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Background: Decannulation from venovenous extracorporeal membrane oxygenation (ECMO) at the earliest and safest possible time may improve outcomes and reduce cost. Yet, no prospective studies have compared weaning strategies for liberation from ECMO.Research Question: Is a protocolized daily assessment of readiness to liberate from venovenous ECMO safe and feasible?Study Design and Methods: We conducted a prospective, single-arm safety and feasibility study of a protocol for daily assessment of readiness to liberate from venovenous ECMO among consecutive adult patients receiving venovenous ECMO across four ICUs at a single center between June 20, 2020, and November 24, 2020. The ECMO-free protocol included three phases: (1) the safety screening, (2) non-ECMO Fio2 titration, and (3) the ECMO-free trial. Enrollment, interventions, and data collection were performed prospectively by trained study staff.Results: Twenty-six patients received the ECMO-free protocol on 385 patient-days. The safety screening was passed during a total of 59 ECMO-free daily assessments (15.3%) among 20 patients. Every passed safety screening proceeded to an ECMO-free trial. Twenty-eight passed ECMO-free trials (47.5%) occurred among 16 patients (61.5%). No missed safety screenings, protocol deviations, or adverse events occurred. Of the 16 patients who passed an ECMO-free trial, 14 patients (87.5%) were decannulated. Among decannulated patients, 12 patients (85.7%) were decannulated on the same day as a passed ECMO-free trial, 6 patients (42.9%) were decannulated on the first day that they passed an ECMO-free trial, and 6 patients (42.9%) passed an ECMO-free trial at least twice consecutively before decannulation. The median time from first passed ECMO-free trial to decannulation was 2 days (interquartile range, 0-3 days).Interpretation: The ECMO-free protocol is feasible and may identify patients for decannulation earlier than gradual approaches to weaning. [ABSTRACT FROM AUTHOR]

The ability of nurses to act as moral agents in accordance with their conscience is both an essential human freedom and an important part of professional ethics. Recent developments in Canada related to Medical Assistance in Dying have revealed new and important challenges related to conscientious objection – challenges that may require rethinking of how nurses do professional ethics. Notably, the inclusion of a personalist bioethical approach is needed to introduce and explicate what conscience is for nurses to be able to apply it to nursing practice. In this article, we explore the importance of conscience and conscientious objection as ethical concepts to support nurses in addressing issues of conscience amid ethically challenging situations. We discuss how a personalist basis for conscience can support nurses to inclusively engage with one another across diverse moral perspectives. [ABSTRACT FROM AUTHOR]

Despite non/minimal adversarial feminist argumentation models heavily critiquing rude, hostile, uncooperative argumentative practices, I argue that these models slip easily into instances of 'white talk' when white individuals are engaged with BIPOC (Black Indigenous People of Color) on matters concerning racial injustices. While these models address overt aggression, a more nuanced modification is needed for the models to handle cases of white passive aggressive argumentative tactics ('white talk'). Moreover, I also argue that given the language and argumentative ideology within academia, 'white talk' cannot be addressed by BIPOC without 'argumentative smothering.' Building heavily from Dotson's conception of 'testimonial smothering,' I argue argumentative smothering occurs when an interlocutor heavily modifies their argumentative practices due to an oppressive environment in an attempt to situate their argument in such a way that it will be receptive and 'acceptable' to the other interlocutor and/or audience. [ABSTRACT FROM AUTHOR]

In late Middle Danish, case was reduced to pronominal case, but in spite of this, Middle Danish case preserved features of a system typologically different from modern Danish. Case grammaticalised semantic roles, with considerable polysemy. Along with the transitivity system, Middle Danish preserved inactive (impersonal) constructions and the polysemy of the case forms was resolved according to construction type. Such a system is indexical in the sense that the case forms point to their predicate types as the locus from which their polysemy is resolved. From this stance, it makes sense to maintain a sharp distinction between predicational structure (argument(s) and predicate), grammatical relations (subject and object) and case paradigms. Inactive constructions do not have oblique subjects, but objects as their basic argument, and subjects are everywhere in the nominative case. So-called oblique subjects cannot be agents. In accordance with this claim by Jan Terje Faarlund, I propose an analysis of the grammaticalised semantic role systems of transitivity and inactivity. The rise of categorical sentence structure, including the alignment of subjecthood, status as the primary argument, subject position and a kind of structural nominative case is a development of post-Reformation Danish. [ABSTRACT FROM AUTHOR]

Background: Cancer patients' end-of-life care may involve complex decision-making processes. Colombia has legislation regarding provision of and access to palliative care and is the only Latin American country with regulation regarding euthanasia. We describe medical end-of-life decision-making practices among cancer patients in three Colombian hospitals. Methods: Cancer patients who were at the end-of-life and attended in participating hospitals were identified. When these patients deceased, their attending physician was invited to participate. Attending physicians of 261 cancer patients (out of 348 identified) accepted the invitation and answered a questionnaire regarding end-of-life decisions: a.) decisions regarding the withdrawal or withholding of potentially life-prolonging medical treatments, b.) intensifying measures to alleviate pain or other symptoms with hastening of death as a potential side effect, and c.) the administration, supply or prescription of drugs with an explicit intention to hasten death. For each question addressing the first two decision types, we asked if the decision was fully or partially made with the intention or consideration that it may hasten the patient's death. Results: Decisions to withdraw potentially life-prolonging treatment were made for 112 (43%) patients, 16 of them (14%) with an intention to hasten death. For 198 patients (76%) there had been some decision to not initiate potentially life-prolonging treatment. Twenty-three percent of patients received palliative sedation, 97% of all patients received opioids. Six patients (2%) explicitly requested to actively hasten their death, for two of them their wish was fulfilled. In another six patients, medications were used with the explicit intention to hasten death without their explicit request. In 44% (n = 114) of all cases, physicians did not know if their patient had any advance care directives, 26% (n = 38) of physicians had spoken to the patient regarding the possibility of certain treatment decisions to hasten death where this applied. Conclusions: Decisions concerning the end of life were common for patients with cancer in three Colombian hospitals, including euthanasia and palliative sedation. Physicians and patients often fail to communicate about advance care directives and potentially life-shortening effects of treatment decisions. Specific end-of-life procedures, patients' wishes, and availability of palliative care should be further investigated. [ABSTRACT FROM AUTHOR]

