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Background: Communication between clinicians and families of dying children in the pediatric intensive care unit (PICU) is critically important for optimal care of the child and the family. Objective: We examined the current state of clinician perspective on communication with families of dying children in the PICU. Design: Prospective case series over a 15-month study period. Setting/Subjects: We surveyed nurses, psychosocial staff, and physicians who cared for dying children in PICUs at five U.S. academic hospitals. Measurements: Clinicians reported on the location of communication, perceived barriers to end-of-life care, and rated the quality of communication (QOC). Results: We collected 565 surveys from 287 clinicians who cared for 169 dying children. Clinicians reported that the majority of communication occurred at the bedside, and less commonly family conferences and rounds. Ten barriers to care were examined and were reported with frequencies of 2%–32%. QOC was rated higher when the majority of conversations occurred during family conferences (p = 0.01) and lower for patients of non-white race (p = 0.03). QOC decreased when 8 of the 10 barriers to care were reported. Conclusions: When a child is dying, clinicians report that communication with the family occurs most frequently at the child's bedside. This has important implications for future ICU communication research as the majority of previous research and education has focused on family care conferences. In addition, findings that QOC is perceived as lower for non-white patients and when clinicians perceive that barriers hindering care are present can help direct future efforts to improve communication in the PICU.

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

The Toughest Triage Of all the medical care that will have to be rationed during the Covid-19 pandemic, the most problematic will be mechanical ventilation. One strategy for avoiding debilitating d...

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically responsible care in this domain are especially timely given recent surges in critically ill patients with prolonged disorders of consciousness associated with coronavirus disease 2019 around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery and ethical issues that arise within the context of caring for people with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.

Two commentaries respond to a case about apnea testing to confirm death by neurologic criteria.

I was a member of the Massachusetts advisory working group that wrote the Commonwealth's crisis standards of care guidance for the Covid‐19 pandemic, and I was proud of the work we did, thinking carefully about whether age should matter and whether priority should be given to essential workers if there was a scarcity of medical resources, about whether protocols should address issues of structural racism, and so forth. But as a critical care physician, I have concluded that, no matter how sophisticated the ethical analysis, the fundamental approach we proposed was flawed and virtually impossible to implement. All the existing allocation protocols that states developed are based on the assumption that clinicians will be faced with the task of selecting which patients will be offered a ventilator from among a population of patients who are each in need of one. The protocols then assign patients a priority category, and the protocols specify “tie‐breaking” criteria to be used when necessary. The problem with this approach for ventilator allocation is that it has no relationship whatsoever to what happens in the real world.

Background: Medical care has shifted from a paternalistic model towards one centered around patient autonomy and shared decision-making (SDM), yet the role of the pediatric patient in decision-making is unclear. Studies suggest that many children with chronic disease are capable of participating in and even making medical decisions at a young age, and yet we do not standardly involve them. Methods: This is a single center survey study investigating physician attitudes towards involvement of children in decisions regarding lung transplantation, utilizing a hypothetical case scenario with systematic manipulation of age and maturity level. We evaluated physician belief regarding ultimate decision-making authority, attempts at reconciliation of parent-child discordance, and views towards utilizing ethics and psychiatry consultation services. Results: The majority of pediatric pulmonologists believe decision-making authority rests with the parents. The effects of age and maturity are unclear. In instances of parent-child disagreement, physician are more likely to try to convince parents to defer to the child if the child is both older and more mature. Physicians are divided on the utility of ethics and psychiatry consultations. Conclusion: Involvement of children in shared decision-making is broadly supported but poorly implemented. Despite evidence that children with chronic disease may have decisional capacity starting at a young age, the majority of physicians still grant decisional authority to parents. There are numerous barriers to involving children in decisions, including legal considerations. The role of age and maturity level in influencing these decisions appears small and warrants further investigation.

