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INTRODUCTION: The incidence of pediatric Wilms tumor (WT) is high in Africa, though patients abandon treatment after initial diagnosis. We sought to identify factors associated with WT treatment abandonment in Uganda. METHODS: A cohort study of patients  25 cm (OR 2.67, 95% CI 1.05-6.81). CONCLUSIONS: Children with WT in Uganda frequently abandon care during neoadjuvant therapy, particularly those with large tumors with poor response. Further investigation into the factors that influence treatment abandonment and a deeper understanding of tumor biology are needed to improve treatment adherence of children with WT in Uganda.

Introduction: Patients with cancer experience physical, mental, and social pain that affects themselves and their families. The increasing cancer incidence and advances in treatment have increased the number of cancer survivors in Korea, and there is an influx of patients in Seoul and other metropolitan areas, leading to shortages of continuous care and comprehensive life support facilities. Patients must travel long distances for treatment, which poses logistical and quality-of-life challenges. Methods: This prospective cohort study targets patients with incurable cancer (n = 720) and their families (n = 288) from ten regional cancer centers and two affiliated hospitals in Korea. The sub-cohorts are based on treatment refusal, spinal metastasis with symptoms, catheter-related symptoms, and skeletal-related events. Medical records and patient-reported outcomes will be collected every three months and for up to three years, with surveys for guardians conducted for one-year post-patient demise. Discussion: The dynamic nature of cancer significantly affects patients and their caregivers. It is necessary to identify the factors that affect their quality of life to integrate them into society. Conclusion: The findings of this study will inform the establishment of a regional cancer center consortium. This will address the unmet needs of local cancer patients and their families, enhance their overall quality of life, and contribute to the well-being of the local community. Trial registration: KCT0009177 (registered at https//cris.nih.go.kr/ on 2024/02/16). [ABSTRACT FROM AUTHOR]

Patients with mental illness, and depression in particular, present clinicians and surrogate decision-makers with complex ethical dilemmas when they refuse life-sustaining non-psychiatric treatment. When treatment rejection is at variance with the beliefs and preferences that could be expected based on their premorbid or "authentic" self, their capacity to make these decisions may be called into question. If capacity cannot be demonstrated, medical decisions fall to surrogates who are usually advised to decide based on a substituted judgment standard or, when that is not possible, best interest. We propose that in cases where the patient meets the widely accepted cognitive criteria for capacity but is making decisions that appear inauthentic, the surrogate may best uphold patient autonomy by following a "restorative representation" model. We see restorative representation as a subset of substituted judgement in which the decision-maker retains responsibility for deciding as the patient would have, but discerns the decision their "truest self" would make, rather than inferring their current wishes, which are directly influenced by illness. Here we present a case in which the patient's treatment refusal and previously undiagnosed depression led to difficulty determining the patient's authentic wishes and placed a distressing burden on the surrogate decision-maker. We use this case to examine how clinicians and ethicists might better advise surrogates who find themselves making these clinically and emotionally challenging decisions. [ABSTRACT FROM AUTHOR]

Abstract Introduction Patients with cancer experience physical, mental, and social pain that affects themselves and their families. The increasing cancer incidence and advances in treatment have increased the number of cancer survivors in Korea, and there is an influx of patients in Seoul and other metropolitan areas, leading to shortages of continuous care and comprehensive life support facilities. Patients must travel long distances for treatment, which poses logistical and quality-of-life challenges. Methods This prospective cohort study targets patients with incurable cancer (n = 720) and their families (n = 288) from ten regional cancer centers and two affiliated hospitals in Korea. The sub-cohorts are based on treatment refusal, spinal metastasis with symptoms, catheter-related symptoms, and skeletal-related events. Medical records and patient-reported outcomes will be collected every three months and for up to three years, with surveys for guardians conducted for one-year post-patient demise. Discussion The dynamic nature of cancer significantly affects patients and their caregivers. It is necessary to identify the factors that affect their quality of life to integrate them into society. Conclusion The findings of this study will inform the establishment of a regional cancer center consortium. This will address the unmet needs of local cancer patients and their families, enhance their overall quality of life, and contribute to the well-being of the local community. Trial registration KCT0009177 (registered at https//cris.nih.go.kr/ on 2024/02/16).

Whether anorexic patients should be able to refuse treatment when this refusal potentially has a fatal outcome is a vexed topic. A recent proposal for a new category of "terminal anorexia" suggests criteria when a move to palliative care or even physician-assisted suicide might be justified. The author argues that this proposed diagnosis presents a false sense of certainty of the illness trajectory by conceptualizing anorexia in analogy with physical disorders and stressing the effects of starvation. Furthermore, this conceptualization is in conflict with the claim that individuals who meet the diagnostic criteria for terminal anorexia have decision-making capacity. It should therefore be rejected. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to examine sex-stratified independent predictors of patient-initiated discharge from an inpatient withdrawal management service and to determine whether those predictors differed by sex. Methods: This study compared people who had self-initiated versus planned discharges and used sex-stratified generalized estimating equations models to identify independent predictors of patient-initiated discharge. Predictors examined included age, ethnicity, substance of concern, tobacco use, mental health comorbidities, day of discharge, referral source, children, and social assistance funds. Results: Among females, there were 722 discharges, 116 of which were patient initiated. Among females, increasing age was associated with lower odds of patient-initiated discharge (OR = 0.97, 95% CI [0.95, 0.98]). Racialized females were nearly 2 times more likely to experience patient-initiated discharge compared with White females (OR = 1.8, 95%CI [1.09, 3.00]). Compared with weekdays, weekends were associated with over 4 times the odds of patient-initiated discharge (OR = 4.77, 95% CI [2.66, 8.56]). Having one ormore mental health comorbidities was associated with lower odds of patient-initiated discharge compared with having no mental health comorbidities (OR = 0.51, 95% CI [0.32, 0.82]). Among males, there were 1,244 discharges, 185 of which were patient initiated. Among males, increasing age was associated with decreased odds of patient-initiated discharge (OR = 0.97, 95% CI [0.95, 0.98]). Compared with weekdays, weekends were associated with nearly 15 times the odds of patientinitiated discharge (OR = 14.9, 95% CI [9.11, 24.3]). Conclusions: Males and females have shared and unique predictors of patient-initiated discharge. Future studies should continue to examine the influence of sex and gender on engagement with addictions care. [ABSTRACT FROM AUTHOR]

Background Aim Materials and Methods Results Conclusion Choice, a fundamental pillar of woman‐centred maternity care, depends in part on the right to decline recommended care. While professional guidance for midwives and obstetricians emphasises informed consent and respect for women's autonomy, there is little guidance available to clinicians or women about how to navigate maternity care in the context of refusal.To describe the process and outcomes of co‐designing resources to support partnership between the woman who declines recommended maternity care and the clinicians and health services who provide her care.Following a participatory co‐design process involving consumer representatives, obstetricians, midwives, maternal fetal medicine specialists, neonatologists, health service executives, and legal and ethics experts, implementation of the resources was trialled in seven Queensland Health services using Improvement Science's Plan‐Do‐Study‐Act cycles.Resources for Partnering with the woman who declines recommended maternity care have now been implemented statewide, in Queensland, including a guideline, two consumer information brochures (available in 11 languages), clinical form, flowcharts, consumer video, clinician education, and culturally capable First Nations resources. Central to these resources is an innovative shared clinical form, that is accessible online, may be initiated and carried by the woman, and where she can document her perspective as part of the clinical notes.Queensland is the first Australian jurisdiction, and perhaps internationally, to formally establish this kind of guidance in clinical practice. Such guidance is identified as an enabler of choice in the national Australian strategy Woman‐centred care: Strategic directions for Australian maternity services. [ABSTRACT FROM AUTHOR]

