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Introduction: Nurses, as frontline healthcare professionals, play a crucial role in ensuring patient safety, making their ability to speak up imperative. However, there are limited studies categorizing nurses based on their speaking‐up behaviors and comparing their organizational characteristics. This study aimed to identify patterns of nurses' speaking‐up behaviors and examine differences in organizational cultures, teamwork climates, and working conditions according to these patterns. Methods: A cross‐sectional survey was conducted, involving 597 nurses directly participating in nursing care in Korean hospitals. The Speaking Up about Patient Safety Questionnaire (SUPS‐Q), Nursing Organizational Culture Questionnaire, and Safety Attitude Questionnaire‐Korean version (SAQ‐K) were employed to measure nurses' speaking‐up‐related behaviors, organizational culture, teamwork climate, and working conditions. Cluster analysis was used to identify clusters of nurses based on their speaking‐up‐related behavior. Differences in nursing organizational culture, teamwork climate, and working conditions among clusters were analyzed using one‐way analyses of variance. Results: Three clusters of nurses were identified based on their speaking‐up‐related behaviors. Cluster 1 (35%) showed high perceived concerns, moderate withholding, and speaking up, while Cluster 2 (37%) had moderate concerns, low withholding, and high speaking up. Cluster 3 (28%) had moderate concerns but low withholding and speaking up. Clinical experience significantly differed among clusters, with less experienced nurses predominantly in Cluster 1. Cluster 2 had the most collaborative culture, best teamwork climate, and working conditions. Conclusion: Ensuring patient safety requires nurses to speak up about patient safety concerns. Creating safe working environments and fostering an organizational culture that prioritizes patient safety are essential steps in promoting nurses' willingness to speak up about patient safety. [ABSTRACT FROM AUTHOR]

Background/Objectives: The change in critically ill patients makes limitation of therapeutic effort (LTE) a widespread practice when therapeutic goals cannot be achieved. We aimed to describe the application of LTE in a post-surgical Intensive Care Unit (ICU), analyze the measures used, the characteristics of the patients, and their evolution. Methods: Retrospective observational study, including all patients to whom LTE was applied in a postsurgical ICU between January 2021 and December 2022. The LTE defined were brain death, withdrawal of measures, and withholding. Withholding limitations included orders for no cardiopulmonary resuscitation, no orotracheal intubation, no reintubation, no tracheostomy, no renal replacement therapies, and no vasoactive support. Patient and ICU admission data were related to the applied LTE. Results: Of the 2056 admitted, LTE protocols were applied to 106 patients. The prevalence of LTE in the ICU was 5.1%. Data were analyzed in 80 patients. A total of 91.2% of patients had been admitted in an emergency situation, and 56.2% had been admitted after surgery. The most widespread limitation was treatment withholding (83.8%) compared to withdrawal (13.8%). No differences were found regarding who made the decision and the type of limitation employed. However, patients with the limitation of no intubation had a longer stay (p = 0.025). Additionally, the order of not starting or increasing vasopressor support resulted in a longer hospital stay (p = 0.007) and a significantly longer stay until death (p = 0.044). Conclusions: LTE is a frequent measure in critically ill patient management and is less common in the postoperative setting. The most widespread measure was withholding, with the do-not-resuscitate order being the most common. The decision was made mainly by the medical team and the family, respecting the wishes of the patients. A joint patient-centered approach should be made in these decisions to avoid futile treatment and ensure end-of-life comfort. [ABSTRACT FROM AUTHOR]

