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Background: The swift advancement of intensive care medicine, coupled with technological possibilities, has prompted numerous ethical inquiries regarding decision-making processes concerning the withholding or withdrawal of treatment due to medical futility. This study seeks to delineate the decision-making approaches employed by intensive care physicians in Türkiye when faced with medical futility at the end of life, along with an ethical evaluation of these practices. Methods: Grounded theory, a qualitative analysis method was employed, conducting semi-structured, in-depth interviews with eleven intensive care physicians in Türkiye. The subsequent text analysis was carried out using MAXQDA software. Results: Participants assert that the decisions made by Turkish physicians determine whether treatment is futile, rely on medical consensus, and lack a standardized decision-making process. The decisions are influenced by legal and social pressures, resource constraints, and occasional conflicts of interest. The significance of professional hierarchy is notable, with limited consideration given to the opinions of nurses and other staff. The unstructured medical consensus processes are shaped by normative concepts such as benefit, age, justice, and conscience. Furthermore, it was observed that the conscientious opinions of physicians carry more weight than adherence to ethical principles and guidelines. Conclusion: To create optimal conditions for doctors to make ethically justifiable decisions, the dynamics within the treatment team should be improved, emphasizing the minimization of hierarchy, and ensuring the active participation of all team members in the decision-making process. Additionally, efforts should be directed toward narrowing the gap between the conscience of the individual doctor and established ethical principles. A potential solution lies in the nationwide implementation of clinical ethics committees and the establishing of clinical ethics guidelines, aiming to address, and overcome the identified challenges. [ABSTRACT FROM AUTHOR]

AbstractThere has been increasing awareness of the medical and moral challenges in the care of unrepresented patients: those who cannot make their own medical decisions, do not have any surrogate decision maker, and have not indicated their treatment preferences. Most discussions have focused on procedural questions such as who should make decisions for these patients. An issue that has not gotten enough attention is the ethical standard that should govern medical decision making. I explore the question of which ethical standard provides better justification for end-of-life decisions for unrepresented patients. Two options are considered: the conventional and less demanding best interest standard, and the novel and more demanding medical futility standard. I explain the similarities and differences between these two standards, examine arguments for and against each one, and suggest that the medical futility standard is ethically superior and should replace the established best interest standard. [ABSTRACT FROM AUTHOR]

Abstract Background The swift advancement of intensive care medicine, coupled with technological possibilities, has prompted numerous ethical inquiries regarding decision-making processes concerning the withholding or withdrawal of treatment due to medical futility. This study seeks to delineate the decision-making approaches employed by intensive care physicians in Türkiye when faced with medical futility at the end of life, along with an ethical evaluation of these practices. Methods Grounded theory, a qualitative analysis method was employed, conducting semi-structured, in-depth interviews with eleven intensive care physicians in Türkiye. The subsequent text analysis was carried out using MAXQDA software. Results Participants assert that the decisions made by Turkish physicians determine whether treatment is futile, rely on medical consensus, and lack a standardized decision-making process. The decisions are influenced by legal and social pressures, resource constraints, and occasional conflicts of interest. The significance of professional hierarchy is notable, with limited consideration given to the opinions of nurses and other staff. The unstructured medical consensus processes are shaped by normative concepts such as benefit, age, justice, and conscience. Furthermore, it was observed that the conscientious opinions of physicians carry more weight than adherence to ethical principles and guidelines. Conclusion To create optimal conditions for doctors to make ethically justifiable decisions, the dynamics within the treatment team should be improved, emphasizing the minimization of hierarchy, and ensuring the active participation of all team members in the decision-making process. Additionally, efforts should be directed toward narrowing the gap between the conscience of the individual doctor and established ethical principles. A potential solution lies in the nationwide implementation of clinical ethics committees and the establishing of clinical ethics guidelines, aiming to address, and overcome the identified challenges.