Background: Not all treatments are appropriate for all individuals with kidney failure (KF). Studies suggest that conversations surrounding end-of-life decisions occur too late or not at all. Objectives: The aim of this research was to identify perceived barriers to such discussions among nephrologists and nephrology fellows to determine if barriers differ by experience level. Design: Phase I consisted of semistructured telephone interviews with nephrologists and fellows. Phase II included focus groups with nominal group technique in which providers ranked barriers to discussions about not initiating/withholding dialysis (NIWD) or discontinuing dialysis (DD). Setting/Subjects: U.S. community-based nephrologists and nephrology fellows. Results: Seven interviews were conducted with each group (n = 14) in phase I. Many barriers cited were similar among providers, however, differences were related to fellows' position as trainees citing the "reaction of their attending/supervising physician or other providers" as a barrier to NIWD and "lacking their attending physician's support" as a barrier to DD. Six focus groups were conducted, nephrologists (n = 22) and fellows (n = 18), in phase II. The highest ranked barrier to NIWD for nephrologists was "discordant opinions among patient and family"; fellows ranked "time to hold conversation" highest. Nephrologists' highest barrier to DD was the "finality of the decision (death)"; fellows ranked the "inertia of the clinical encounter" highest. Conclusions: Capturing the perspectives of nephrologists and fellows concerning the barriers to conservative management of patients with KF may inform the development of targeted education/training interventions by experience level focused on communication skills, conflict resolution, and negotiation. [ABSTRACT FROM AUTHOR]

A reprint of the article "Listening to the Heartbeat of the Pro-Life Movement" by Edward Short, which appeared in the September 30, 2021 issue of the periodical "Catholic World Report," is presented. The article highlights an interview with Maria McFadden Maffucci, editor-in-chief of the periodical Human Life Review," about the challenge to the Roe v. Wade case in 2021. She cites the response of the periodical to the Dobbs v. Jackson case. She expresses her concern on the Texas Heartbeat Act.

Objective: Effectiveness of antipsychotic drugs is inferred from relatively small randomized clinical trials conducted with carefully selected and monitored participants. This evidence is not necessarily generalizable to individuals treated in daily clinical practice. The authors compared the clinical effectiveness between all oral and long-acting injectable (LAI) antipsychotic medications used in the treatment of schizophrenia in the U.S. Department of Veterans Affairs (VA) health care system.Methods: This was an observational study utilizing VA pharmacy data from 37,368 outpatient veterans with schizophrenia. Outcome measures were all-cause antipsychotic discontinuation and psychiatric hospitalizations. Oral olanzapine was used as the reference group.Results: In multivariable analysis, clozapine (hazard ratio=0.43), aripiprazole long-acting injectable (LAI) (hazard ratio=0.71), paliperidone LAI (hazard ratio=0.76), antipsychotic polypharmacy (hazard ratio=0.77), and risperidone LAI (hazard ratio=0.91) were associated with reduced hazard of discontinuation compared with oral olanzapine. Oral first-generation antipsychotics (hazard ratio=1.16), oral risperidone (hazard ratio=1.15), oral aripiprazole (hazard ratio=1.14), oral ziprasidone (hazard ratio=1.13), and oral quetiapine (hazard ratio=1.11) were significantly associated with an increased risk of discontinuation compared with oral olanzapine. No treatment showed reduced risk of psychiatric hospitalization compared with oral olanzapine; quetiapine was associated with a 36% worse outcome in terms of hospitalizations compared with olanzapine.Conclusions: In a national sample of veterans with schizophrenia, those treated with clozapine, two of the LAI second-generation antipsychotics, and antipsychotic polypharmacy continued the same antipsychotic therapy for a longer period of time compared with the reference drug. This may reflect greater overall acceptability of these medications in clinical practice. [ABSTRACT FROM AUTHOR]

Abstract Background Euthanasia can be thought of as being either active or passive; but the precise definition of “passive euthanasia” is not always clear. Though all passive euthanasia involves the withholding of life-sustaining treatment, there would appear to be some disagreement about whether all such withholding should be seen as passive euthanasia. Main text At the core of the disagreement is the question of the importance of an intention to bring about death: must one intend to bring about the death of the patient in order for withholding treatment to count as passive euthanasia, as some sources would indicate, or does withholding in which death is merely foreseen belong to that category? We may expect that this unclarity would be important in medical practice, in law, and in policy. The idea that withholding life-sustaining treatment is passive euthanasia is traced to James Rachels’s arguments, which lend themselves to the claim that passive euthanasia does not require intention to end life. Yet the argument here is that Rachels’s arguments are flawed, and we have good reasons to think that intention is important in understanding the moral nature of actions. As such, we should reject any understanding of passive euthanasia that does not pay attention to intent. Short conclusion James Rachels’s work on active and passive euthanasia has been immensely influential; but this is an influence that we ought to resist.

The issue of euthanasia presents a contact area of ethics, law, and politics. This text provides a contribution to the expert public debate on the introduction of euthanasia into Serbian legislation. It does so first by clarifies the term - euthanasia (as a right to die with dignity). Further, it considers the obligations of other persons that arise from this right and the conditions under which they present a restriction on personality rights. By citing examples from the fields of ethics and law, the text states that the distinction between active and passive euthanasia is in fact a product of inadequate deliberation during the implementation of this differentiation.

Having in mind the obligation of a physician, as stipulated in the Law on Patients' Rights, to respect the will of the patient even when the will is directed toward the refusal of life-sustaining medical treatment, as well as the misdemeanor liability of a physician, prescribed by the same law, for treatment without informed consent, the paper considers how the patient's right to refuse medical treatment affects the physician's responsibility for the patient's death in terms of the provisions of the Criminal Code. Also, the paper analyzes whether in certain situations the physician is even able to comply with the provisions of both of the mentioned regulations, or whether the harmonization of legal solutions is needed.