Supplemental Digital Content is available in the text., Objectives: Coronavirus disease 2019 patients are currently overwhelming the world’s healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. Data Sources: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. Study Selection: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. Data Extraction: References and data were based on relevance and author consensus. Data Synthesis: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. “First come, first served” is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. Conclusions: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

Global health care is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation due to the COVID-19 pandemic. The requirement for relatively long periods of ventilation in those who survive means that many are considered for tracheostomy to free patients from ventilatory support and maximise scarce resources. COVID-19 provides unique challenges for tracheostomy care: health-care workers need to safely undertake tracheostomy procedures and manage patients afterwards, minimising risks of nosocomial transmission and compromises in the quality of care. Conflicting recommendations exist about case selection, the timing and performance of tracheostomy, and the subsequent management of patients. In response, we convened an international working group of individuals with relevant expertise in tracheostomy. We did a literature and internet search for reports of research pertaining to tracheostomy during the COVID-19 pandemic, supplemented by sources comprising statements and guidance on tracheostomy care. By synthesising early experiences from countries that have managed a surge in patient numbers, emerging virological data, and international, multidisciplinary expert opinion, we aim to provide consensus guidelines and recommendations on the conduct and management of tracheostomy during the COVID-19 pandemic.

A 15-year-old girl is scheduled to undergo an upper lobectomy to debulk metastatic Ewing sarcoma. The anesthesiologist recommended placement of a thoracic epidural catheter to provide postoperative analgesia. The patient did not want a needle to be placed near her spine. She was terrified that the procedure would be painful and that it might paralyze her. Although the anesthesiologist reassured her that sedation and local anesthesia would make the procedure comfortable, she remained vehemently opposed to the epidural procedure. The parents spoke privately to the anesthesiologist and asked for placement of the epidural after she was asleep. They firmly believed that this would provide optimal postoperative analgesia and thus would be in her best interest. Experts discuss the pros and cons of siding with the patient or parents.

This special report is published in commemoration of the fiftieth anniversary of the "Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death," a landmark document that proposed a new way to define death, with implications that advanced the field of organ transplantation. This remarkable success notwithstanding, the concept has raised lasting questions about what it means to be dead. Is death defined in terms of the biological failure of the organism to maintain integrated functioning? Can death be declared on the basis of severe neurological injury even when biological functions remain intact? Is death essentially a social construct that can be defined in different ways, based on human judgment? These issues, and more, are discussed and debated in this report by leading experts in the field, many of whom have been engaged with this topic for decades.

Objectives To examine the circumstance of death in the PICU in the setting of ongoing curative or life-prolonging goals. Data sources Multidisciplinary author group, international expert opinion, and use of current literature. Data synthesis We describe three common clinical scenarios when curative or life-prolonging goals of care are pursued despite a high likelihood of death. We explore the challenges to providing high-quality end-of-life care in this setting. We describe possible perspectives of families and ICU clinicians facing these circumstances to aid in our understanding of these complex deaths. Finally, we offer suggestions of how PICU clinicians might improve the care of children at the end of life in this setting. Conclusions Merging curative interventions and optimal end-of-life care is possible, important, and can be enabled when clinicians use creativity, explore possibilities, remain open minded, and maintain flexibility in the provision of critical care medicine. When faced with real and perceived barriers in providing optimal end-of-life care, particularly when curative goals of care are prioritized despite a very poor prognosis, tensions and conflict may arise. Through an intentional exploration of self and others' perspectives, values, and goals, and working toward finding commonality in order to align with each other, conflict in end-of-life care may lessen, allowing the central focus to remain on providing optimal support for the dying child and their family.

Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.

In this paper, we argue that a defence of the moral equivalence of withholding and withdrawing life-sustaining treatment (LST) would be more difficult if withdrawing life-sustaining treatment is considered to be a form of killing rather than letting die. Dominic Wilkinson and Julian Savulescu have defended the equivalence thesis (the moral equivalence of withholding and withdrawing LST) in a number of papers. But Savulescu has also claimed that withdrawing life-sustaining treatment is killing. We argue that if Savulescu is right about this, then he and his co-authors face a very significant hurdle in defending the equivalence thesis, because they would need to argue for the very controversial view that killing and letting die are morally equivalent. After decades of debate, however, there is no consensus on this issue. Fortunately, there is a different option. We should simply reject the claim that withdrawing LST is a form of killing. If we reject this claim, it is far easier to defend the claim that withholding and withdrawing LST are morally equivalent, because we would then only need to claim that different forms of letting die are morally equivalent, rather than claim that killing and letting die are morally equivalent. Savulescu and colleagues should therefore drop the claim that withdrawing LST is a form of killing.