Purpose: Among patients with cancer, a comorbid mental disorder is associated with higher mortality. This could be partially attributed to reduced access to oncological care, sometimes due to treatment refusal. Recommendations were issued in 2018 by the French and Francophone Society of Psycho-Oncology concerning the management of oncological treatment refusal. This study aimed to examine oncology residents’ view on psychiatric assessment in this context. Methods: In February 2021, we conducted a descriptive, observational, cross-sectional pilot study among French residents involved in oncology regarding their management of cancer treatment refusal and the importance they assign to psychiatric assessment, using an online questionnaire with 12 multiple-choice questions. Results: Among 87 respondents, only 35.6% systematically explore the history of mental disorders when facing cancer treatment refusal. Even in cases with a known history of mental disorders, only 42.5% systematically refer the patient to a psychiatrist. 96.5% of them were unaware of the 2018 recommendations. Conclusion: The importance given to psychiatric assessment in cases of oncological treatment refusal remains insufficient. Qualitative studies are needed to understand the underlying reasons for this refusal. The development of psychiatric consultation-liaison interventions in oncology centers is necessary to improve the management of these cases and provide appropriate training. [ABSTRACT FROM AUTHOR]

While many cancer patients who use tobacco try to quit post-diagnosis, some prefer to quit without using tobacco treatment, despite evidence against unassisted quit attempts. This study aimed to understand the rationale for some cancer patients' desire to quit tobacco without assistance. Thirty-five adult cancer patients who currently used tobacco and declined tobacco treatment because of the desire to quit unassisted provided data via a standardized questionnaire and a semi-structured interview. The sample was predominately White, non-Hispanic (85.71%) and female (68.57%). The most common cancer site was gynecological. Key themes that emerged from the interviews were: self-reliance, willpower, social norms, and negative attitudes toward tobacco treatment. The most frequently endorsed barrier to tobacco treatment was " I know others who have quit without tobacco treatment" (82.86%). This study with cancer patients identified affective, cognitive, and personality factors related to quitting unassisted, and social and systemic reasons to not use tobacco treatment. [ABSTRACT FROM AUTHOR]

Aim. To describe and analyze a series of cases of absolute non-adherence to treatment (ANA), as well as to study the relationship of the phenomenon of refusal of treatment with long-term adverse outcomes in patients with acute cerebrovascular accident (ACVA), according to the LIS-2 registry (Lyubertsy Mortality Study 2).Material and methods. The study analyzed the results of two stages of prospective follow-up of patients with acute cerebrovascular accident included in the LIS-2 registry (n=960). After 2.8 [2.1; 3.5] years, an examination, a survey, and an assessment of treatment adherence according to the original questionnaire were conducted in 370 patients. After 6.9 [6.1;7.7] years, the outcomes of these patients were evaluated. The survival analysis included death from all causes, nonfatal myocardial infarctions and repeated ACVA, and emergency hospitalization for cardiovascular diseases also. These are the components of the primary combined endpoint.Results. According to the results of the questionnaire, 23 (6,2%) patients replied that they did not take prescribed medications, i.e. they were absolutely not adherent to treatment. Absolutely non-adherent patients smoked more often (p=0.004), were less comorbid, and had statistically significant difference in hypertension and coronary heart disease (CHD) (p

Objective: To identify determinants of medication non-adherence in a Swedish population of systemic lupus erythematosus (SLE). Methods: Patients with SLE from Karolinska and Örebro University Hospitals participated in a survey-based cross-sectional study. Demographics, disease activity, organ damage, HRQoL (LupusQol, EQ-5D-5 L), medication non-adherence (<80% on CQR-19 or MASRI) and beliefs about medicines (BMQ) were registered. MASRI was used to report adherence to different drugs/drug classes, categorised into (i) antimalarial agents (AMA), (ii) glucocorticoids and (iii) other SLE medications. Multivariable logistic regression adjusted for age, sex, disease activity and organ damage. Results: Among 205 respondents, the median age was 52.0 years (IQR: 34.0–70.0), 86.3% were women, 66.8% were non-adherent to their medications according to CQR-19, and 6.6% and 6.3% were non-adherent to AMA and glucocorticoids, respectively, according to MASRI. Positive beliefs about glucocorticoids (OR; 95% CI: 0.77; 0.59–0.99; p =.039) and medications overall (0.71; 0.52–0.97; p =.029) were protective against non-adherence to glucocorticoids. Anxiety/depression (3.09; 1.12–8.54; p =.029), medication concerns (1.12; 1.05–1.20; p <.001) and belief that medications are overused (1.30; 1.15–1.46; p <.001) or harmful (1.36; 1.19–1.56; p <.001) were associated with medication non-adherence (CQR-19); beliefs in the necessity of medications (0.73; 0.65–0.82; p <.001) and positive beliefs in medications were protective (0.72; 0.60–0.86; p <.001). No associations were found between other investigated factors and medication non-adherence. Conclusions: Beliefs about medications were a major determinant of medication non-adherence. Patient education may help alleviate the negative impact of misinformation/unawareness on adherence. [ABSTRACT FROM AUTHOR]

Background: Since the COVID-19 pandemic, clinical ethics consultation services have faced new challenges such as medical decision-making in the setting of unprecedented resource and staffing shortages and increased public mistrust of the healthcare system. This study aims to analyze shifts in consultation patterns due to long-lasting consequences of the pandemic in a healthcare system in New York City. We hypothesized an increase in consults placed for refusal of medical treatment due to heightened public distrust. Methods: We used the clinical ethics consultation service database to extract data on volume and reason for consult. Consults placed between 2015 and 2021 were included, except those placed during the height of the COVID-19 surge in March and April 2020. Chi-squared tests were used to compare the proportion of consults requested for each ethical issue between pre-COVID and post-COVID cohorts. Logistic regression was used to compare proportions of consults between the cohorts while controlling for confounding demographic variables. Results: 547 consults in the pre-COVID cohort and 215 in the post-COVID cohort were included. There was no significant difference pre- and post-COVID in the proportion of ethics consults placed for refusal of medical care in either the unadjusted or adjusted analysis (27% and 24% respectively). There were some statistically significant differences in other categories of consultation, however the absolute numbers were small. Conclusions: Our findings did not support the hypothesis that increased public mistrust in the post-COVID era has increased consultations related to refusal of recommended medical care. Perceptions of increases in refusal of medical care may be related to overall increases in clinician moral distress and emotional fatigue. [ABSTRACT FROM AUTHOR]