The subject of the study is the ethical aspects of euthanasia. The framework of the article does not allow for a comprehensive and complex analysis of the issue presented in the title. In view of the above, the purpose of the article has been limited to two aspects. The first one is the clarification of terminology and an attempt to draw out the classification of euthanasia. The second one is showing the arguments that supporters and antagonists take in the ongoing debate on the subject of euthanasia. In the author’s opinion, the subject that strictly corresponds to the subject matter in the study remains the legal regulations of individual countries regarding euthanasia. This issue has been highlighted at the end of the article and may constitute a contribution to the discussion.

Surgeons who care for patients with active SARS-CoV-2 infection represent a unique population of health care providers whose risk of infection has not been elucidated. The objective of this study was to examine SARS-CoV-2 seroprevalence among surgeons who cared for patients with active SARS-CoV-2 infection compared to other employees within our health care system and also the general public of New Orleans. 105 surgeons at our facilities provided direct surgical care to patients with active SARS-CoV-2 infection and underwent voluntary antibody testing. 2/105 (1.9% CI.2%-6.7%) tested positive for SARS-CoV-2 antibodies. 13 343 hospital employees underwent antibody testing and 1066/13 343 (8.0% CI 7.5%-8.5%) tested positive (1.9% vs. 8.0%; P =.03). We saw a significantly lower SARS-CoV-2 seroprevalence among surgeons who directly cared for infected patients versus other hospital employees. When compared to community seroprevalence (6.9% CI 6.0%-8.0%), seroprevalence among our surgeons is also significantly lower (1.9% vs. 6.9%; P =.04). [ABSTRACT FROM AUTHOR]

Background: Patients with depression who are treated in primary care practices may receive antidepressants for prolonged periods. Data are limited on the effects of maintaining or discontinuing antidepressant therapy in this setting.Methods: We conducted a randomized, double-blind trial involving adults who were being treated in 150 general practices in the United Kingdom. All the patients had a history of at least two depressive episodes or had been taking antidepressants for 2 years or longer and felt well enough to consider stopping antidepressants. Patients who had received citalopram, fluoxetine, sertraline, or mirtazapine were randomly assigned in a 1:1 ratio to maintain their current antidepressant therapy (maintenance group) or to taper and discontinue such therapy with the use of matching placebo (discontinuation group). The primary outcome was the first relapse of depression during the 52-week trial period, as evaluated in a time-to-event analysis. Secondary outcomes were depressive and anxiety symptoms, physical and withdrawal symptoms, quality of life, time to stopping an antidepressant or placebo, and global mood ratings.Results: A total of 1466 patients underwent screening. Of these patients, 478 were enrolled in the trial (238 in the maintenance group and 240 in the discontinuation group). The average age of the patients was 54 years; 73% were women. Adherence to the trial assignment was 70% in the maintenance group and 52% in the discontinuation group. By 52 weeks, relapse occurred in 92 of 238 patients (39%) in the maintenance group and in 135 of 240 (56%) in the discontinuation group (hazard ratio, 2.06; 95% confidence interval, 1.56 to 2.70; P<0.001). Secondary outcomes were generally in the same direction as the primary outcome. Patients in the discontinuation group had more symptoms of depression, anxiety, and withdrawal than those in the maintenance group.Conclusions: Among patients in primary care practices who felt well enough to discontinue antidepressant therapy, those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy. (Funded by the National Institute for Health Research; ANTLER ISRCTN number, ISRCTN15969819.). [ABSTRACT FROM AUTHOR]

Objectives: How frequently patient-reported outcome (PRO) data are collected in commercial cancer clinical trials after treatment discontinuation and the quality of that data are poorly understood. We reviewed treatment discontinuation follow-up PRO data collection to learn about trials collecting these data and understand data quality. The review included 4 cancer types representing potential for long- (prostate cancer), medium-/long- (breast cancer), and short-term (pancreatic cancer and hepatocellular carcinoma) follow-up owing to disease trajectory.Methods: We reviewed registration trials in US Food and Drug Administration databases between January 2010 and January 2019. Protocols were reviewed to determine whether PROs were collected and, if so, whether these included the follow-up phase. Clinical study reports were reviewed when follow-up PROs were collected to determine completion rates. Results were summarized using descriptive analyses.Results: Of the 46 trials containing PRO data, 46% had at least 1 follow-up PRO assessment. Follow-up schedules of assessment were wide ranging; the first assessment occurred between 30 days and 6 months after stopping treatment with follow-up for as long as 3 years. PRO completion rates were reported in 57% of 21 trials; at the first follow-up assessment, completion rates for the treatment arm ranged from 38% to 91% and from 41% to 100% in the control arm.Conclusions: The quality of the follow-up PRO data, based on completion rates, was variable, as was the duration of follow-up. A clear research objective should be developed for follow-up PRO data, accounting for patient burden. If PRO data are collected, monitoring should be implemented to improve completion because poor completion limits data use in the benefit-risk assessment. [ABSTRACT FROM AUTHOR]

Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation. [ABSTRACT FROM AUTHOR]

Euthanasia is the act or practice of painlessly putting to death persons suffering from incurable and distressing disease as an act of mercy. This act is illegal in many countries as it is against medical ethics. It has been legalised in few countries during the early 21st century.The objective of this article is to review the current status of euthanasia, the status of the act in the Netherlands and to compare the same with the laws in India. It is also aimed at giving an analytical review of the laws in the two countries during the period 2001 to 2020.Euthanasia in the Netherlands is regulated by the “Termination of Life on Request and Assisted Suicide (Review Procedures) Act”, 2002. The numbers of requests in the Netherlands for euthanasia have risen to more than double over the period of ten years and as seen the numbers of requests fulfilled have not followed the same trend over these years.In India, the act of euthanasia has been classified as unethical except in cases where the life support system is used only to continue the cardio-pulmonary actions of the body. In such cases, subject to the certification by the term of doctors, the life support system may be removed. Passive euthanasia is permissible under the supervision of law in exceptional circumstances. There are various arguments for euthanasia based on principles of autonomy whereas the central argument against legalizing euthanasia is society’s view of the sanctity of life. [ABSTRACT FROM AUTHOR]