Background and aimThis study explores healthcare professionals’ perspectives on end-of-life care in pediatric intensive care units (ICUs) in Croatia, aiming to illuminate their experiences with such practices, underlying attitudes, and major decision-making considerations. Amid the high variability, complexity, and emotional intensity of pediatric end-of-life decisions and practices, understanding these perspectives is crucial for improving care and policies.MethodsThe study utilized a cross-sectional survey intended for physicians and nurses across all pediatric ICUs in Croatia. It included healthcare professionals from six neonatal and four pediatric ICUs in total. As the data from neonatal and pediatric ICUs were examined jointly, the term pediatric ICU was used to denominate both types of ICUs. A statistical analysis was performed using Python and JASP, focusing on professional roles, professional experience, and regional differences.ResultsThe study included a total of 103 participants (with an overall response rate—in relation to the whole target population—of 48% for physicians and 29% for nurses). The survey revealed diverse attitudes toward and experiences with various aspects of end-of-life care, with a significant portion of healthcare professionals indicating infrequent involvement in life-sustaining treatment (LST) limitation discussions and decisions, as well as somewhat ambiguous attitudes regarding such practices. Notably, discrepancies emerged between different professional roles and, in particular, regions, underscoring the high variability of LST limitation-related procedures.ConclusionsThe findings highlight a pressing need for more straightforward guidelines, legal frameworks, support mechanisms, and communication strategies to navigate the complex terrain of rather burdensome end-of-life pediatric care, which is intrinsically loaded with profound ethical quandaries.

Abstract Background Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. Methods This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. Results There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p

Making decisions to withhold or withdraw treatment in the paediatric intensive care setting can be complex, emotive and morally challenging. The process draws on the expertise and experience of both the families and the medical teams, their understanding of the needs and (where possible) choices of the child, and a balance of trust between all parties to want to achieve the right outcome. It is important that all healthcare professionals caring for children, particularly those living with potentially life-limiting or life-threatening conditions, are aware of the processes involved so they can support patients and families with confidence and sensitivity. This paper explores the basic aspects of withholding and withdrawing interventions in the PICU with the aim of demonstrating the situations in which these decisions might be necessary. It explains the frameworks and considerations guiding the decision-making process and describes the practicalities of providing ongoing care through collaboration with hospital and community services. [ABSTRACT FROM AUTHOR]

Abstract Background Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. Methods Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. Results This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. Conclusions This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Background/Objectives: The change in critically ill patients makes limitation of therapeutic effort (LTE) a widespread practice when therapeutic goals cannot be achieved. We aimed to describe the application of LTE in a post-surgical Intensive Care Unit (ICU), analyze the measures used, the characteristics of the patients, and their evolution. Methods: Retrospective observational study, including all patients to whom LTE was applied in a postsurgical ICU between January 2021 and December 2022. The LTE defined were brain death, withdrawal of measures, and withholding. Withholding limitations included orders for no cardiopulmonary resuscitation, no orotracheal intubation, no reintubation, no tracheostomy, no renal replacement therapies, and no vasoactive support. Patient and ICU admission data were related to the applied LTE. Results: Of the 2056 admitted, LTE protocols were applied to 106 patients. The prevalence of LTE in the ICU was 5.1%. Data were analyzed in 80 patients. A total of 91.2% of patients had been admitted in an emergency situation, and 56.2% had been admitted after surgery. The most widespread limitation was treatment withholding (83.8%) compared to withdrawal (13.8%). No differences were found regarding who made the decision and the type of limitation employed. However, patients with the limitation of no intubation had a longer stay (p = 0.025). Additionally, the order of not starting or increasing vasopressor support resulted in a longer hospital stay (p = 0.007) and a significantly longer stay until death (p = 0.044). Conclusions: LTE is a frequent measure in critically ill patient management and is less common in the postoperative setting. The most widespread measure was withholding, with the do-not-resuscitate order being the most common. The decision was made mainly by the medical team and the family, respecting the wishes of the patients. A joint patient-centered approach should be made in these decisions to avoid futile treatment and ensure end-of-life comfort.