Disputes over life-sustaining treatment between clinicians and patients or their surrogates are common in the intensive care unit and expected to increase in America because of an aging population, shifts in medical training, and trends in popular opinions on end-of-life decisions. Clinicians struggle to effectively communicate the recommendation that withdrawing life-sustaining treatment is appropriate when the burdens of treatment outweigh the benefits. This view seems foreign and unimaginable to surrogates like family members with deeply held values motivate them to insist "everything be done" as long as the patient can be physiologically kept alive. For over three decades now, clinicians and bioethicists have sought preventative ethical and policy solutions to avoid or resolve these treatment disputes, including efforts to improve the communication between medical professionals and surrogates. Looking at the history of proposed solutions shows that giving providers more and better communication and negotiation tools may be inadequate on its own. However, better communication has the potential to unearth the motivations and deeper values of the disagreeing parties so that differing perspectives can be recognized and common ground can be established. The latest emphasize on communication has the potential to succeed where other historical solutions have failed. If bioethics is going to successfully analyze and remedy these disputes, the values motivating these views, even ones outside the bioethical consensus, must be acknowledged and respected. In short, better communication will not avoid or resolve life-sustaining treatment disputes in the intensive care unit unless the deeper ethical convictions of the disagreeing parties are recognized and engaged. [ABSTRACT FROM AUTHOR]

BackgroundDespite the high burden of Staphylococcus aureus infections among persons who use drugs, limited data exist comparing outcomes of patient-directed discharge (known as discharge against medical advice) compared with standard discharge among persons who use drugs hospitalized with S. aureus infection.MethodsWe conducted a retrospective study of hospitalizations among adults with S. aureus bacteremia, endocarditis, epidural abscess, or vertebral osteomyelitis at 2 San Francisco hospitals between 2013 and 2018. We compared odds of 1-year readmission for infection persistence or recurrence and 1-year mortality via multivariable logistic regression models adjusting for age, sex, Charlson comorbidity index, and homelessness.ResultsOverall, 80 of 340 (24%) of hospitalizations for invasive S. aureus infections among persons who use drugs involved patient-directed discharge. More than half of patient-directed discharges 41 of 80 (51%) required readmission for persistent or recurrent S. aureus infection compared with 54 of 260 (21%) patients without patient-directed discharge (adjusted odds ratio 3.8, 95% confidence interval [CI] 2.2-6.7). One-year cumulative mortality was 15% after patient-directed discharge compared with 11% after standard discharge (P = .02); however, this difference was not significant after adjustment for mortality risk factors. More than half of deaths in the patient-directed discharge group (7 of 12, 58%) were due to drug overdose; none was due to S. aureus infection.ConclusionsAmong persons who use drugs hospitalized with invasive S. aureus infection, odds of hospital readmission for infection were almost 4-fold higher following patient-directed discharge compared with standard discharge. All-cause 1-year mortality was similarly high in both groups, and drug overdose was a common cause of death in patient-directed discharge group.

Abstract Background Each individual’s unique health-related beliefs can greatly impact the patient-clinician relationship. When there is a conflict between the patient’s preferences and recommended medical care, it can create a serious ethical dilemma, especially in an emergency setting, and dramatically alter this important relationship. Case presentation A 56-year-old man, who remained comatose after out-of-hospital cardiac arrest, was rushed to our hospital. The patient was scheduled for emergency coronary angiography when his adolescent daughter reported that she and her father held sincere beliefs against radiation exposure. We were concerned that she did not fully understand the potential consequences if her father did not receive the recommended treatment. A physician provided her with in depth information regarding the risks and benefits of the treatment. While we did not want to disregard her statement, we opted to save the patient’s life due to concerns about the validity of her report. Conclusions Variations in beliefs regarding medical care force clinicians to incorporate patient beliefs into medical practice. However, an emergency may require a completely different approach. When faced with a patient in a life-threatening condition and unconscious, we should take action to prioritize saving their life, unless we are highly certain about the validity of their advance directives.

Simple Summary: In a cohort of 828 patients undergoing surgery for sarcomas of the extremities, pelvis, and trunk, approximately half of them were advised to receive radiotherapy. Notably, 4.7% declined the recommended treatment regimen, resulting in a decrease of both overall survival and local recurrence-free survival. Similarly, 40% of patients within the same group were advised to undergo chemotherapy; 8.8% of these patients rejected the recommendation, leading to a reduced local recurrence-free survival. Enhancing physician-patient communication and addressing underutilization of recommended therapies in sarcoma patients should be a priority for surgeons and oncologists alike. Background: In soft tissue or bone sarcomas, multimodal therapeutic concepts represent the standard of care. Some patients reject the therapeutic recommendations due to several reasons. The aim of this study was to assess the impact of that rejection on both prognosis and local recurrence. Methods: Between 2012 and 2019, a total of 828 sarcoma patients were surgically treated. Chemotherapy was scheduled as a neoadjuvant, and adjuvant multi-agent therapy was performed following recommendations from an interdisciplinary tumor board. Radiotherapy, if deemed appropriate, was administered either in a neoadjuvant or an adjuvant manner. The recommended type of therapy, patient compliance, and the reasons for refusal were documented. Follow-ups included local recurrences, diagnosis of metastatic disease, and patient mortality. Results: Radiotherapy was recommended in 407 (49%) patients. A total of 40 (10%) individuals did not receive radiation. A reduction in overall survival and local recurrence-free survival was evident in those patients who declined radiotherapy. Chemotherapy was advised for 334 (40%) patients, 250 (75%) of whom did receive all recommended cycles. A total of 25 (7%) individuals did receive a partial course while 59 (18%) did not receive any recommended chemotherapy. Overall survival and local recurrence-free survival were reduced in patients refusing chemotherapy. Overall survival was worst for the group of patients who received no chemotherapy due to medical reasons. Refusing chemotherapy for non-medical reasons was seen in 8.8% of patients, and refusal of radiotherapy for non-medical reasons was seen in 4.7% of patients. Conclusions: Divergence from the advised treatment modalities significantly impacted overall survival and local recurrence-free survival across both treatment modalities. There is an imperative need for enhanced physician-patient communication. Reducing treatment times, as achieved with hypofractionated radiotherapy and with therapy in a high-volume sarcoma center, might also have a positive effect on complying with the treatment recommendations. [ABSTRACT FROM AUTHOR]