Moral distress can impact nurses and the care team significantly. A profession dedicated to the principles of caring and compassion is often subjected to patients receiving futile treatment. With the proliferation of extreme life-prolonging measures come the difficulties in the withdrawal of those medical modalities. If a prognosis is poor and care is perceived as curative rather than palliative, providers may often feel conflicted and distressed by their interventions. The American Association of Colleges of Nursing has expressed growing concern about an increase in the use of inappropriate life-support treatments related to futile care. The compelling case of a severely beaten 69-year-old homeless manwho had cardiac-arrested and was resuscitated after an unknown amount of down-time, provides the contextual framework for this report. Ethical conflicts can become very challenging, which inevitably increases the suffering of the patient and their caregivers. Research findings suggest that health care organizations can benefit from enacting processes that make ethical considerations an early and routine part of everyday clinical practice. A proactive approach to ethical conflicts may improve patient care outcomes and decrease moral distress. [ABSTRACT FROM AUTHOR]

PURPOSE: To compare taxane maintenance chemotherapy, paclitaxel (P) and paclitaxel poliglumex (PP), with surveillance (S) in women with ovarian, peritoneal, or fallopian tube (O/PC/FT) cancer who attained clinical complete response after first-line platinum-taxane therapy. METHODS: Women diagnosed with O/PC/FT cancer who attained clinical complete response after first-line platinum-taxane-based chemotherapy were randomly allocated 1:1:1 to S or maintenance, P 135 mg/m2 once every 28 days for 12 cycles, or PP at the same dose and schedule. Overall survival (OS) was the primary efficacy end point. RESULTS: Between March 2005 and January 2014, 1,157 individuals were enrolled. Grade 2 or worse GI adverse events were more frequent among those treated with taxane (PP: 20%, P: 27% v S: 11%). Grade 2 or worse neurologic adverse events occurred more often with taxane treatment (PP: 46%, P: 36% v S: 14%). At the fourth scheduled interim analysis, both taxane regimens passed the OS futility boundary and the Data Monitoring Committee approved an early release of results. With a median follow-up of 8.1 years, 653 deaths were reported; none were attributed to the study treatment. Median survival durations were 58.3, 56.8, and 60.0 months for S, P, and PP, respectively. Relative to S, the hazard of death for P was 1.091 (95% CI, 0.911 to 1.31; P = .343) and for PP, it was 1.033 (95% CI, 0.862 to 1.24; P = .725). The median times to first progression or death (PFS) were 13.4, 18.9, and 16.3 months for S, P, and PP, respectively. Hazard ratio = 0.801; 95% CI, 0.684 to 0.938; P = .006 for P and hazard ratio = 0.854; 95% CI, 0.729 to 1.00; P = .055 for PP. CONCLUSION: Maintenance therapy with P and PP did not improve OS among patients with newly diagnosed O/tubal/peritoneal cancer, but may modestly increase PFS. GI and neurologic toxicities were more frequent in the taxane treatment arms.

The discontinuation of life-sustaining therapy has been the subject of dispute for many years. Despite the guidelines, which were created to facilitate the resolution of disputes between the doctor (hospital) and the patient (family, surrogate), new cases of seriously ill patients continue to emerge and stir up controversy. One such case was the RS case. A Polish citizen living in the UK suffered severe brain damage as a result of cardiac arrest. The hospital applied to the court to withdraw ventilation, hydration, and nutrition for RS. The judge ultimately ruled that it was in RS’s best interest to withdraw ventilation and nutrition, but he left the decision on hydration to RS’s wife and the hospital. The court’s ruling has stirred up controversy among the Polish public. Some Polish doctors assessed the UK court’s decision as “legal murder” and “euthanasia”. I believe that it is worth examining the RS case for at least two reasons. Firstly, it provides a better understanding of the difference in approaches to therapy cessation in the UK and Poland. Secondly, many Poles live in the UK, and therefore similar disputes may arise in the future. In this paper, I point out several differences between the British and Polish approaches to discontinuing life-sustaining therapy. These differences are focused on the definitions of medical futility and persistent therapy, best interest and dignity, and quality of life and sanctity of life. [ABSTRACT FROM AUTHOR]