One argument often made against capital punishment is that it would involve the risk of killing innocent people and that such a mistake cannot be corrected in ways that other punishments can. I call this the 'Irrevocability Argument'. In this article, I argue that the Irrevocability Argument is symmetrical with respect to capital punishment and active voluntary euthanasia. If the Irrevocability Argument works against capital punishment, then it also works against active voluntary euthanasia and vice versa. The main upshot of this is that it means at least some of the moral positions that people hold to treat them differently are untenable. Those who rely on the Irrevocability Argument as an argument against capital punishment are also committed to it as an argument against active voluntary euthanasia. [ABSTRACT FROM AUTHOR]

One argument often made against capital punishment is that it would involve the risk of killing innocent people and that such a mistake cannot be corrected in ways that other punishments can. I call this the 'Irrevocability Argument'. In this article, I argue that the Irrevocability Argument is symmetrical with respect to capital punishment and active voluntary euthanasia. If the Irrevocability Argument works against capital punishment, then it also works against active voluntary euthanasia and vice versa. The main upshot of this is that it means at least some of the moral positions that people hold to treat them differently are untenable. Those who rely on the Irrevocability Argument as an argument against capital punishment are also committed to it as an argument against active voluntary euthanasia. [ABSTRACT FROM AUTHOR]

Recent changes in paediatrics with the growing provision of life-sustaining interventions in both complex and rare diseases have increased the prevalence of chronic and life-limiting conditions in children. This has, in turn, led to changes in the population of children cared for and, consequently, the modes of death in paediatric intensive care units. In many countries, children with chronic conditions now constitute a large proportion of both admissions to paediatric intensive care units and the deaths occurring there. Managing end-of-life decisions and care is an integral part of practice and constitutes an imperative skill for all professionals working in paediatric intensive care. The process of end-of-life care involves many uncertainties and ethical, legal, religious, cultural and social considerations. A child's death will always be a tragic and challenging experience, but the way it is managed can influence the impact it has on everyone involved. This article provides a review of the issues surrounding the end-of-life process for patients in paediatric intensive care units and explores the challenges and considerations involved in decision-making to withhold or withdraw life-sustaining therapy. We discuss the practicalities of managing and optimising end-of-life care within and beyond the paediatric intensive care unit and the different aspects that healthcare teams need to address before and after a child's death. [ABSTRACT FROM AUTHOR]

Decisions surrounding withholding and withdrawing medical interventions are common within the palliative and hospice care community. The unexpected effects of the recent pandemic ignited conversations about scarcity of resources and withholding medical interventions, based on age, among providers with limited expertise in palliative care. Using a case study and literature review, the aim of this article was to examine the best ethical considerations for resource allocation decision making that minimizes the effects of ageism. Public health ethics differs from clinical ethics by giving priority to promoting the greatest good over the protection of individual autonomy. This divide in ethics sheds light on the dangers associated with ageism. Age is often a component within clinical instruments that guide clinicians with allocation decisions. Basing decisions solely on age without evaluating health and functional status is dangerous and further propagates the discriminatory practices that fuel ageism. Previous research identified using ethical principles to guide resource allocation decisions but that may not be enough to protect the rights of older adults. A new model to guide these decisions should include advance directives and goals of care, medical indicators instead of demographics, functionality, transparent medical team, and impact of social determinants of health. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of withholding doxycycline on the success rate of natural cycle frozen embryo transfers (NC-FET).Design: Retrospective cohort study.Setting: Single academic institution.Patient(s): Women undergoing 250 NC-FET with euploid blastocysts performed by a single provider.Intervention(s): One hundred and twenty-five NC-FET cycles performed after January 2019 without antibiotic administration compared with 125 NC-FET cycles before January 2019 with doxycycline administration.Main Outcome Measure(s): Primary outcome: live birth (LB) or ongoing pregnancy rate (OPR, defined as pregnancies ≥13 weeks); secondary outcomes included positive β-human chorionic gonadotropin (β-hCG) level and clinical pregnancy rate (CPR, defined as the presence of fetal cardiac activity on ultrasound).Result(s): Each group of women comprised 125 NC-FET during the study period of March 2017 to March 2020. The women's mean age was 36.3 years and mean body mass index was 24 kg/m2. Between the two groups, the baseline characteristics were similar, including age, body mass index, race, smoking status, parity, endometrial thickness, Society of Assisted Reproductive Technology diagnosis, and number of prior failed transfers. Comparing NC-FET with doxycycline administration versus without, we found no statistically significant difference in LB-OPR (64% vs. 62.6%), positive β-hCG (72.8% vs. 74.0%), or CPR (68% vs. 65.9%). After controlling for all variables in a logistic regression, doxycycline still had no effect on LB-OPR.Conclusion(s): In this analysis of similar patients undergoing NC-FET by a single provider, withholding doxycycline does not reduce success rates. Given the risks of antibiotics, our findings support withholding their use in NC-FET. [ABSTRACT FROM AUTHOR]