Objective: To understand topical fluoride-related beliefs and refusal behaviors for caregivers of children with special health care needs (CSHCN). Methods: This was an explanatory sequential mixed methods study. For the quantitative analyses, we surveyed 520 caregivers to (a) compare fluoride-related beliefs between caregivers of CSHCN and caregivers of healthy children and (b) evaluate the association between special health care need (SHCN) status and topical fluoride refusal. We used logistic regression models to generate unadjusted odds ratios, confounder-adjusted odds ratios (AOR), and 95% confidence intervals (CI). For the qualitative analyses, we interviewed 56 caregivers who refused or were hesitant about topical fluoride. Data were coded deductively and compared by SHCN status to an existing conceptual model of topical fluoride refusal. Results: In the quantitative analysis, 41.3% of caregivers refused or thought about refusing topical fluoride. There were no significant differences in fluoride beliefs by SHCN status (p-values > 0.05) nor was there a significant association between SHCN status and topical fluoride refusal (AOR: 0.65, 95% CI 0.37–1.14; p = 0.13). In the qualitative analysis, the relative importance of each domain of the conceptual model was similar between the caregiver groups. Two differences were that all caregivers of CSHCN thought fluoride was unnecessary and wanted to keep chemicals out of their child's body. Conclusions for Practice: While caregivers of CSHCN were not more likely to refuse topical fluoride than caregivers of healthy children, there may be important differences in the underlying reasons for refusing topical fluoride. Significance: What is already known on this subject? CSHCN are at increased risk for tooth decay. Topical fluoride helps prevent tooth decay, but large numbers of caregivers refuse topical fluoride. A conceptual model of caregiver topical fluoride refusal has been developed, but its applicability to caregivers of CSHCN has not yet been evaluated. What this study adds? This study provides empirical insight into fluoride refusal behaviors for caregivers of CSHCN. Caregivers of CSHCN may have different reasons for refusing topical fluoride. Findings from this study will help guide the development of tailored communication approaches for caregivers of CSHCN who refuse or may be hesitant about topical fluoride. [ABSTRACT FROM AUTHOR]

Background and Objectives: Compared with White patients, Black and American Indian/Alaskan Native (AI/AN) patients experience higher rates of kidney cancer incidence, and Black, AI/AN, and Hispanic patients face later stages of disease at diagnosis, poorer survival rates, and greater risk of mortality. Despite the importance that appropriate treatment has in ensuring positive outcomes, little is known about the association between race and ethnicity and receipt of treatment for kidney cancer. Accordingly, the aim of this study was to explore differences in receipt of treatment and patterns of refusal of recommended treatment by race and ethnicity. Design: 96,745 patients ages 45-84 with kidney cancer were identified in the Surveillance, Epidemiology, and End Results (SEER) program between 2007 and 2014. Logistic regression models were used to examine the association of race and ethnicity with treatment and with patient refusal of recommended treatment. Outcomes of interest were (1) receiving any surgical procedure, and (2) refusing recommended surgery. Results: Relative to White patients, Black and AI/AN patients had lower odds of undergoing any surgical procedure (OR = 0.76; 95% CI: 0.72-0.81; p < 0.001, and OR = 0.92; 95% CI: 0.76-1.10; p = 0.36, respectively) after adjusting for gender, age, insurance status, stage at diagnosis, unemployment status, education status, and income as additive effects. Black and AI/AN patients also had higher odds of refusing recommended surgery (OR = 1.93; 95% CI: 1.56-2.39; p <0.001, and OR = 1.99; 95% CI: 1.05-3.76; p = 0.035, respectively). Hispanic patients had slightly higher odds of undergoing any surgical procedure (OR = 1.10; 95% CI: 1.04-1.17; p = 0.001) and lower odds of refusal (OR = 0.67; 95% CI: 0.50-0.90; p = 0.007, respectively). Conclusions: Compared with White patients, Black patients were less likely to receive potentially life-saving surgery, and both Black and AI/AN patients were more likely to refuse recommended surgery. [ABSTRACT FROM AUTHOR]

BackgroundThere is a need to update the understanding of treatment refusal among cancer patients in China, taking into account recent developments. This study investigated how public insurance coverage of the first breast cancer targeted therapy contributed to the changes in treatment refusal among HER2-positive breast cancer patients in China. And it intensively examined and discussed additional barriers affecting patient utilization of innovative anticancer medicines based on the types and reasons for treatment refusal.MethodsThis retrospective study included female breast cancer patients diagnosed as HER2-positive who received treatment at a provincial oncology center in southern China between 2014 and 2020. Multivariable analysis was conducted using a binary logistic regression model. Subgroup analysis was performed with the same regression model.ResultsAmong the 1,322 HER2-positive breast cancer patients who received treatment at the study hospital between 2014 and 2020, 327 (24.55%) had ever refused treatment. Economic reasons were reported as the primary cause by 142 patients (43.43%). Patients diagnosed after September 2017, when the first breast cancer targeted therapy was included in the public health insurance, were less likely to refuse treatment (OR = 0.64, 95% CI:0.45 ~ 0.91, p = 0.01) compared to those diagnosed before September 2017. Patients enrolled in the resident health insurance were more likely to refuse treatment (OR = 2.43, 95% CI:1.77 ~ 3.35, p

Background: Each individual's unique health-related beliefs can greatly impact the patient-clinician relationship. When there is a conflict between the patient's preferences and recommended medical care, it can create a serious ethical dilemma, especially in an emergency setting, and dramatically alter this important relationship. Case presentation: A 56-year-old man, who remained comatose after out-of-hospital cardiac arrest, was rushed to our hospital. The patient was scheduled for emergency coronary angiography when his adolescent daughter reported that she and her father held sincere beliefs against radiation exposure. We were concerned that she did not fully understand the potential consequences if her father did not receive the recommended treatment. A physician provided her with in depth information regarding the risks and benefits of the treatment. While we did not want to disregard her statement, we opted to save the patient's life due to concerns about the validity of her report. Conclusions: Variations in beliefs regarding medical care force clinicians to incorporate patient beliefs into medical practice. However, an emergency may require a completely different approach. When faced with a patient in a life-threatening condition and unconscious, we should take action to prioritize saving their life, unless we are highly certain about the validity of their advance directives. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The elderly population is the most at risk regarding adherence, especially in the coexistence of multiple diseases. This study aims to detect factors contributing to therapeutic non-adherence in elderly patients in home settings. MATERIALS AND METHODS: A review protocol was developed to conduct the umbrella review using the methodological framework of the Richardson et al study. The search strategy was developed in December 2022 to conduct a systematic search and to perform an Umbrella Review of systematic reviews, meta-analyses and integrative reviews published from 2012 to 2022 in English. RESULTS: A total of 26,038 articles were identified and screened. 18 relevant articles were included in the study. CONCLUSIONS: Therapeutic adherence in elderly patients with comorbidities in polypharmacotherapy at home is a significant problem in public health and health care. Several factors of non-adherence have been identified in the studies reviewed, confirming that the problem is multifactorial. Reducing the number of medications prescribed would appear optimal, although often not possible, as this has been seen to have an immediate positive impact. A multidisciplinary approach makes it possible not to fragment care, ensuring positive feedback on therapeutic adherence. [ABSTRACT FROM AUTHOR]

Background: Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. Methods: A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. Results: Ten patients (60% male, median age = 78.5 years) completed interviews. Patients' passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients' overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. Conclusion: Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment. [ABSTRACT FROM AUTHOR]

