1961 complete questionnaires (56%) were received from 21 countries. Sixty-two percent of physicians from Northern and Central Europe said they involved nurses in end-of-life discussions compared with only 32% of physicians in Southern Europe, 38% in Brazil, 39% in Japan, and 29% in the United States (P<.001 for all comparisons). Written do-not-resuscitate orders were preferred in Northern and Central Europe, whereas oral orders took preference in Southern Europe, Turkey, and Brazil. One third of Japanese physicians said that they would not apply do-not-resuscitate orders. Most participants from Japan, Turkey, the United States, Southern Europe, and Brazil chose to treat the hypothetical patient with antibiotics if he/she developed septic shock, whereas in Northern Europe, Central Europe, Canada, and Australia, terminal withdrawal of mechanical ventilation and extubation were the more commonly chosen responses. CONCLUSIONS: In countries where intensive care medicine is relatively well developed, considerable differences remain in physicians' attitudes toward end-of-life care in the intensive care unit. Substantial work remains if an international consensus on these issues is to be reached.

Attitude to Death↗
PubMed2005

New and lingering controversies in pediatric end-of-life care.

OBJECTIVES: Professional societies, ethics institutes, and the courts have recommended principles to guide the care of children with life-threatening conditions; however, little is known about the degree to which pediatric care providers are aware of or in agreement with these guidelines. The study's objectives were to determine the extent to which physicians and nurses in critical care, hematology/oncology, and other subspecialties are in agreement with one another and with widely published ethical recommendations regarding the withholding and withdrawing of life support, the provision of adequate analgesia, and the role of parents in end-of-life decision-making. METHODS: Three children's hospitals and 4 general hospitals with PICUs in eastern, southwestern, and southern parts of the United States were surveyed. This population-based sample was composed of attending physicians, house officers, and nurses who cared for children (age: 1 month to 18 years) with life-threatening conditions in PICUs or in medical, surgical, or hematology/oncology units, floors, or departments. Main outcome measures included concerns of conscience, knowledge and beliefs, awareness of published guidelines, and agreement or disagreement with guidelines. RESULTS: A total of 781 clinicians were sampled, including 209 attending physicians, 116 house officers, and 456 nurses. The overall response rate was 64%. Fifty-four percent of house officers and substantial proportions of attending physicians and nurses reported, "At times, I have acted against my conscience in providing treatment to children in my care." For example, 38% of critical care attending physicians and 25% of hematology/oncology attending physicians expressed these concerns, whereas 48% of critical care nurses and 38% of hematology/oncology nurses did so. Across specialties, approximately 20 times as many nurses, 15 times as many house officers, and 10 times as many attending physicians agreed with the statement, "Sometimes I feel we are saving children who should not be saved," as agreed with the statement, "Sometimes I feel we give up on children too soon." However, hematology/oncology attending physicians (31%) were less likely than critical care (56%) and other subspecialty (66%) attending physicians to report, "Sometimes I feel the treatments I offer children are overly burdensome." Many respondents held views that diverged widely from published recommendations. Despite a lack of awareness of key guidelines, across subspecialties the vast majority of attending physicians (range: 92-98%, depending on specialty) and nurses (range: 83-85%) rated themselves as somewhat to very knowledgeable regarding ethical issues. CONCLUSIONS: There is a need for more hospital-based ethics education and more interdisciplinary and cross-subspecialty discussion of inherently complex and stressful pediatric end-of-life cases. Education should focus on establishing appropriate goals of care, as well as on pain management, medically supplied nutrition and hydration, and the appropriate use of paralytic agents. More research is needed on clinicians' regard for the dead-donor rule.

Analgesics, Opioid↗