We study the optimality of allowing the designer to withhold or damage resources in Bayesian incentive compatible mechanisms for bilateral trade with independent private values. The following results hold when the buyer and the seller have discrete value distributions. Burning money or withholding the good from both traders never enhances welfare. Similarly, damaging the good for the buyer cannot increase welfare. By contrast, damaging the good for the seller may improve welfare. However, such welfare improvements are possible only if the damage hurts some lower valuation type of seller more severely than the highest valuation type. Results extend to the case of continuous value distributions under certain hypotheses regarding virtual values. Methods also apply to optimal Bayesian implementation for allocation problems. In the absence of property rights, damaging goods for any agent has negative welfare consequences. [ABSTRACT FROM AUTHOR]

Background: Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. Methods: Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. Results: This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. Conclusions: This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field. [ABSTRACT FROM AUTHOR]

Abstract Background Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. Methods This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. Results The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. Conclusions Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.

The number of diagnoses and the number of persons having diagnoses have increased substantially, and studies indicate that diagnoses are given or upheld even if they are unwarranted, that is, that they do not satisfy professionally accepted diagnostic criteria. In this article, the authors investigate the ethics of withholding and withdrawing unwarranted diagnoses. First, they investigate ethical aspects that make it difficult to withhold and to withdraw such diagnoses. Second, they scrutinize whether there are psychological factors, both in persons/patients and healthcare professionals, making it difficult to withdraw and withhold unwarranted diagnoses. Lastly, they use recent elements of the withholding-versus-withdrawing treatment debate in medical ethics to investigate whether there are any differences between withholding and withdrawing treatment and withdrawing and withholding unwarranted diagnoses. The authors conclude that it is crucial to acknowledge and address all these issues to reduce and avoid unwarranted diagnoses. [ABSTRACT FROM AUTHOR]

Background: Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. Methods: This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. Results: The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. Conclusions: Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017. [ABSTRACT FROM AUTHOR]

This study aims at investigating the phenomenon of censoring and withholding translated books in Jordan. The source of data is a list of all banned translated books at Yarmouk University Library in Jordan (n = 60). The list was first analyzed and classified thematically. Qualitative data were obtained via semi-structured interviews with the librarians. When available, reference was made to the paratextual material of the withheld translated books. Moreover, the official website of the Jordan Media Commission was consulted to identify the factors that may contribute to censoring and blocking translated works in Jordan. The results show that librarians ban books for various religious, moral, social, political, and ideological reasons. Furthermore, it was revealed that censorship in Jordan is subjectively conducted and does not follow clear-cut rules and regulations. Finally, using paratextual elements in investigating the motives for censoring books proved to be an effective method. [ABSTRACT FROM AUTHOR]

Our choice to withhold or disclose displeasing information to another can motivate concern about damage to our social bonds. In two experiments, using two different samples of university students in Norway, (N = 174 and N = 217), we found that withholding unpleasant information led to greater concern for self- image and social-image than did disclosure. We also found that withholding elicited more shame, inferiority and rejection than disclosure, and in Experiment 2, withholding elicited more defensive motivation than disclosure. Consistent with our model, defensive motivation was mostly explained by concern for social-image, whereas relationship repair motivation was mostly explained by concern for self-image and felt shame. We discuss implications for the literature on shame and social bonds. [ABSTRACT FROM AUTHOR]

Objectives: Here, we report the management of a catastrophic COVID-19 Delta variant surge, which overloaded ICU capacity, using crisis standards of care (CSC) based on a multiapproach protocol.Design: Retrospective observational study.Setting: University Hospital of Guadeloupe.Patients: This study retrospectively included all patients who were hospitalized for COVID-19 pneumonia between August 11, 2021, and September 10, 2021, and were eligible for ICU admission.Intervention: Based on age, comorbidities, and disease severity, patients were assigned to three groups: Green (ICU admission as soon as possible), Orange (ICU admission after the admission of all patients in the Green group), and Red (no ICU admission).Measurements and Main Results: Among the 328 patients eligible for ICU admission, 100 (30%) were assigned to the Green group, 116 (35%) to the Orange group, and 112 (34%) to the Red group. No patient in the Green group died while waiting for an ICU bed, whereas 14 patients (12%) in the Orange group died while waiting for an ICU bed. The 90-day mortality rates were 24%, 37%, and 78% in the Green, Orange, and Red groups, respectively. A total of 130 patients were transferred to the ICU, including 79 from the Green group, 51 from the Orange group, and none from the Red group. Multivariate analysis revealed that among patients admitted to the ICU, death was independently associated with a longer time between ICU referral and ICU admission, the Sequential Organ Failure Assessment score, and the number of comorbidities, but not with triage group.Conclusions: CSC based on a multiapproach protocol allowed admission of all patients with a good prognosis. Higher mortality was associated with late admission, rather than triage group. [ABSTRACT FROM AUTHOR]