• Daily chlorhexidine gluconate (CHG) bathing can reduce patient's infection risk. • Patient refusal of CHG bathing is noted to be a major barrier to compliance. • Iterative Plan-Do-Study-Act cycles were implemented to target patient refusals. • After 6 months, patient refusal of CHG bathing and CLABSI rates decreased. Daily chlorhexidine gluconate (CHG) bathing is a well-supported intervention to reduce patient's risk of central line associated bloodstream infection (CLABSI); however, compliance with this practice is suboptimal. One major barrier is patient refusals of CHG bathing. The purpose of this project was to implement tailored interventions to mitigate this barrier. The specific aims were to reduce patient refusals, increase compliance with CHG bathing, and evaluate CLABSI rates and nursing staff's knowledge of CHG bathing. Iterative Plan-Do-Study-Act (PDSA) cycles were implemented over the course of 6 months. Run charts were used to identify signals of improvement. Interventions included printed educational flyers for staff and patients, educational sessions, an electronic learning module, and a "badge buddy." We saw a reduction in the median percentage of patient refusals documented, from 23% to 8% after the PDSA cycles. Documentation compliance with CHG bathing increased only slightly from 46% to 47%. CLABSI rates decreased 6% from 0.69 to 0.65. Using interventions tailored to the clinical setting can impact patient outcomes. Other health care systems should consider implementing PDSA cycles to improve evidence-based practices. Using PDSA cycles can result in a reduction in patient refusal documentation, and may slightly improve CHG bathing compliance and CLABSI rates. [ABSTRACT FROM AUTHOR]

To evaluate the consequences of treatment refusal in total laryngectomy (TL) candidates with T3-4M0 endolaryngeal squamous cell carcinoma (SCC). A retrospective observational study was conducted in an inception cohort of 576 isolated T3-4M0 endolaryngeal SCC candidates for TL consecutively managed between 1970 and 2019 in a French university teaching hospital. The main endpoint was survival time and cause of death in 2 groups. Group A, 4.5% of the cohort, consisted of 26 patients who declined any laryngeal treatment. Group B consisted of 550 patients who accepted TL. Accessory endpoints were causes of TL refusal and associated variables. The STROBE guideline was applied. The significance threshold was set at P < 0.005. One-and 3-year actuarial survival estimates increased significantly (P < 0.0001) from 39% and 15% in group A, to 83% and 63% in group B, respectively. In group A, 92% of causes of death implicated index SCC progression, whereas in group B intercurrent disease, metachronous second primary, locoregional and/or metastatic SCC progression and postoperative complications accounted for 37%, 31%, 29%, and 2%, respectively. The actuarial survival estimates within group A increased significantly (P = 0.0003) from 0% at 1-year in patients managed with isolated supportive care to 56% in patients managed with chemotherapy (reaching 0% at 5 years). Reasons for TL refusal were fear of surgery, refusal of tracheostoma, loss of physiologic phonation, and certain comorbidities. Age and chronologic period correlated significantly with TL refusal. Median age decreased (P < 0.001) from 69 years in group A to 58 years in group B. Percentage TL refusal increased (P < 0.0001) from 2% to 11% before and after start 1990, respectively. The current study determined loss of survival with refusal of any laryngeal treatment including TL, noted benefit of chemotherapy associated to supportive care, and discussed the possible contribution of immunotherapy. [ABSTRACT FROM AUTHOR]

Background: Complementary and alternative medicine (CAM) is a broad set of nonconventional practices used alongside or instead of conventional treatment: The latter poses obvious risks related to cancer prognosis. Patient-physician dialogue about CAM is crucial for patient safety and mutual trust. Little is known about communication in the rare situations when patients decline recommended cancer treatment and consider using CAM. The objective of this study was to explore patients' and physicians' experiences from situations when patients decline recommended cancer treatment and consider using CAM. Materials and Methods: Semi-structured interviews were carried out with 7 CAM-using cancer patients who had declined some or all conventional treatment as well as 10 physicians from oncology and palliative care. Framework analysis was used. Results: Regarding treatment choices, there was a dissonance between physicians' focus on medical reasoning and patients' expression of complex values. Physicians' difficulty in understanding patients' treatment decline was exacerbated when patients considered using CAM, impairing communication even further. Inequalities in roles resulting in power struggles risked pushing both parties toward extreme and inflexible standpoints. Despite these challenges regarding treatment choices and hierarchical roles, both parties considered open and respectful communication as crucial. Conclusions: This study highlights the difficulty of shared decision-making in practice when patients' and physicians' views on treatment decisions deviate in clinically challenging situations. Our results point to a need to address the complexity of these situations, pay attention to patients' values, and improve knowledge among physicians about CAM. Little is known about communication in situations when patients decline recommended cancer treatment and consider using complementary and alternative medicine (CAM). This article explores patients' and physicians' experiences in such situations. [ABSTRACT FROM AUTHOR]

Perioperative management of patients declining transfusions of blood products can be challenging both ethically and clinically. Jehovah's Witnesses (JW) decline treatment with blood products and have published a list of interventions they might accept as substitutes. No detailed documentation of available substitute interventions at Danish hospitals exists. Likewise, no national guidelines exist on how to optimise patients who refuse to receive treatment with blood products. The primary aim was to investigate which treatments are currently available to healthcare professionals in Denmark when treating patients who refuse transfusion of blood components. Additionally, we wanted to investigate how many departments have local guidelines for treatment for this group of patients. Based on our findings we would suggest potential improvements in the treatment of patients declining transfusion of blood components. Consultants from Danish departments of anaesthesiology, abdominal surgery and obstetrics were invited to participate in a nationwide cross‐sectional online survey. The questionnaire explored available interventions offered perioperatively. Respondents were all on‐call consultants. The questionnaire underwent content, face and technical validation during pilot testing. Ninety‐six of 108 (89%) respondents from 55 departments completed the questionnaire. Thirty‐five (36%) respondents reported having a departmental guideline mostly dealing with judicial aspects regarding patients declining transfusions with blood, and 34 (35%) would in collaboration with other professionals make an interdisciplinary strategy for patients declining transfusions with blood. For patients declining treatment with blood products in anticoagulant treatment, and hence with a greater risk of bleeding, reverting treatment is essential. Depending on the type of anticoagulant, between 31 (32%) and 59 (60%) of respondents reported locally available guidelines for reverting anticoagulant treatments. We found a considerable variation and limited availability of interventions to minimise blood loss in patients declining transfusion of blood components. This scarcity of local guidelines together with the considerable variation of available treatment documented in our survey could possibly be enhanced by a lack of national guidelines. [ABSTRACT FROM AUTHOR]

Abstract Background All cancer patients, except for a small fraction, seek treatment after becoming aware of the disease. That small fraction do not seek any treatment due to various reasons, and this phenomenon is unknown to us. Therefore, the present study aimed to discover the reasons for treatment refusal in cancer patients. Methods This qualitative grounded theory study was conducted on 22 participants including patients, caregivers, physicians, and nurses. Purposive theoretical sampling was employed. Data were collected through in-depth interviews. All interviews were gradually transcribed and analyzed. Data analysis was carried out through the three-step method of open, axial, and selective coding and was continued until theoretical saturation. Straussian Grounded Theory was used for data analysis. Results A total of 4 themes and 20 sub-themes were extracted in this study. The core variable extracted from the interviews was “resilience” Other related themes included encounter with cancer, fighting cancer, and coping with cancer. The findings showed that in the context of fighting cancer, patients lost their resilience through various processes and refused treatment. Conclusion Cancer patients abandon the treatment in silence, oncologists and even family members being unaware of the matter. In other words, refusal of treatment is like an iceberg and the majority of the patients who have abandoned treatment are unknown to the health system. The model obtained in this study can increase the knowledge of the process that leads patients to lose their resilience against cancer and abandon treatment, which can increase the possibility of recognizing and predicting treatment refusal for oncologists.