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Background: More effective recruitment strategies like alternative approaches to consent are needed to facilitate adequately powered trials. Witholding Enteral feeds Around Transfusion was a multicentre, randomised, pilot trial that compared withholding and continuing feeds around transfusion. The primary clinical outcome was necrotising enterocolitis. The trial used simplified opt-out consent with concise parent information and no consent form.Objective: To explore the views and experiences of parents and health professionals on the acceptability and feasibility of opt-out consent in randomised comparative effectiveness trials.Methods: A qualitative, descriptive interview-based study nested within a randomised trial. Semistructured interview transcripts were analysed using inductive thematic analysis.Setting: Eleven neonatal units in England.Participants: Eleven parents and ten health professionals with experience of simplified consent.Results: Five themes emerged: 'opt-out consent operationalised as verbal opt-in consent', 'opt-out consent normalises participation while preserving parental choice', 'opt-out consent as an ongoing process of informed choice', 'consent without a consent form' and 'choosing to opt out of a comparative effectiveness trial', with two subthemes: 'wanting "normal care"' and 'a belief that feeding is better'.Conclusion: Introducing a novel form of consent proved challenging in practice. The principle of a simplified, opt-out approach to consent was generally considered feasible and acceptable by health professionals for a neonatal comparative effectiveness trial. The priority for parents was having the right to decide about trial participation, and they did not see opt-out consent as undermining this. Describing a study as 'opt-out' can help to normalise participation and emphasise that parents can withdraw consent. [ABSTRACT FROM AUTHOR]

Objective: To identify sociodemographic and clinical factors associated with withholding or withdrawing life-sustaining treatment (WWLST) for extremely low gestational age neonates.Design: Observational study of prospectively collected registry data from 19 National Institute of Child Health and Human Development Neonatal Research Network centres on neonates born at 22-28 weeks gestation who died >12 hours through 120 days of age during 2011-2016. Sociodemographic and clinical factors were compared between infants who died following WWLST and without WWLST.Results: Of 1168 deaths, 67.1% occurred following WWLST. Withdrawal of assisted ventilation (97.4%) was the primary modality. WWLST rates were inversely proportional to gestational age. Life-sustaining treatment was withheld or withdrawn more often for non-Hispanic white infants than for non-Hispanic black infants (72.7% vs 60.4%; 95% CI 1.00 to 1.92) or Hispanic infants (72.7% vs 67.2%; 95% CI 1.32 to 3.72). WWLST rates varied across centres (38.6-92.6%; p<0.001). The centre with the highest rate had adjusted odds 4.89 times greater than the average (95% CI 1.18 to 20.18). The adjusted odds of WWLST were higher for infants with necrotiing enterocolitis (OR 1.77, 95% CI 1.21 to 2.59) and severe brain injury (OR 1.98, 95% CI 1.44 to 2.74).Conclusions: Among infants who died, WWLST rates varied widely across centres and were associated with gestational age, race, ethnicity, necrotiing enterocolitis, and severe brain injury. Further exploration is needed into how race, centre, and approaches to care of infants with necrotiing enterocolitis and severe brain injury influence WWLST. [ABSTRACT FROM AUTHOR]

Objective: Methamphetamine use is associated with systolic dysfunction, pulmonary arterial hypertension and may also be associated with diastolic dysfunction. The impact of methamphetamine cessation on methamphetamine-associated heart failure (MethHF) remains poorly characterised. We aimed to longitudinally characterise methamphetamine-associated heart failure patients with reduced (METHrEF) and preserved (METHpEF) left ventricular ejection fraction (EF), and evaluate the relationship between methamphetamine cessation and clinical outcomes.Methods: We performed a retrospective cohort study, and reviewed medical records of patients with METHrEF, METHpEF and heart failure controls without methamphetamine use. Echocardiographic variables were recorded for up to 12 months, with clinical follow-up extending to 24 months.Results: Among METHrEF patients (n=28, mean age 51±9 years, 82.1% male), cessation was associated with improvement in EF (+10.6±13.1%, p=0.009) and fewer heart failure admissions per year compared with continued use (median 0.0, IQR 0.0-1.0 vs median 2.0, IQR 1.0-3.0, p=0.039). METHpEF patients (n=28, mean age 50±8 years, 60.7% male) had higher baseline right ventricular systolic pressure (median 53.44, IQR 43.70-84.00 vs median 36.64, IQR 29.44-45.95, p=0.011), and lower lateral E/E' ratio (8.1±3.6 vs 11.2±4., p<0.01) compared with controls (n=32). Significant improvements in echocardiographic parameters and clinical outcomes were not observed following cessation in this group.Conclusions: METHrEF patients who cease methamphetamine use have significant improvement in left ventricular systolic function and fewer heart failure admissions, suggesting that METHrEF may be reversible. Echocardiographic parameters suggest that some patients with METHpEF may have pulmonary hypertension in the absence of overt signs of left ventricular diastolic dysfunction, but additional study is needed to characterise this patient cohort. [ABSTRACT FROM AUTHOR]

Aims: The ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial randomised patients with atrial fibrillation at risk of stroke to apixaban or warfarin. We sought to describe patients from ARISTOTLE who prematurely permanently discontinued study drug.Methods/results: We performed a posthoc analysis of patients from ARISTOTLE who prematurely permanently discontinued study drug during the study or follow-up period. Discontinuation rates and reasons for discontinuation were described. Death, thromboembolism (stroke, transient ischaemic attack, systemic embolism), myocardial infarction and major bleeding rates were stratified by ≤30 days or >30 days after discontinuation. A total of 4063/18 140 (22.4%) patients discontinued study drug at a median of 7.3 (2.2, 15.2) months after randomisation. Patients with discontinuation were more likely to be female and had a higher prevalence of cardiovascular disease, diabetes, renal impairment and anaemia. Premature permanent discontinuation was more common in those randomised to warfarin than apixaban (23.4% vs 21.4%; p=0.002). The most common reasons for discontinuation were patient request (46.1%) and adverse event (34.9%), with no significant difference between treatment groups. The cumulative incidence of clinical events ≤30 days after premature permanent discontinuation for all-cause death, thromboembolism, myocardial infarction, and major bleeding was 5.8%, 2.6%, 0.9%, and 3.0%, respectively. No significant difference was seen between treatment groups with respect to clinical outcomes after discontinuation.Conclusion: Premature permanent discontinuation of study drug in ARISTOTLE was common, less frequent in patients receiving apixaban than warfarin and was followed by high 30-day rates of death, thromboembolism and major bleeding. Initiatives are needed to reduce discontinuation of oral anticoagulation. [ABSTRACT FROM AUTHOR]