Abstract Background There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying. Methods A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson’s coefficient) and multiple regression analysis for data analysis. Results 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures. Conclusions The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia.

Secrecy, privacy, confidentiality, concealment, disclosure, and gossip all involve sharing and withholding access to information. However, existing theories do not account for the fundamental similarity between these concepts. Accordingly, it is unclear when sharing and withholding access to information will have positive or negative effects and why these effects might occur. We argue that these problems can be addressed by conceptualizing these phenomena more broadly as different kinds of information-access regulation. Furthermore, we outline a social-identity theory of information-access regulation (SITIAR) that proposes that information-access regulation shapes shared social identity, explaining why people who have access to information feel a sense of togetherness with others who have the same access and a sense of separation from those who do not. This theoretical framework unifies diverse findings across disparate lines of research and generates a number of novel predictions about how information-access regulation affects individuals and groups. [ABSTRACT FROM AUTHOR]

Life expectancy is rising worldwide and increasing numbers of elderly patients are being admitted to the intensive care unit (ICU). Because ageing is associated with changes in organ function, increased frailty, reduced activities of daily living, reduced mobility, and reduced cognition, elderly patients represent a particular subgroup of ICU patients. Ethical decisions related to the appropriateness of intensive care and/or life‐sustaining interventions, the withdrawing and withholding of life support, and terminal sedation are more frequent in these patients and will be discussed in this review. Such decisions must be tailored to the individual to take into consideration personal beliefs and wishes. [ABSTRACT FROM AUTHOR]

Intensive care units (ICUs) around the world have been hugely impacted by the SARS-CoV-2 pandemic and the vast numbers of patients admitted with COVID-19, requiring respiratory support and prolonged stays. This pressure, with resulting shortages of ICU beds, equipment, and staff has raised ethical dilemmas as physicians have had to determine how best to allocate the sparse resources. Here, we reflect on some of the major ethical aspects of the COVID-19 pandemic, including resource allocation and rationing, end-of-life decision-making, and communication and staff support. Importantly, these issues are regularly faced in non-pandemic ICU patient management and useful lessons can be learned from the discussions that have occurred as a result of the COVID-19 situation. [ABSTRACT FROM AUTHOR]

Background: There has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying.Methods: A cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson's coefficient) and multiple regression analysis for data analysis.Results: 38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person's autonomous decisions regarding end-of-life procedures.Conclusions: The study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people's views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia. [ABSTRACT FROM AUTHOR]

Abstract Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU). Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate). Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.

Abstract Background The Coronavirus Disease 2019 (COVID-19) that first occurred in Wuhan, China, is currently spreading throughout China. The majority of infected patients either traveled to Wuhan or came into contact with an infected person from Wuhan. Investigating members of the public with a travel history to Wuhan became the primary focus of the Chinese government’s epidemic prevention and control measures, but several instances of withheld histories were uncovered as localized clusters of infections broke out. This study investigated the public’s willingness and beliefs associated with reporting travel history to high-risk epidemic regions, to provide effective suggestions and measures for encouraging travel reporting. Methods A cross-sectional study was conducted online between February 12 and 19, 2020. Descriptive analysis, chi-squared test, and Fisher’s exact test were used to identify socio-demographic factors and beliefs associated with reporting, as well as their impact on the willingness to report on travel history to high-risk epidemic regions. Results Of the 1344 respondents, 91 (6.77%) expressed an inclination to deliberately withhold travel history. Those who understood the benefits of reporting and the legal consequences for deliberately withholding information, showed greater willingness to report their history (P