Purpose: The relevance of the study is that today, there is no unanimous position on the right to euthanasia implementation. The European Court of Human Rights (ECtHR), in making its decision, relies on the national legislation of the respective state, as there is no single decision on the right to euthanasia in the European space. Therefore, the aim of the article is to comprehensively study the phenomenon of euthanasia, elaborate the decisions of the ECtHR on euthanasia and related rights, and develop recommendations on the possibility of legalizing euthanasia in Ukraine and prospects for the right to die implementation. Methodology: The leading method of research of this issue is comparative and law, which allows to comprehensively consider the right to euthanasia and its positive and negative components and helps to establish trends in the implementation of the outlined phenomenon. Findings: The article analyzes the current state of international and domestic legislation of some states on the use of euthanasia, reveals the meaning of the term “euthanasia,” provides a classification of euthanasia, analyzes the decisions of the ECtHR, and presents examples of national legislation of states within which euthanasia is legalized, the peculiarities of euthanasia recognition in the world are analyzed, as well as the research on the possibility of euthanasia legalization in Ukraine is presented. Value: The materials of the article have practical value for all those interested in euthanasia and the realization of the right to die, as well as for practicing lawyers and judicial authorities.

Healthcare providers in prehospital care and emergency departments are often at the frontline of medical crises, facing a range of ethical dilemmas, particularly when it comes to patients refusing treatment. This study aimed to delve into the attitudes of these providers toward treatment refusal, unearthing the strategies they employ in navigating such challenging situations while actively working in prehospital emergency health services. Our findings showed that, as the participants' age and experience increased, so did their inclination to respect patient autonomy and avoid persuading them to change their decision about treatment. It was noted that doctors, paramedics, and emergency medical technicians demonstrated a deeper understanding of patients' rights than other medical specialists. However, even with this understanding, the prioritization of patients' rights tended to diminish in life-threatening situations, giving rise to ethical dilemmas. This underlines the complexity of balancing the healthcare professionals' responsibilities and the patients' autonomy, which can generate ethically challenging scenarios for those working in emergency healthcare. By investigating these attitudes and experiences, this study seeks to foster a more profound understanding of the ethical quandaries faced by emergency healthcare providers. Our ultimate aim is to contribute to the development of effective strategies that support both patients and professionals in managing these tough circumstances. [ABSTRACT FROM AUTHOR]

Objectives Although adjuvant radiotherapy may be indicated in patients with sinonasal squamous cell carcinoma (SNSCC) following primary surgery, some patients choose to forgo recommended postoperative radiation therapy (PORT). This study aimed to elucidate factors associated with patient refusal of recommended PORT in SNSCC and examine overall survival. Methods Retrospective analysis of patients with SNSCC treated with primary surgery from the National Cancer Database diagnosed between 2004 and 2016. A multivariable logistic regression model was created to determine the association between clinical or demographic covariates and likelihood of PORT refusal. Unadjusted Kaplan–Meier estimates, log-rank tests, and a multivariable Cox proportional hazard model were used to assess overall survival. Results A total of 2,231 patients were included in the final analysis, of which 1,456 (65.3%) were males and 73 (3.3%) refused recommended PORT. Patients older than 74 years old were more likely to refuse PORT than those younger than 54 (odds ratio [OR] 3.43, 95% confidence interval [CI]: 1.84–6.62). Median survival among the entire cohort, those who received recommended PORT, and those who refused PORT was 83.0 months (95% CI: 74.6–97.1), 83.0 months (95% CI: 74.9–98.2), and 63.6 months (95% CI: 37.3–101.4), respectively. Refusal of PORT was not associated with overall survival (hazard ratio: 0.99, 95% CI: 0.69–1.42). Conclusions PORT refusal in patients with SNSCC is rare and was found to be associated with several patient factors. The decision to forgo PORT is not independently associated with overall survival in this cohort. Further study is required to determine the clinical implications of these findings as the treatment decisions are complex. [ABSTRACT FROM AUTHOR]

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Social media posts regarding measles vaccination were classified as pro-vaccination, expressing vaccine hesitancy, uncertain, or irrelevant. Spearman correlations with Centers for Disease Control and Prevention-reported measles cases and differenced smoothed cumulative case counts over this period were reported (using time series bootstrap confidence intervals). A total of 58,078 Facebook posts and 82,993 tweets were identified from 4 January 2009 to 27 August 2016. Pro-vaccination posts were correlated with the US weekly reported cases (Facebook: Spearman correlation 0.22 (95% confidence interval: 0.09 to 0.34), Twitter: 0.21 (95% confidence interval: 0.06 to 0.34)). Vaccine-hesitant posts, however, were uncorrelated with measles cases in the United States (Facebook: 0.01 (95% confidence interval: -0.13 to 0.14), Twitter: 0.0011 (95% confidence interval: -0.12 to 0.12)). These findings may result from more consistent social media engagement by individuals expressing vaccine hesitancy, contrasted with media- or event-driven episodic interest on the part of individuals favoring current policy.

ObjectiveDespite American Academy of Pediatrics recommendations, some parents refuse intramuscular (IM) vitamin K as prophylaxis against vitamin K deficiency bleeding for their newborns. The purpose of our study was to describe attitudes and perceptions of parents who choose to defer IM vitamin K for their newborns.MethodsUsing qualitative methodology, we conducted in-depth semi-structured interviews with parents of newborns in 3 hospitals in Connecticut and California. We used the grounded theory approach and the constant comparative method until saturation was reached.ResultsNineteen participants (17 mothers and 2 fathers) of 17 newborns were interviewed; 14 newborns did not receive IM vitamin K due to refusal by the parents, and for 3 newborns IM vitamin K administration was delayed due to initial hesitation by the parents. Four major themes emerged: 1) risk-to-benefit ratio, where parents refused IM vitamin K due to a perceived risk to their newborn from preservatives, for example; 2) "natural" approaches, which led to seeking oral vitamin K or increasing the mother's own prenatal dietary vitamin K intake; 3) placement of trust and mistrust, which involved mistrust of the medical and pharmaceutical community with overlapping concerns about vaccines and trust of self, like-minded allopathic and non-allopathic health care providers, the social circle, the internet, and social media; and 4) informed by experiences, reflecting hospital experiences with prior pregnancies and communication with health care providers.ConclusionsParents' perception of risk, preference for alternative options, trust, and communication with health care providers were pivotal factors when making decisions about IM vitamin K.