Health implications of politically charged phenomena are particularly difficult for physicians to discuss with their patients and communities. Addressing climate change and its associated health effects involves trade-offs between health and economic prosperity, necessitating that physicians weigh the potential benefits and risks of discussing climate change health effects. We argue that the potential benefits of physician communication and advocacy ultimately outweigh the potential risks. Therefore, physicians should be supported in their efforts to educate their patients and communities about climate change health effects. Furthermore, democratic deliberation could prove helpful in addressing disagreements among physicians within a practice about such politicized health topics.

The concepts of medical futility and rationing are often misunderstood and lead to significant consternation when resources are stretched and pediatric intensive care unit (PICU) beds are unavailable. While the two concepts overlap, each has its own distinct application and moral justification. Most importantly, we should avoid using one to justify the other. Bioethics professionals should assist critical care clinicians in clarifying when each rubric should be applied as well as how to develop policies to standardize the approach.

Historically, the practice of medicine has been a physically intimate endeavor. Physicians have used their hands to palpate and reveal the secrets hidden within the body. Smelling the breath for the ketosis of diabetes or tasting the skin for the saltiness of cystic fibrosis were among the physician's essential practices. Today, perhaps the most defining characteristic of a brilliant clinician is the ability to synthesize many images-from electrocardiograms, ultrasounds, CT scans, and so forth-into a coherent picture that can guide our diagnosis and treatment. Yet this is rapidly becoming a Sisyphean task. Just as we are about to drown in a deluge of data, AI is throwing us a life preserver, to save not only our patients but ourselves. But where will AI take us?

OBJECTIVES: There is growing recognition that high-quality care for patients and families in the ICU requires exemplary interprofessional collaboration and communication. One important aspect is how the ICU team makes complex decisions. However, no recommendations have been published on interprofessional shared decision-making. The aim of this project is to use systematic review and normative analysis by experts to examine existing evidence regarding interprofessional shared decision-making, describe its principles and provide ICU clinicians with recommendations regarding its implementation.DATA SOURCES: We conducted a systematic review using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases and used normative analyses to formulate recommendations regarding interprofessional shared decision-making.STUDY SELECTION: Three authors screened titles and abstracts in duplicate.DATA SYNTHESIS: Four papers assessing the effect of interprofessional shared decision-making on quality of care were identified, suggesting that interprofessional shared decision-making is associated with improved processes and outcomes. Five recommendations, largely based on expert opinion, were developed: 1) interprofessional shared decision-making is a collaborative process among clinicians that allows for shared decisions regarding important treatment questions; 2) clinicians should consider engaging in interprofessional shared decision-making to promote the most appropriate and balanced decisions; 3) clinicians and hospitals should implement strategies to foster an ICU climate oriented toward interprofessional shared decision-making; 4) clinicians implementing interprofessional shared decision-making should consider incorporating a structured approach; and 5) further studies are needed to evaluate and improve the quality of interprofessional shared decision-making in ICUs.CONCLUSIONS: Clinicians should consider an interprofessional shared decision-making model that allows for the exchange of information, deliberation, and joint attainment of important treatment decisions.

Trustworthiness before Trust If Black communities are to participate in Covid-19 trials, clinicians, investigators, and pharmaceutical companies must provide convincing evidence — sufficient to ove...

Jahi McMath's case has raised challenging uncertainties about one of the most profound existential questions that we can ask: how do we know whether someone is alive or dead? The case is striking in at least two ways. First, how can it be that a person diagnosed as dead by qualified physicians continued to live, at least in a biological sense, more than four years after a death certificate was issued? Second, the diagnosis of brain death has been considered irreversible; in fact, there has never been a case of a person correctly diagnosed as brain-dead who improved to the point that the person no longer fulfilled the diagnostic criteria. If the neurologist Alan Shewmon is correct that, prior to her cardiac arrest in June 2018, McMath no longer met the criteria for brain death and was actually in a minimally conscious state, this case could have momentous implications for how we think about this diagnosis going forward. In this essay, I will offer a hypothesis that could, perhaps, explain both these aspects of the case. The hypothesis is based on differences in how we distinguish between biological and legal categories. The law tends to prefer to draw bright-line distinctions between categories, whereas biological categories tend to fall along a spectrum, without sharp distinctions.

A new infrastructure is urgently needed at the global level to facilitate exchange on key issues concerning genome editing. We advocate the establishment of a global observatory to serve as a center for international, interdisciplinary, and cosmopolitan reflection. This article is the second of a two-part series. Keywords: CRISPR; genome editing; bioethics; science policy; science and technology studies; ethics.