As options for advanced cardiopulmonary support proliferate, the use of mechanical circulatory support, such as left ventricular assist device as destination therapy (LVAD-DT), is becoming increasingly commonplace. In the current case, a patient was hospitalized for complications related to his LVAD-DT requests ?full code? status, despite a clinician's warning that performing chest compressions may damage the LVAD device or vascular structures leading to poor outcome. This discussion explores the ethical and legal considerations regarding a patient request for cardiopulmonary resuscitation when limited options for survival or further treatment are available.

When it is ethically justifiable to stop medical treatment? For many Muslim patients, families, and clinicians this ethical question remains a challenging one as Islamic ethico-legal guidance on such matters remains scattered and difficult to interpret. In light of this gap, we conducted a systematic literature review to aggregate rulings from Islamic jurists and juridical councils on whether, and when, it is permitted to withdraw and/or withhold life-sustaining care. A total of 16 fatwās were found, 8 of which were single-author rulings, and 8 represented the collective view of a juridical council. The fatwās are similar in that nearly all judge that Islamic law, provided certain conditions are met, permits abstaining from life-sustaining treatment. Notably, the justifying conditions appear to rely on physician assessment of the clinical prognosis. The fatwās differ when it comes to what conditions justify withdrawing or withholding life- sustaining care. Our analyses suggest that while notions of futility greatly impact the bioethical discourse regarding with holding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. Therefore, clinicians, Islamic jurists, and bioethicists need to come together in order to unify a conception of medical futility and relate it to the ethics of withholding and/or withdrawal of treatment.

Background and Aim: This study explores healthcare professionals' perspectives on end-of-life care in pediatric intensive care units (ICUs) in Croatia, aiming to illuminate their experiences with such practices, underlying attitudes, and major decision-making considerations. Amid the high variability, complexity, and emotional intensity of pediatric end-of-life decisions and practices, understanding these perspectives is crucial for improving care and policies., Methods: The study utilized a cross-sectional survey intended for physicians and nurses across all pediatric ICUs in Croatia. It included healthcare professionals from six neonatal and four pediatric ICUs in total. As the data from neonatal and pediatric ICUs were examined jointly, the term pediatric ICU was used to denominate both types of ICUs. A statistical analysis was performed using Python and JASP, focusing on professional roles, professional experience, and regional differences., Results: The study included a total of 103 participants (with an overall response rate-in relation to the whole target population-of 48% for physicians and 29% for nurses). The survey revealed diverse attitudes toward and experiences with various aspects of end-of-life care, with a significant portion of healthcare professionals indicating infrequent involvement in life-sustaining treatment (LST) limitation discussions and decisions, as well as somewhat ambiguous attitudes regarding such practices. Notably, discrepancies emerged between different professional roles and, in particular, regions, underscoring the high variability of LST limitation-related procedures., Conclusions: The findings highlight a pressing need for more straightforward guidelines, legal frameworks, support mechanisms, and communication strategies to navigate the complex terrain of rather burdensome end-of-life pediatric care, which is intrinsically loaded with profound ethical quandaries., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Curkovic, Rubic, Jozepovic, Novak, Filipovic-Grcic, Mestrovic, Lah Tomulic, Peter, Spoljar, Grosek, Janković, Vukovic, Kujundžić Tiljak, Štajduhar and Borovecki.)