There is a rise in burden of end-stage renal disease globally and in India. The symptom burden, prognosis, and mortality in chronic kidney disease closely mimics that of cancer. However, the palliative and end of life care needs of these patients are seldom addressed. A consensus opinion statement was developed outlining the provision of end of life care in end-stage kidney disease. Recognition of medical futility, consensus on medical futility, and cessation of potentially inappropriate therapies and medications are the initial steps in providing end of life care. Conducting a family meeting, communicating prognosis, discussing various treatment modalities, negotiating goals of care, shared decision-making, and discussion and documentation of life sustaining treatment are essential aspects of end of life care provision. The provision of end of life care entails assessment and the management of end-stage kidney disease symptoms and the care extends beyond the death of the patient to their families in the bereavement period. [ABSTRACT FROM AUTHOR]

Background: Nephrologists commonly engage in decision making regarding the withholding or withdrawal of dialysis and palliative care in patients at end of life (EoL). However, these issues remain an unsolved dilemma for nephrologists. Objective: To explore nephrologists' perceptions on the decision-making process about withholding or withdrawing dialysis and palliative care in Korea. Design: A nationwide 25-item questionnaire online survey via e-mail. Setting/Subjects: A total of 369 Korean nephrologists completed the survey. Results: The proportions of respondents who stated that withholding or withdrawing dialysis at EoL is ethically appropriate were 87.3% and 86.2%, respectively. A total of 72.4% respondents thought that withdrawal of dialysis in a maintenance dialysis patient is ethically appropriate. Responses regarding patient features that should be considered to withhold or withdraw dialysis were as follows: dialysis intolerance (84.3%), poor performance status (74.8%), patient's active request (47.2%), age (28.7%), very severe dementia (27.1%), and several comorbidities (16.5%). Among those nephrologists who responded to the question about the minimum age, at which dialysis should be withheld or withdrawn, most specified an age between 80 and 90 years (94.3%). Fifty-eight percent of respondents stated that terminally ill dialysis patients should be allowed to use palliative care facilities. In addition, a number of nephrologists thought that adequate palliative care facilities, specific treatment guidelines, enough time to manage patients, financial support, and adequate medical experts are necessary. Conclusions: Korean nephrologists thought that withholding or withdrawing dialysis at EoL is ethically appropriate, even in maintenance dialysis patients. Therefore, consensus guidelines for palliative care after withholding or withdrawal of dialysis are needed. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to examine the life-sustaining treatment decisions of terminal cancer patients. Methods: Data on 10 terminal cancer patients who decided to withhold or withdraw from treatment were collected using in-depth interviews conducted from February 8 to October 30, 2019. Data were collected until saturation was reached and then analyzed using Colaizzi's phenomenological method. Results: In this study, six thematic clusters were identified: "having complicated feelings", "making choices to protect everyone", "accepting and preparing for death", "feeling distress", "pursuing spiritual wellbeing", and "evaluating the new system". Conclusion: When facing death, terminal cancer patients often made choices to protect their family and their dignity with uneasiness of mind when deciding to withdraw from life-sustaining treatments. Though many patients had accepted and prepared for death, they experienced distress about leaving children behind after death. They also pursued spiritual well-being to find peace after deciding to withdraw from life-sustaining treatment. In addition, participants evaluated the new system of policies pertaining to decisions on life-sustaining treatment. Thus, various approaches regarding acceptance and preparation for death, communication with family, hope, and spiritual comfort should be taken in educational interventions to assist terminal cancer patients as they decide whether to withdraw from life-sustaining treatment. [ABSTRACT FROM AUTHOR]

Introduction: The basic human right is the right to life, along with the issue of the right to die. Euthanasia, as the right to die, is an urgent problem, the solution of which takes place on the border of medical science and jurisprudence. The Aim: Analyze the international experience of social and legal regulation of euthanasia. Materials and Method: To achieve the set goal, research method such as a comparative law method, theoretical analysis, system-analytical method and a method of conclusions systematization were applied is not prohibited, but it is not legalized in Germany, Spain, France, Albania, Israel. Conclusions: Analyzing the current international experience of euthanasia legal regulation, it stands to mention that even with the prohibition of euthanasia, there are some gaps in the legislation, which create the possibility of passive euthanasia legal use by means of terminating life sustaining measures. It is important to enshrine the rules clearly regulating euthanasia in international law, otherwise this issue will be latent, and in the countries where there are legal gaps, excessive use of euthanasia will take place. [ABSTRACT FROM AUTHOR]

Introduction: Euthanasia which is done by doctors to their patients is considered as a part of the act of human rights violations, this matter would raise a dilemma for those who are pursuing a medical profession. Therefore, it is necessary to conduct research concerning legal liability related to euthanasia from the perspective of a medical code of ethics in Indonesia. Purpose: This research aims to acknowledge and analyze the legal liability related to euthanasia from the perspective of a medical code of ethics in Indonesia. Research Methodology: This research uses qualitative method with a normative juridical approach. The data collection technique is done through literature study. Conclusion: Doctors must not neglect the obligation to always protect human life, as regulated in the medical code of ethics in Indonesia so that the act of euthanasia is contrary to professional and legal ethics and if it continues to be carried out, it can create criminal liability as regulated in the Criminal Code. [ABSTRACT FROM AUTHOR]

Surrogate decision makers are called upon to inform medical teams what unconscious and decisionally incapacitated patients would have wanted for themselves. This task poses significant challenges for surrogates as they struggle to determine what the patient they represent would have wanted, which often takes a physical and emotional toll on the surrogate. Surrogates commonly voice hesitancy regarding withholding or withdrawing treatments, leading to the provision of potentially non-beneficial treatments, driving up costs both to the system and to the family, prolonging the dying process, and increasing distress for the family and the medical team. These ethical issues have been highlighted and exacerbated by the contemporary COVID-19 pandemic. Here we explore the unique manifestations of ethical issues surrounding surrogate decision-making in the COVID-19 context, particularly focusing on how triage, communication, time course and isolation impact the ethics of surrogate decision-making. [ABSTRACT FROM AUTHOR]