The ethical challenges of pediatric cancer care across Arab countries are not well addressed, despite medical advancements and increased awareness of children's rights. The ethical challenges related to pediatric cancer in Saudi Arabia were investigated by surveying 400 respondents at King Abdulaziz Medical City in Riyadh, Jeddah, and Dammam, Saudi Arabia, from four groups: pediatricians, medical students, nurses, and parents of children with cancer. Respondents' characteristics were surveyed across three outcomes: awareness of care, knowledge, and parent consent/child assent, developed from a systematic review and a qualitative analysis. A majority of respondents (89.0%) considered pediatric cancer different from adult cancer. Families considered alternative treatment, according to 64.3% of respondents, while 88.0% emphasized understanding the family's needs and values. Furthermore, 95.8% of respondents believed physicians should offer time for pedagogy, 92.3% viewed parental consent as essential, and 94.5% thought that sufficient discussion about the plan and type of treatment should precede consent. However, child assent showed lower levels of agreement, with only 41.3% and 52.5% agreeing with getting child assent and having a discussion. Finally, 56% agreed that parents might refuse suggested treatment, while only 24.3% agreed that the child could refuse it. In all these ethical considerations, nurses and physicians showed significantly more positive results compared with other groups. [ABSTRACT FROM AUTHOR]

Women's autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife's willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines. Women's reasons for making such choices have received some research attention, however there is a paucity of research examining this phenomenon from the perspective of caseloading midwives' and their perception of personal/professional risk in such situations. To synthesise qualitative research which includes the voices of midwives working in a continuity of carer model who perceive any kind of risk to themselves when caring for women who decline current established recommendations. Systematic literature search and meta-synthesis were carried out following a pre-determined search strategy. The search was executed in April 2021 and updated in July 2021. Studies were assessed for quality using JBI Critical Appraisal Checklist for Qualitative Research. Data extraction was assisted by JBI QARI Data Extraction Tool for Qualitative Research. GRADE-CERQual was applied to the findings. Eight studies qualified for inclusion. Five main themes were synthesised as third order constructs and were incorporated into a line of argument: Women's rights to bodily autonomy and choice in childbearing are violated, and their ability to access safe midwifery care in pursuit of physiological birth is restricted, when midwives practise within a maternity system which is adversarial towards midwives who provide the care which women require. Midwives who provide such care place themselves at risk of damaged reputation, collegial conflict, intimidating disciplinary processes, tensions of 'being torn', and a heavy psychological load. Despite these personal and professional risks, midwives who provide this care do so because it is the ethical and moral thing to do, because they recognise that women need them to, because it can be very rewarding, and because they are able to. Maternity systems and colleagues can be key risk factors for caseloading midwives who facilitate women's right to decline recommendations. These identified risks can make it unsustainable for midwives to continue providing woman-centred care and contribute to workforce attrition, reducing options/choices for women which paradoxically increases risk to women and babies. [ABSTRACT FROM AUTHOR]

Background: All cancer patients, except for a small fraction, seek treatment after becoming aware of the disease. That small fraction do not seek any treatment due to various reasons, and this phenomenon is unknown to us. Therefore, the present study aimed to discover the reasons for treatment refusal in cancer patients. Methods: This qualitative grounded theory study was conducted on 22 participants including patients, caregivers, physicians, and nurses. Purposive theoretical sampling was employed. Data were collected through in-depth interviews. All interviews were gradually transcribed and analyzed. Data analysis was carried out through the three-step method of open, axial, and selective coding and was continued until theoretical saturation. Straussian Grounded Theory was used for data analysis. Results: A total of 4 themes and 20 sub-themes were extracted in this study. The core variable extracted from the interviews was "resilience" Other related themes included encounter with cancer, fighting cancer, and coping with cancer. The findings showed that in the context of fighting cancer, patients lost their resilience through various processes and refused treatment. Conclusion: Cancer patients abandon the treatment in silence, oncologists and even family members being unaware of the matter. In other words, refusal of treatment is like an iceberg and the majority of the patients who have abandoned treatment are unknown to the health system. The model obtained in this study can increase the knowledge of the process that leads patients to lose their resilience against cancer and abandon treatment, which can increase the possibility of recognizing and predicting treatment refusal for oncologists. [ABSTRACT FROM AUTHOR]

Abstract Gaurav Kumar Background Retinoblastoma (RB) is the most common primary intraocular malignancy in children. We sought to provide a comprehensive assessment of epidemiological profile and treatment outcomes of children with RB. Methods In this retrospective study, we analyzed 189 children diagnosed with RB at our center between 2004 and 2017. Survival was analyzed with the Kaplan–Meier method and log-rank test. Results Median age at presentation was 14 months with male: female ratio 1.2:1. Mean duration between onset of symptoms and presentation was 49 days (standard deviation ± 79). Most common presenting symptom was white pupillary reflex in 60% of children. Family history of RB and other cancers was found in one (0.5%) and seven (4%) children, respectively. Primary mode of diagnosis and staging was ocular ultrasonography (bone scan) in 87% of patients. Computed tomographic scan and magnetic resonance imaging were done in 124 (66%) and 30 (16%) patients, respectively. International staging system grade E disease was found in 144 (76%), extraocular disease in 55 (29%), bilateral disease in 49 (26%), and trilateral disease in 3 (1.5%) children. Out of 189 children with RB, 33 (18%) refused treatment and 156 children received treatment (24 children [15%] abandoned treatment midway and 132 [85%] completed treatment). One hundred children (64%) received systemic therapy as neoadjuvant or adjuvant chemotherapy and 20 (13%) received local therapy. Eyeball and vision salvage rate with chemotherapy were 20 (13%) and 9 (6%), respectively. Cryotherapy was the most common modality of local treatment used in 11 (55%) children. Five-year survival for patients who received treatment was 76% (median survival not reached). In the treatment refusal group, median survival was 9 months. Conclusion In developing countries, RB is mostly detected in advanced stages resulting in poor outcomes. Increased awareness and accessibility to dedicated centers for treating childhood malignancy can lead to early diagnosis, better prognosis, and increased vision salvage.

Plain English summary This study investigated the method of assessing the mental capacity of anorexia nervosa (AN) patients who refuse treatment in Japan, the United Kingdom, and the United States. Approximately one-third of clinicians who assessed patients with AN declared that those patients showed impaired decision-making capacity when refusing treatment. Clinicians who considered patients with AN to have impaired decision-making ability tended to focus on the level of psychopathological values when assessing their mental capacity.

Plain English summary This study aimed to investigate the attitudes of physicians in Japan, the UK, and the US toward refusal of treatment for anorexia nervosa. Physicians in all three countries received an anonymous questionnaire comprising four fictitious cases for which they had to respond whether they would choose compulsory inpatient treatment or not. The study revealed that in all three countries, compulsory treatment tended to be the prevalent choice in cases of life-threatening malnutrition, regardless of the patient's age or duration of illness. Moreover, in all the three countries, treatment tended to be forced if a family member requested treatment, and this trend was particularly strong in Japan. The influence of family request was stronger for acute AN in the U.K. and the U.S., and for SE-AN in Japan.

BackgroundMedically hospitalized patients who lack decisional capacity may request, demand, or attempt to leave the hospital despite grave risk to themselves. The treating physician in this scenario must determine how to safeguard such patients, including whether to attempt to keep them in the hospital. However, in many jurisdictions, there are no laws that address this matter directly. In this absence, psychiatrists are often called upon to issue an involuntary psychiatric hold (civil commitment) to keep the patient from leaving. Yet, civil commitment statutes were not intended for, and generally do not address, the needs of the medically ill patient without psychiatric illness. Civil commitment is permitted for patients who pose a danger to themselves or others, or who are gravely disabled, specifically as the result of a mental illness, and allows the transport of such individuals to facilities for psychiatric evaluation. It does not permit detention for medical illnesses nor the involuntary administration of medical treatments. Therefore, the establishment of hospital policies and procedures may be the most appropriate means of detaining medically hospitalized patients who lack capacity to understand the risks of leaving the hospital, in addition to mitigating the potential tort risk faced by the physician for acting in a manner that protects the patient.ObjectiveThe purpose of this article is to identify the array of clinical and medical-legal concerns in these scenarios, and to describe the development of a "medical incapacity hold" policy as a means of addressing this unresolved issue.