Pediatric surgeons need to learn to give as much importance to the ethical approach as they have been giving to the systemic methodology in their clinical approach all along. The law of the land and the governmental rules also need to be kept in mind before deciding the final solution. They need to always put medical problems in the background of ethical context, reach a few solutions keeping in mind the available resources, and apply the best solution in the interest of their pediatric patients. [ABSTRACT FROM AUTHOR]

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ABSTRACT BACKGROUND: Advance Directive documents allow citizens to choose the treatments they want for end-of-life care without considering therapeutic futility. OBJECTIVES: To analyze patients’ and caregivers’ answers to Advance Directives and understand their expectations regarding their decisions. DESIGN AND SETTING: This study analyzed participants’ answers to a previously published trial, conceived to test the document’s efficacy as a communication tool. METHODS: Sixty palliative patients and 60 caregivers (n = 120) registered their preferences in the Advance Directive document and expressed their expectations regarding whether to receive the chosen treatments. RESULTS: In the patient and caregiver groups, 30% and 23.3% wanted to receive cardiorespiratory resuscitation; 23.3% and 25% wanted to receive artificial organ support; and 40% and 35% chose to receive artificial feeding and hydration, respectively. The participants ignored the concept of therapeutic futility and expected to receive invasive treatments. The concept of therapeutic futility should be addressed and discussed with both the patients and caregivers. Legal Advanced Directive documents should be made clear to reduce misinterpretations and potential legal conflicts. CONCLUSION: The authors suggest that all citizens should be clarified regarding the futility concept before filling out the Advance Directives and propose a grammatical change in the document, replacing the phrase “Health Care to Receive / Not to Receive” with the sentence “Health Care to Accept / Refuse” so that patients cannot demand treatments, but instead accept or refuse the proposed therapeutic plans. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT05090072 URL: https://clinicaltrials.gov/ct2/show/NCT05090072.

BackgroundMultiple system atrophy (MSA) is a fatal neurodegenerative disease characterized by the aggregation of α-synuclein in glia and neurons. Sirolimus (rapamycin) is an mTOR inhibitor that promotes α-synuclein autophagy and reduces its associated neurotoxicity in preclinical models.ObjectiveTo investigate the efficacy and safety of sirolimus in patients with MSA using a futility design. We also analyzed 1-year biomarker trajectories in the trial participants.MethodsRandomized, double-blind, parallel group, placebo-controlled clinical trial at the New York University of patients with probable MSA randomly assigned (3:1) to sirolimus (2-6 mg daily) for 48 weeks or placebo. Primary endpoint was change in the Unified MSA Rating Scale (UMSARS) total score from baseline to 48 weeks. (ClinicalTrials.gov NCT03589976).ResultsThe trial was stopped after a pre-planned interim analysis met futility criteria. Between August 15, 2018 and November 15, 2020, 54 participants were screened, and 47 enrolled and randomly assigned (35 sirolimus, 12 placebo). Of those randomized, 34 were included in the intention-to-treat analysis. There was no difference in change from baseline to week 48 between the sirolimus and placebo in UMSARS total score (mean difference, 2.66; 95% CI, -7.35-6.91; P = 0.648). There was no difference in UMSARS-1 and UMSARS-2 scores either. UMSARS scores changes were similar to those reported in natural history studies. Neuroimaging and blood biomarker results were similar in the sirolimus and placebo groups. Adverse events were more frequent with sirolimus. Analysis of 1-year biomarker trajectories in all participants showed that increases in blood neurofilament light chain (NfL) and reductions in whole brain volume correlated best with UMSARS progression.ConclusionsSirolimus for 48 weeks was futile to slow the progression of MSA and had no effect on biomarkers compared to placebo. One-year change in blood NfL and whole brain atrophy are promising biomarkers of disease progression for future clinical trials. © 2022 International Parkinson and Movement Disorder Society.