Background: Mineralocorticoid receptor antagonists (MRAs) and sodium glucose co-transporter 2 inhibitors favorably influence the clinical course of patients with heart failure and reduced ejection fraction.Objectives: This study sought to study the mutual influence of empagliflozin and MRAs in EMPEROR-Reduced (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction).Methods: Secondary analysis that compared the effects of empagliflozin versus placebo in 3,730 patients with heart failure and a reduced ejection fraction, of whom 71% used MRAs at randomization.Results: The effects of empagliflozin on the primary endpoint, on most efficacy endpoints, and on safety were similar in patients receiving or not receiving an MRA (interaction p > 0.20). For cardiovascular death, the hazard ratios for the effect of empagliflozin versus placebo were 0.82 (95% confidence interval [CI]: 0.65 to 1.05) in MRA users and 1.19 (95% CI: 0.82 to 1.71) in MRA nonusers (interaction p = 0.10); a similar pattern was seen for all-cause mortality (interaction p = 0.098). Among MRA nonusers at baseline, patients in the empagliflozin group were 35% less likely than those in the placebo group to initiate treatment with an MRA following randomization (hazard ratio: 0.65; 95% CI: 0.49 to 0.85). Among MRA users at baseline, patients in the empagliflozin group were 22% less likely than those in the placebo group to discontinue treatment with an MRA following randomization (hazard ratio: 0.78; 95% CI: 0.64 to 0.96). Severe hyperkalemia was less common in the empagliflozin group.Conclusions: In EMPEROR-Reduced, the use of MRAs did not influence the effect of empagliflozin to reduce adverse heart failure and renal outcomes. Treatment with empagliflozin was associated with less discontinuation of MRAs. (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Reduced Ejection Fraction [EMPEROR-Reduced]; NCT03057977). [ABSTRACT FROM AUTHOR]

Objective: Euthanasia is the decision to terminate the lives of patients who do not improve with medical treatment at their explicit request. This study was carried out to determine the opinions of medical students regarding euthanasia and to evaluate the effect of medical education on this issue. Methods: This cross-sectional study was conducted among first and sixth-year students of the Gaziantep University School of Medicine during the 2018-2019 academic years. Results: Of the 242 students who participated in the study, 54.1% (131) were first-year and 45.9% (111) were sixth-year students. Overall, 39.7% of the first-year students and 31.5% of the sixth-year students supported active euthanasia. The percentage of students who were against passive euthanasia and physician-assisted suicide (PAS) was 63.4% and 53.4% for first-year students and 49.5% and 54.1% for sixth-year students, respectively. Conclusion: Approximately half of the first and the sixth-year students were opposed to active euthanasia, passive euthanasia, and PAS, and there was no significant difference between these two groups of students in their being against euthanasia. However, there were significant differences between these two groups with respect to their reasons against euthanasia. [ABSTRACT FROM AUTHOR]

The legal and social perspectives of euthanasia have been widely debated in India since the 1990s. The Indian constitution is a strong pillar that supports a peaceful society and practice of morality. This paper deals with the legal and social perspectives of euthanasia in the context of India. Article 21 of the Indian Constitution assures that every Indian citizen has the right to live with dignity. While it provides all citizens the right to life, some social customs like 'thalikoothal' in Tamil Nadu southern part of India and 'sallekahana' (fasting unto the last) among Jain monks in Banaras Northern part of India are practiced. These are the challenges to the Indian Constitution and individual rights. Sallekhana is a religious custom but 'thalikoothal' is a social custom. This paper discusses social and legal points of euthanasia. The landmark case of euthanasia in the Indian Supreme Court in 2007, and the plea of Nurse Aruna Shangbarg and permission for passive euthanasia are discussed. [ABSTRACT FROM AUTHOR]

Background: Medical Assistance in Dying comprises interventions that can be provided by medical practitioners to cause death of a person at their request if they meet predefined criteria. In June 2016, Medical Assistance in Dying became legal in Canada, sparking intense debate in the palliative care community. Aim: This study aims to explore the experience of frontline palliative care providers about the impact of Medical Assistance in Dying on palliative care practice. Design: Qualitative descriptive design using semi-structured interviews and thematic analysis Settings/participants: We interviewed palliative care physicians and nurses who practiced in settings where patients could access Medical Assistance in Dying for at least 6 months before and after its legalization. Purposeful sampling was used to recruit participants with diverse personal views and experiences with assisted death. Conceptual saturation was achieved after interviewing 23 palliative care providers (13 physicians and 10 nurses) in Southern Ontario. Results: Themes identified included a new dying experience with assisted death; challenges with symptom control; challenges with communication; impact on palliative care providers personally and on their relationships with patients; and consumption of palliative care resources to support assisted death. Conclusion: Medical Assistance in Dying has had a profound impact on palliative care providers and their practice. Communication training with access to resources for ethical decision-making and a review of legislation may help address new challenges. Further research is needed to understand palliative care provider distress around Medical Assistance in Dying, and additional resources are necessary to support palliative care delivery. [ABSTRACT FROM AUTHOR]

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID‐19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time‐limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care. [ABSTRACT FROM AUTHOR]

Disconnecting a patient from artificial life support, on their request, is often if not always a matter of letting them die, not killing them—and sometimes, permissibly doing so. Stopping a patient's heart on request, by contrast, is a kind of killing, and rarely if ever a permissible one. The difference seems to be that procedures of the first kind remove an unwanted external support for bodily functioning, rather than intervening in the body itself. What should we say, however, about cases at the boundary—procedures involving items that seem bodily in some respects, but not others? When, for instance, does deactivating an implanted device like a pacemaker count as killing, and when as letting die? Contra existing proposals, I argue that the boundaries of the body for this purpose are not drawn at the boundaries of the self, or (if this is different) the human organism. Nor should we determine when we are killing and when we are letting die by deferring to existing practices for distinguishing ongoing from completed treatment. Rather, I argue that whether something (organic or inorganic) counts as body part for purposes of this distinction depends on the results of a normative analysis of the particular character of our rights in it—particularly, whether and in what way these rights ought to be alienable. I conclude by arguing that there are likely good reasons to recognize distinctively "bodily" rights and restrictions in at least some implantable devices. [ABSTRACT FROM AUTHOR]