A new infrastructure is urgently needed at the global level to facilitate exchange on key issues concerning genome editing. We advocate the establishment of a global observatory to serve as a center for international, interdisciplinary, and cosmopolitan reflection. This article is the first of a two-part series.

Clinical equipoise—the idea that the community of medical experts is uncertain about the relative therapeutic merits of the arms of a clinical trial at its outset—mitigates physicians’ responsibility for patients’ poor outcomes when patients are assigned to the control arm or are harmed by an investigational agent.

Uncertainty in diagnosing disorders of consciousness, and specifically in determining whether consciousness has been lost or retained, poses challenging scientific and ethical questions. Recent neuroimaging-based tests for consciousness have cast doubt on the reliability of behavioral criteria in assessing states of consciousness and generate new questions about the assumptions used in formulating coherent diagnostic criteria. The reflex, a foundational diagnostic tool, offers unique insight into these disorders; behaviors produced by unconscious patients are thought to be purely reflexive, whereas those produced by conscious patients can be volitional. Further investigation, however, reveals that reflexes cannot be reliably distinguished from conscious behaviors on the basis of any generalizable empirical characteristics. Ambiguity between reflexive and conscious behaviors undermines the capacity of the reflex to distinguish between disorders of consciousness and has implications for how these disorders should be conceptualized in future diagnostic criteria.

Context. In the pediatric intensive care setting, an accurate measure of the dying and death experience holds promise for illuminating how critical care nurses, physicians, and allied psychosocial staff can better manage end-of-life care for the benefit of children and their families, as well as the caregivers. Objectives. The aim was to assess the reliability and validity of a clinician measure of the quality of dying and death (Pediatric Intensive Care UnitdQuality of Dying and Death 20 [PICU-QODD-20]) in the pediatric intensive care setting. Methods. In a retrospective cohort study, five types of clinicians (primary nurse, bedside nurse, attending physician, and the psychosocial clinician and critical care fellow most involved in the case) were asked to complete a survey for each of the 94 children who died over a 12 month period in the pediatric intensive care units of two children’s hospitals in the northeast U.S. Analyses were conducted within type of clinician. Results. In total, 300 surveys were completed by 159 clinicians. Standard item analyses and substantive review led to the selection of 20 items for inclusion in the PICU-QODD-20. Cronbach alpha for the PICU-QODD-20 ranged from 0.891 for bedside nurses to 0.959 for attending physicians. For each type of clinician, the PICU-QODD-20 was significantly correlated with the quality of end-of-life care and with meeting the family’s needs. In addition, when patient/family or team barriers were encountered, the PICU-QODD-20 score tended to be significantly lower than for cases in which the barrier was not encountered. Conclusion. The PICU-QODD-20 shows promise as a valid and reliable measure of the quality of dying and death in pediatric intensive care. J Pain Symptom

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues.To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders.A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders.A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD.The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.

The death of a child in the pediatric intensive care unit is perhaps one of the most devastating and challenging experiences a parent can ever endure. This article examines how parents of children dying in the pediatric intensive care unit understood their role and discusses implications for clinical care and policy.Retrospective, qualitative study.Two pediatric intensive care units located in children's hospitals within academic medical centers in the northeastern United States.Parents of 18 children who died in the pediatric intensive care unit.Semistructured telephone interviews, digitally recorded and transcribed.Many of the factors deemed important by the parents related to their capacity to be a "good parent" to their child throughout his or her stay in the pediatric intensive care unit. Specifically, parents sought meaningful ways to express and assert their parenthood across three domains: 1) providing love, comfort, and care; 2) creating security and privacy for the family; and 3) exercising responsibility for what happens to one's child.Parents' ability to fulfill the essential features of their role as parents of children dying in the pediatric intensive care unit shapes how they perceive the quality of the experience. Pediatric intensive care unit clinical care and policies can and should uphold and protect these features enabling parents to feel that, despite the outcome, they had done their best on behalf of their children.

Direct radiologist-to-patient disclosure of harmful radiologic errors comports with our profession’s aspirations toward enhanced patient care, professionalism, and visibility; obstacles to disclosure may be mitigated with education and research and managed by radiology guidelines.