Purpose: In Korea, the act on hospice and palliative care and decisions on life-sustaining treatment (LST) was implemented on February 4, 2018. We aimed to investigate relevant factors and clinical changes associated with LST decisions after law enforcement., Materials and Methods: This single-center retrospective study included patients who completed LST documents using legal forms at Asan Medical Center from February 5, 2018, to June 30, 2020., Results: 5896 patients completed LST documents, of which 2704 (45.8%) signed the documents in person, while family members of 3,192 (54%) wrote the documents on behalf of the patients. Comparing first year and following year of implementation of the act, the self-documentation rate increased (43.9% to 47.2%, p=0.014). Moreover, the number of LST decisions made during or after ICU admission decreased (37.8% vs. 35.2%, p=0.045), and the completion rate of LST documents during chemotherapy increased (6.6% vs. 8.9%, p=0.001). In multivariate analysis, age < 65 (OR, 1.724; 95% CI, 1.538-1.933; p<0.001), unmarried status (OR, 1.309; 95% CI, 1.097-1.561; p=0.003), palliative care consultation (OR, 1.538; 95% CI, 1.340-1.765; p<0.001), malignancy (OR, 1.864; 95% CI, 1.628-2.133; p<0.001), and changes in timing on the first year versus following year (OR, 1.124, 95% CI, 1.003-1.260, p=0.045) were related to a higher self-documentation rate., Conclusion: Age < 65, unmarried status, malignancy, and referral to a palliative care team were associated with patients making LST decisions themselves. Furthermore, the subject and timing of LST decisions have changed with the LST act.

While epistemologists routinely employ disbelief talk, it is not clear that they really mean it, given that they often equate disbelieving p with believing ¬p. I argue that this is a mistake—disbelief is a doxastic attitude of rejection and is distinct from belief (and withholding). I first clarify this claim and its opposition, then show that we must distinguish disbelieving p from believing ¬p in order to account for the fact that we continue to hold doxastic attitudes toward propositions that we reject. After defending this argument against some possible objections, I examine several cases that reveal disbelieving p to be not only non-identical to believing ¬p, but independent of that attitude as well. Finally, I sketch some immediate and potential consequences of recognizing disbelief as a distinct doxastic attitude, particularly for work on epistemic rationality. [ABSTRACT FROM AUTHOR]

For many Muslim patients, families and intensive care physicians, deciding on whether to withhold or withdraw life support remains challenging. This point of transition from active intervention to the palliation process requires a crucial decision-making process. The decision involves conveying information to families to be well prepared beforehand, especially during the process of withdrawing life-sustaining treatment. Once the final decision to withdraw life sustainment has been made, procedure on cessation of care, treatment withdrawal and nature of follow-up support will be informed to the family members. This is especially so considering that the relationship between Islamic ethico-legal guidance and clinical protocols on such matters remains scattered and difficult to interpret. In light of this gap, we conducted a short review to aggregate clinical protocols and rulings from Islamic fatwas on whether, and when, it is permitted to withdraw and/or withhold life-sustaining care. This article aims to explore relationship regarding decision in withholding and withdrawing life-sustaining treatment, based on guidelines by Malaysian intensive care unit protocol and the fatwa in Malaysia. The methodology chosen for this study is content analysis of the relevant published literatures. We found the decision for withholding and withdrawing life sustaining treatment in intensive care unit are correlated between the ICU protocol and fatwa in Malaysia. In addressing the withholding and withdrawal of life-sustaining measures, the Muslim health-care workers as well as families should take a more cohesive approach, as this is parallel to the fatwa in Islam. [ABSTRACT FROM AUTHOR]

Withholding and withdrawal of life-sustaining treatments is one of the hot topics discussing in intensive care unit as most of the death occurs as a result of it. This point of transition from active intervention to the palliation process required a crucial decision-making process. The decision conveys information to families to be well prepared beforehand especially during the process of withdrawing life-sustaining treatment. Once the final decision to withdraw the treatment has been made, procedure of cessation of care, treatment withdrawal and nature of follow-up support will be informed to the family members. This article aims to explore the relationship between decision in withholding and withdrawal of life-sustaining treatment based on Malaysian intensive care unit protocol and the related fatwa in Malaysia. The methodology chosen for this study is content analysis of the relevant published literatures. This study reveals the decision for withholding and withdrawal life sustaining treatment in intensive care unit has correlation between the protocol and related fatwa in Malaysia.