This investigation addressed family member perceptions of preparation for withdrawal of life-sustaining treatment in the intensive care unit. These families are at a high risk for psychosocial and physical sequelae. The quantitative results of this mixed methods study are reported. A control group received usual care and an educational booklet component of the intervention. The experimental group received the above plus exposure to comfort cart items and additional psychological support. Twenty-eight family members enrolled over a 13-month period. Sixty-one percent (10 intervention, 7 control) completed the follow-up. Fourteen family members (82%) recalled the booklet. Some family members reported moderate to severe depression (12.5%), anxiety (12.5%), and stress (12.6%). Satisfaction with care (83.7%-85.2%) and family member well-being (44.1) were within the norm. Short Form-36 physical component score was higher than the norm, and the mental component score was lower than the norm. This study demonstrated feasibility and acceptability of the interventions and follow-up questionnaires when families make the difficult decision to withdraw treatment. Strategies are suggested to strengthen statistical power. [ABSTRACT FROM AUTHOR]

Our hypothesis is that the past participle is a singular form in the TAM (tense-aspect-mood) linguistic system in French, in that it represents the internal time of the process on its terminal point ([R = Et]). Due to this representation of internal time, the p.p. can be related to the second argument – the patientive argument – of a direct transitive process: it is the essential element of the passive construction. Contrary to what is often written, the copula être 'be', is an optional element: it may serve to develop the construction in its periphrastic dimension, but it is not necessary to the passive construction itself, as the cases of the passive in the participial clause demonstrate. Moreover, the p.p. is not intrinsically resultative or processive, no more than it is active or passive: from its aspect [R = Et], it can, in interaction with different contexts, participate in the production of these different effects of meaning in discourse. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to explore the role of drugs re-challenge at the disease progression after a chemotherapy-free interval for pancreatic adenocarcinoma (PDAC) patients.Methods: We retrospectively analyzed the outcome of re-treatments at the progression in two cohorts of advanced PDAC patients who had disease control (DC) and a treatment holiday ≥ 3 months after upfront chemotherapy.Results: Between 2015 and 2019, 66 advanced PDAC patients (cohort A) had DC with nab-paclitaxel-based chemotherapy (i.e. AG or PAXG = cisplatin, nab-paclitaxel, gemcitabine, capecitabine). At the time of progressive disease (PD), 34 patients were re-treated with AG (A1) and 32 were treated with other regimens (A2). The median (m) duration of chemotherapy holiday was 6.1 and 5.9 months in A1 and A2, respectively. Partial response (PR) and stable disease (SD) were found in 14 (41%) and 12 (35%) of patients in A1 and in 8 (25%) and 6 (19%) patients in A2. CA19-9 response was recorded in 23/33 evaluable patients (70%) in A1 and in 5/20 (25%) in A2. mPFS2 and mOS2, defined as the time between the second line of treatment start and the disease progression or death, were 4.8 and 12.2 months in A1 and 3.9 and 8.4 months in A2, respectively. Similarly, between 2006 and 2013, 64 patients (cohort B) had DC with upfront PEFG/PEXG/PDXG regimens (epirubicin or docetaxel, cisplatin, gemcitabine, capecitabine or 5-fluorouracil) and were re-treated at PD with either 4-drug (B1; N = 30) or other regimens (B2; N = 34), yielding a mOS2 of 10.9 and 7.2 months, respectively.Conclusion: Our data endorse the strategy of resuming prior drugs after a chemotherapy holiday ≥ 3 months in advanced PDAC patients who achieved a  durable disease control after upfront treatments. [ABSTRACT FROM AUTHOR]

This article aims to develop the argument that the strength of scientific denialism (negationism) and the normalization of death in the conduct of the Covid-19 pandemic in Brazil were possible in recent years insofar as it has been attributed to the president of Brazil, Jair Bolsonaro, by diverse social interests and agents, the role of leadership and authority responsible for the purification of politics, the economy and the nation. His strategy of "to make live and to let die" found active or passive support in a significant part of Brazilian society because Bolsonaro is able to establish himself in this pole of purification and restoration of a supposedly lost-regime of truth. The research encompasses diverse textual productions and official and informal statements by the social agents in question. To analyze them, social theories, especially in sociology, were used in order to identify the agents, ideologies and discursive that produce meanings about life and death. As a result, it is possible to affirm that the government's objective of making the virus circulate, outlined as an implicit and explicit goal since the beginning of the pandemic, demanded a normalization of preventable deaths, which only the neo-fascist language, which is capable of producing an alternative meaning of life more authentic and purer, it has been able to achieve so far. [ABSTRACT FROM AUTHOR]

Argument coding splits such as differential (= split) object marking and split ergative marking have long been known to be universal tendencies, but the generalizations have not been formulated in their full generality before. In particular, ditransitive constructions have rarely been taken into account, and scenario splits have often been treated separately. Here I argue that all these patterns can be understood in terms of the usual association of role rank (highly ranked A and R, low-ranked P and T) and referential prominence (locuphoric person, animacy, definiteness, etc.). At the most general level, the role-reference association universal says that deviations from usual associations of role rank and referential prominence tend to be coded by longer grammatical forms. In other words, A and R tend to be referentially prominent in language use, while P and T are less prominent, and when less usual associations need to be expressed, languages often require special coding by means of additional flags (case-markers and adpositions) or additional verbal voice coding (e.g., inverse or passive markers). I argue that role-reference associations are an instance of the even more general pattern of form-frequency correspondences, and that the resulting coding asymmetries can all be explained by frequency-based predictability and coding efficiency. [ABSTRACT FROM AUTHOR]