INTRODUCTION Growing pressures to ration intensive care unit beds and services pose novel challenges to clinicians. Whereas the question of how to allocate scarce intensive care unit resources has received much attention, the question of whether to disclose these decisions to patients and surrogates has not been explored. KEY CONSIDERATIONS We explore how considerations of professionalism, dual agency, patients' and surrogates' preferences, beneficence, and healthcare efficiency and efficacy influence the propriety of disclosing rationing decisions in the intensive care unit. CONCLUSIONS There are compelling conceptual reasons to support a policy of routine disclosure. Systematic disclosure of prevailing intensive care unit norms for making allocation decisions, and of at least the most consequential specific decisions, can promote transparent, professional, and effective healthcare delivery. However, many empiric questions about how best to structure and implement disclosure processes remain to be answered. Specifically, research is needed to determine how best to operationalize disclosure processes so as to maximize prospective benefits to patients and surrogates and minimize burdens on clinicians and intensive care units.

Advances in life-saving technologies in the past few decades have challenged our traditional understandings of death. Traditionally, death was understood to occur when a person stops breathing, their heart stops beating and they are cold to the touch. Today, physicians determine death by relying on a diagnosis of 'total brain failure' or by waiting a short while after circulation stops. Evidence has emerged, however, that the conceptual bases for these approaches to determining death are fundamentally flawed and depart substantially from the established biological conception of death. We argue that the current approach to determining death consists of two different types of unacknowledged legal fictions. These legal fictions were developed for practices that are largely ethically legitimate but need to be reconciled with the law. The considerable debate over the determination of death in the medical and scientific literature has not informed the public that vital organs are being procured from still-living donors and it seems unlikely that this information can remain hidden for long. Given the instability of the status quo and the difficulty of making the substantial legal changes required by complete transparency, we argue for a second-best policy solution: acknowledging the legal fictions involved in determining death to move in the direction of greater transparency. This may someday result in more substantial legal change to directly confront the challenges raised by life-sustaining and life-preserving technologies without the need for fictions.

Introduction: Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach. Methods: The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach’s Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman’s Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics. Results: Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received. Conclusions: Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and “safe” environment, may assist in the delivery of feedback to trainees. (Sim Healthcare 4:22–29, 2009)

Accepted medical practice already violates the dead donor rule. Explicitly jettisoning the rule -- allowing vital organs to be extracted, under certain conditions, from living patients -- is a radical change only at the conceptual level. But it would expand the pools of eligible organ donors.

This paper reframes the futility debate, moving away from the question "Who decides when to end what is considered to be a medically inappropriate or futile treatment?" and toward the question "How can society make policy that will best account for the multitude of values and conflicts involved in such decision-making?" It offers a pragmatist moral epistemology that provides us with (1) a clear justification of why it is important to take best standards, norms, and physician judgment seriously and (2) a clear justification of why ample opportunity must be made for patients, families, and society to challenge those standards and norms.

Background: There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered. Purpose: This multisociety statementprovides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units. Methods: The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care). Main Results: The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term "potentially inappropriate" should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan they believe is appropriate. Conflicts regarding potentially inappropriate treatments that remain intractable despite intensive communication and negotiation should be managed by a fair process of conflict resolution; this process should include hospital review, attempts to find a willing provider at another institution, and opportunity for external review of decisions. When time pressures make it infeasible to complete all steps of the conffict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should seek procedural oversight to the extent allowed by the clinical situation and need not provide the requested treatment. (3) Use of the term "futile" should be restricted to the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal. Clinicians should not provide futile interventions. (4) The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used. Conclusions: The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

End‐of‐life decision‐making is controversial. There are different views about when it is appropriate to limit life‐sustaining treatment, and about what palliative options are permissible. One approach to decisions of this nature sees consensus as crucial. Decisions to limit treatment are made only if all or a majority of caregivers agree. We argue, however, that it is a mistake to require professional consensus in end‐of‐life decisions. In the first part of the article we explore practical, ethical, and legal factors that support agreement. We analyse subjective and objective accounts of moral reasoning: accord is neither necessary nor sufficient for decisions. We propose an alternative norm for decisions – that of ‘professional dissensus’. In the final part of the article we address the role of agreement in end‐of‐life policy. Such guidelines can ethically be based on dissensus rather than consensus. Disagreement is not always a bad thing.