Purpose: The relevance of the study is that today, there is no unanimous position on the right to euthanasia implementation. The European Court of Human Rights (ECtHR), in making its decision, relies on the national legislation of the respective state, as there is no single decision on the right to euthanasia in the European space. Therefore, the aim of the article is to comprehensively study the phenomenon of euthanasia, elaborate the decisions of the ECtHR on euthanasia and related rights, and develop recommendations on the possibility of legalizing euthanasia in Ukraine and prospects for the right to die implementation. Methodology: The leading method of research of this issue is comparative and law, which allows to comprehensively consider the right to euthanasia and its positive and negative components and helps to establish trends in the implementation of the outlined phenomenon. Findings: The article analyzes the current state of international and domestic legislation of some states on the use of euthanasia, reveals the meaning of the term "euthanasia," provides a classification of euthanasia, analyzes the decisions of the ECtHR, and presents examples of national legislation of states within which euthanasia is legalized, the peculiarities of euthanasia recognition in the world are analyzed, as well as the research on the possibility of euthanasia legalization in Ukraine is presented. Value: The materials of the article have practical value for all those interested in euthanasia and the realization of the right to die, as well as for practicing lawyers and judicial authorities. [ABSTRACT FROM AUTHOR]

Objectives: Topical fluoride helps prevent dental caries. However, many caregivers are hesitant about topical fluoride for their children and may refuse it during clinic visits. In this qualitative study, we assessed the relevance of the extended parallel process model (EPPM) and health belief model (HBM) in caregivers' decision‐making about topical fluoride. Methods: We interviewed 56 fluoride‐hesitant or fluoride‐refusing caregivers using a semi‐structured interview script that included questions based on select constructs from the EPPM (perceived severity, susceptibility, response efficacy) and HBM (perceived benefits and consequences). Two team members conducted a thematic analysis of the interview data. Results: Most caregivers acknowledged the severity of cavities but did not believe their child was susceptible. Caregivers also understood the general benefits of fluoride in preventing tooth decay, but reported low response efficacy of fluoride for their children especially compared to the other ways of reducing caries risk like reducing sugar intake and toothbrushing. Many caregivers had concerns about topical fluoride, especially regarding safety, with the potential consequences of fluoride outweighing its benefits. Conclusion: Our findings were generally consistent with the EPPM and HBM, which appear to be relevant in understanding fluoride hesitancy behaviors. Additional research is needed on ways to improve provider communications about topical fluoride with caregivers. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to identify the main barriers that prevent patients with diabetes mellitus from accepting insulin therapy. Methods: This cross-sectional study was conducted from May to December 2019. Convenience sampling was used to recruit participants from three diabetes clinics in Muscat, Oman. Eligible participants were interviewed in person based on a pre-prepared questionnaire. The questionnaire, which was administered in Arabic, includes demographic data and 19 specific items on barriers to insulin therapy. Results: A total of 201 participants (response rate: 93%) were enrolled in the study. The most common barriers were as follows: concern of frequent blood glucose checking (36.3%), long-term injections (33.8%), side-effects of insulin (29.9%) and weight gain (29.4%). Needle phobia was considered a barrier by only 9% of the participants. Overall, 125 (62.2%) participants were willing to initiate insulin therapy despite the presence of these barriers and only 20 (10%) of them were influenced by these barriers to such a degree that they rejected the insulin therapy. Conclusion: The majority of participants had no identifiable reasons to stop them from accepting insulin therapy. Effective strategies should be developed to address each of the main barriers to improve acceptance and adherence to insulin therapy. [ABSTRACT FROM AUTHOR]

Competing Interests: Edward J. Despott has acted as a consultant for Boston Scientific and Ambu. He has also received academic grants and speaker honoraria from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus. Alberto Murino has acted as a consultant for Boston Scientific and GI Supply He has also received academic grants from Fujifilm, Aquilant Endoscopy, Norgine, and Olympus. All other authors have no conflicts of interest to declare.

The issue of left against medical advice (LAMA) patients is common in today's emergency departments (EDs). This issue represents a medico-legal risk and may result in potential readmission, mortality, or revenue loss. Thus, understanding the factors that cause patients to "leave against medical advice" is vital to mitigate and potentially eliminate these adverse outcomes. This paper proposes a framework for studying the factors that affect LAMA in EDs. The framework integrates machine learning, metaheuristic optimization, and model interpretation techniques. Metaheuristic optimization is used for hyperparameter optimization-one of the main challenges of machine learning model development. Adaptive tabu simulated annealing (ATSA) metaheuristic algorithm is utilized for optimizing the parameters of extreme gradient boosting (XGB). The optimized XGB models are used to predict the LAMA outcomes for patients under treatment in ED. The designed algorithms are trained and tested using four data groups which are created using feature selection. The model with the best predictive performance is then interpreted using the SHaply Additive exPlanations (SHAP) method. The results show that best model has an area under the curve (AUC) and sensitivity of 76% and 82%, respectively. The best model was explained using SHAP method., Competing Interests: Declarations. Ethical approval: The data was obtained from our partner hospital after obtaining authorization from Institutional Review Board for Human Use (IRB). Conflicts of interest: The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Against medical advice (AMA) discharges are practically and emotionally challenging for both patients and clinicians. Moreover, they are common after admissions for respiratory conditions such as COPD and asthma, and they are associated with poor outcomes. Despite the challenges presented by AMA discharges, clinicians rarely receive formal education and have limited guidance on how to approach these discharges. Often, the approach to AMA discharges prioritizes designating the discharge as "AMA," whereas effective coordination of discharge care receives less attention. Such an approach can lead to stigmatization of patients and low-quality care. Although evidence for best practices in AMA discharges remains lacking, we propose a set of strategies to improve care in AMA discharges by focusing on respect, in which clinicians treat patients as equals and honor differing values. We describe five strategies, including (1) preventing an AMA discharge; (2) conducting a patient-centered and truthful discussion of risk; (3) providing harm-reducing discharge care; (4) minimizing stigma and bias; and (5) educating trainees. Through a case of a patient discharging AMA after a COPD exacerbation, we highlight how these strategies can be applied to common issues in respiratory-related hospitalizations, such as prescribing inhalers and managing oxygen requirements. We argue that, by using these strategies, clinicians can deliver more respectful and higher quality care to an often-marginalized population of patients with respiratory disease., Competing Interests: Financial/Nonfinancial Disclosures None declared, (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices. Methods: A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022. Results: Ten patients (60% male, median age = 78.5 years) completed interviews. Patients’ passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients’ overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers. Conclusion: Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.