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]

Background: Life-sustaining treatment limitation (LSV) is the medical act of withdrawing or not initiating measures that are considered futile in a patient's specific situation. LSV in critically ill patients remains a difficult topic to study, due to the multitude of factors that condition it., Objective: To determine factors related to LSV in ICU in cases of post-ICU in-hospital mortality, as well as factors associated with survival after discharge from ICU., Design: Retrospective longitudinal study., Ambit: Intensive care unit of a tertiary hospital., Patients: People who died in the hospitalization ward after ICU treatment between January 2014 and December 2019., Interventions: None. This is an observational study., Variables of Interest: Age, sex, probability of death, type of admission, LSV in ICU, oncological disease, dependence, invasive mechanical ventilation, emergency hemodialysis, transfusion of blood products, nosocomial infection (NI), pre-ICU, intra-ICU and post-ICU stays., Results: Of 114 patients who died outside the ICU, 49 had LSV registered in the ICU (42.98%). Age and stay prior to ICU admission were positively associated with LSV (OR 1,03 and 1,08, respectively). Patients without LSV had a higher post-ICU stay, while it was lower for male patients., Conclusions: Our results support that LSV established within the ICU can avoid complications commonly associated with unnecessary prolongation of stay, such as NI., (Copyright © 2023 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

When it is ethically justifiable to stop medical treatment? For many Muslim patients, families, and clinicians this ethical question remains a challenging one as Islamic ethico-legal guidance on such matters remains scattered and difficult to interpret. In light of this gap, we conducted a systematic literature review to aggregate rulings from Islamic jurists and juridical councils on whether, and when, it is permitted to withdraw and/or withhold life-sustaining care. A total of 16 fatwās were found, 8 of which were single-author rulings, and 8 represented the collective view of a juridical council. The fatwās are similar in that nearly all judge that Islamic law, provided certain conditions are met, permits abstaining from life-sustaining treatment. Notably, the justifying conditions appear to rely on physician assessment of the clinical prognosis. The fatwās differ when it comes to what conditions justify withdrawing or withholding life- sustaining care. Our analyses suggest that while notions of futility greatly impact the bioethical discourse regarding with holding and/or withdrawal of treatment, the conceptualization of futility lacks nuance. Therefore, clinicians, Islamic jurists, and bioethicists need to come together in order to unify a conception of medical futility and relate it to the ethics of withholding and/or withdrawal of treatment. [ABSTRACT FROM AUTHOR]

Background: The Coronavirus Disease 2019 (COVID-19) that first occurred in Wuhan, China, is currently spreading throughout China. The majority of infected patients either traveled to Wuhan or came into contact with an infected person from Wuhan. Investigating members of the public with a travel history to Wuhan became the primary focus of the Chinese government's epidemic prevention and control measures, but several instances of withheld histories were uncovered as localized clusters of infections broke out. This study investigated the public's willingness and beliefs associated with reporting travel history to high-risk epidemic regions, to provide effective suggestions and measures for encouraging travel reporting.Methods: A cross-sectional study was conducted online between February 12 and 19, 2020. Descriptive analysis, chi-squared test, and Fisher's exact test were used to identify socio-demographic factors and beliefs associated with reporting, as well as their impact on the willingness to report on travel history to high-risk epidemic regions.Results: Of the 1344 respondents, 91 (6.77%) expressed an inclination to deliberately withhold travel history. Those who understood the benefits of reporting and the legal consequences for deliberately withholding information, showed greater willingness to report their history (P < 0.05); conversely, those who believed reporting would stigmatize them and feared being quarantined after reporting showed less willingness to report (P < 0.05).Conclusions: As any incident of withheld history can have unpredictable outcomes, the proportion of people who deliberately withhold information deserves attention. Appropriate public risk communication and public advocacy strategies should be implemented to strengthen the understanding that reporting on travel history facilitates infection screening and prompt treatment, and to decrease the fear of potentially becoming quarantined after reporting. Additionally, social support and policies should be established, and measures should be taken to alleviate stigmatization and discrimination against potential patients and reporters of travel history. Reinforcing the legal accountability of withholding travel history and strengthening systematic community monitoring are the measures that China is currently taking to encourage reporting on travel history to high-risk epidemic regions. These non-pharmaceutical interventions are relevant for countries that are currently facing the spread of the epidemic and those at risk of its potential spread. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented.Method: Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test.Results: When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030).Conclusion: Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making.Practice Implications: Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making. [ABSTRACT FROM AUTHOR]