There has been an important shift toward openness regarding adverse events and their communication to patients. Recent research suggests that saying sorry is a key element of successful disclosure practice. However, fear of legal action has been identified as a major barrier to issuing an apology in

To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States.Prospective case series.Five U.S. teaching hospitals.We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures.None.The overall mortality rate was 2.39% (range, 1.85-3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death.The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.

Introduction: Interprofessional education is central to the mission of the Institute for Professionalism and Ethical Practice, based at Boston Children's Hospital and affiliated with Harvard Medical School. The Institute’s Program to Enhance Relational and Communication Skills (PERCS) offers simulation-based interprofessional workshops designed to help trainees and practitioners engage in challenging healthcare conversations across situations such as critical care, primary care, parent presence during resuscitation, spiritual distress, adverse medical outcomes, informed consent, organ donation, and others.Objective: To describe the pedagogy, recruitment statistics and sustained participant outcomes of the Program to Enhance Relational and Communication Skills (PERCS).Methods: The pedagogical framework is based on creating safety for learning, emphasizing moral and relational aspects of care, suspending hierarchy to support interprofessional learning, honoring multiple perspectives, and valuing reflection and self-discovery. Programs bring together physicians, nurses, social workers, psychologists, chaplains and other healthcare professionals for a wide range of innovative educational offerings. Core learning occurs through live enactments of challenging conversations with professional actors portraying patients and family members, followed by guided debriefings that support individual and group reflection.Results: Approximately 3000 local, national and international professionals have participated since the program’s inception in 2002. PERCS workshop participants have reported a greater sense of preparation, confidence, improved communication and relational skills, and decreased anxiety when holding challenging healthcare conversations immediately following training and up to 12 months later. Benefits of the training were not related to discipline, level of experience or previous educational opportunities.Conclusions: Participants reported enhanced communication and relational skills. The program strives to develop relational competence in the healthcare world, including qualities of compassion, trust, and respect between clinicians and patients, and increased attention to interprofessional collaboration and knowledge sharing.

Although established in the law and current practice, the determination of death according to neurological criteria continues to be controversial. Some scholars have advocated return to the traditional circulatory and respiratory criteria for determining death because individuals diagnosed as 'brain dead' display an extensive range of integrated biological functioning with the aid of mechanical ventilation. Others have attempted to refute this stance by appealing to the analogy between decapitation and brain death. Since a decapitated animal is obviously dead, and 'brain death' represents physiological decapitation, brain dead individuals must be dead. In this article we refute this 'decapitation gambit.' We argue that decapitated animals are not necessarily dead, and that, moreover, the analogy between decapitation and the clinical syndrome of brain death is flawed.

T HIS OFFICIAL STATEMENT OF THE A MERICAN T HORACIC S OCIETY WAS ADOPTED BY THE ATS B OARD OF D IRECTORS , M ARCH 1997. SUMMARY American Thoracic Society (ATS) members, as health care practitioners caring for critically ill patients in intensive care units (ICUs) or as ICU directors, commonly must make decisions that allocate ICU resources. Some decisions necessitate prioritization of ICU beds while others limit access to particular scarce resources. Although these decisions arise when providing medical care for ICU patients, they occur in a larger context that includes ethical, economic, social, and legal considerations. In this context health care systems in the United States and in other countries face the consequences of increasing demand for expensive health care services in times of limited financial resources and competing societal needs. If one accepts the premise that demand for health care resources will inevitably outstrip financial constraints, one then must face the basic question of how to allocate those resources fairly. How health care organizations will meet increasing demand for services within financial constraints raises specific questions relating to the fair allocation of ICU resources

Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted.To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds.The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles and recommendations. Investigators and consultants were sent the statements and responded with their agreement or disagreement.The Eldicus project (triage decision making for the elderly in European intensive care units).Eldicus investigators, consultants, and experts consisting of intensivists, users of ICU services, ethicists, administrators, and public policy officials.Consensus development was used to grade the statements and recommendations.Consensus was defined as 80% agreement or more. Consensus was obtained for 54 (87%) of 62 statements including all (19) general principles, 31 (86%) of the specific principles, and 10 (71%) of the recommendations. Inconsistencies in responses were noted for ICU admission and discharge. Despite agreement for guidelines applying to individual patients and an objective triage score, there was no agreement for a survival cutoff for triage, not even for a chance of survival of 0.1%.Consensus was reached for most general and specific ICU triage principles and recommendations. Further debate and discussion should help resolve the remaining discrepancies.