Background: ITP is a nonthreatening disorder disturbing children at any age but mostly below 5 years. Objective: To evaluate the outcome of children with acute ITP who were not specified with any pharmacologic action and linked with those who were treated. Patients and Methods: A prospective case- control study was done between Jan. 2002 to May 2016 at Mukalla children and Maternity Hospital and University Hospital for Children and Mother Health in Mukalla/ Hadhramout /Yemen, where 20 children with acute ITP. the control group was 18 children given the conventional therapy. The identification and grouping of ITP were made according to the 2009 International Working Group criteria. Results: In group A there were 11( 55%) boys and 9(45%) girls, while control group B there were 18 children 10 (55.5%) boys and 8 (44.5%) girls. the ages were from 2 to 12 years. The mean age is 4.7 years with the median age at identification was 4r years. There was no statistical significant difference between both groups regarding outcome. Conclusion: The recovery percentage has some relation with age at appearance and preliminary platelet count where younger children and those with platelet amount of <20000 /µL have better recovery percentage. There was no statistical significant difference between both groups regarding outcome. [ABSTRACT FROM AUTHOR]

Background: Legal concerns have been implicated in the occurrence of variability in decisions of limitations of medical treatment (LOMT) before death. Objective: We aimed to assess differences in perceptions between physicians and prosecutors toward LOMT. Measurements: We sent a survey to intensivists, oncologists, and prosecutors from Brazil, from February 2018 to May 2018. Respondents rated the degree of agreement with withholding or withdrawal of therapies in four different vignettes portraying a patient with terminal lung cancer. We measured the difference in agreement between respondents. Results: There were 748 respondents, with 522 (69.8%) intensivists, 106 (14.2%) oncologists, and 120 (16%) prosecutors. Most respondents agreed with withhold of chemotherapy (95.2%), withhold of mechanical ventilation (MV) (90.2%), and withdrawal of MV (78.4%), but most (75%) disagreed with withdrawal of MV without surrogate's consent. Prosecutors were less likely than intensivists and oncologists to agree with withhold of chemotherapy (95.7% vs. 99.2% vs. 100%, respectively, p < 0.001) and withhold of MV (82.4% vs. 98.3% vs. 97.9%, respectively, p < 0.001), whereas intensivists were more likely to agree with withdrawal of MV than oncologists (87.1% vs. 76.1%, p = 0.002). Moreover, prosecutors were more likely to agree with withholding of active cancer treatment than with withholding of MV [difference (95% confidence interval, CI) = 13.2% (5.2 to 21.6), p = 0.001], whereas physicians were more likely to agree with withholding than with withdrawal of MV [difference (95% CI) = 10.9% (7.8 to 14), p < 0.001]. Conclusions: This study found differences and agreements in perceptions toward LOMT between prosecutors, intensivists, and oncologists, which may inform the discourse aimed at improving end-of-life decisions. [ABSTRACT FROM AUTHOR]