Aim:The knowledge and understanding of medical futility and decisions about termination of resuscitation (TOR) for out-of-hospital cardiac arrest (OHCA) are highly heterogeneous and dependent on the practice and beliefs of the attending emergency physicians. The objective of this study was to determine current practice, knowledge and attitude among emergency medical practitioners regarding medical futility and termination of cardiopulmonary resuscitation (CPR) in OHCA patients in Hospital Ampang, Pusat Perubatan University Malaya, Hospital Kuala Lumpur and Hospital Serdang.Materials and Methods:A cross-sectional survey was conducted among medical practitioners in emergency departments in the Klang Valley. The questionnaire assessed the participants’ demography, knowledge, attitudes and behaviors (KAB) about TOR of OHCA and identification of medical futility. Subgroup analysis regression analysis was used to identify the relationship between respondents’ demography, KAB.Results:The sample size of this survey was 152 taken at 90% confidence interval. Results show that those with more than 5 years of experience in emergency medicine (EM) had a higher attitude score compared to those with less than 1-year experience (p

BackgroundPotentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited.ObjectivesDetermine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate.MethodsProspective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0–17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale.ResultsOf 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty.ConclusionsWhile treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.

Abstract Background In Colombia, cancer incidence is increasing, as is the demand for end-of-life care. Understanding how patients who die from cancer experience this phase will allow the identification of factors associated with greater suffering and actions to improve end-of-life care. We aimed to explore associations between the level of suffering of patients who died from cancer and were cared for in three Colombian hospitals with patient, tumor, treatment, and care characteristics and provided information. Methods Data on the last week of life and level of suffering were collected through proxies: Bereaved caregivers of patients who died from cancer in three participating Colombian hospitals. Bereaved caregivers participated in a phone interview and answered a series of questions regarding the last week of the patient’s life. An ordinal logistic regression model explored the relationship between the level of suffering reported by bereaved caregivers with the patient’s demographic and clinical characteristics, the bereaved caregivers, and the care received. Multivariate analyses were adjusted for place of death, treatments to prolong of life, prolongation of life during the dying process, suffering due to prolongation of life, type of cancer, age, if patient had partner, rural/urban residence of patient, importance of religion for the caregiver, caregivers´ relationship with the patient, and co-living with the patient. Results A total of 174 interviews were included. Median age of the deceased patients was 64 years (IQR 52–72 years), and 93 patients were women (53.4%). Most caregivers had rated the level of suffering of their relative as “moderately to extremely” (n = 139, 80%). In multivariate analyses, factors associated with a higher level of suffering were: unclear information about the treatment and the process before death Odds Ratio (OR) 2.26 (90% CI 1.21–4.19), outpatient palliative care versus home care OR 3.05 (90% CI 1.05–8.88), procedures inconsistent with the patient’s wishes OR 2.92 (90% CI 1.28–6.70), and a younger age (18–44 years) at death versus the oldest age group (75–93 years) OR 3.80 (90% CI 1.33–10.84, p = 0.04). Conclusion End-of-life care for cancer patients should be aligned as much as possible with patients´ wishes, needs, and capacities. A better dialogue between doctors, family members, and patients is necessary to achieve this.

Background: Palliative cancer patients suffer from a condition which needs to take many medications for supportive care and comorbid illnesses management. Therefore, they are at risk of drug-rated problems, such as futile medications. We aimed to discover the futile medication occurrence and identification as well as medication futility associated predictor factors. Method: In a prospective cross-sectional study, we included patients with advanced/incurable malignancies admitted to Ala palliative clinic, a charity clinic affiliated to Omid Hospital in Isfahan, Iran, between June 2018 and April 2019. To identify the use of fruitless medicine towards the end of life, we conducted a thorough analysis of the demographic information and prescription lists of terminally ill patients. The phrase "futile drugs" refers to those that are superfluous or redundant, have no significant benefits in terms of illness symptom management or survival time extension, or have a long-term chronic usage. Results: From 133 involved patients, 114 (85.7%) were considered to use at least one futile medication (including only administration of unnecessary medications (70%) or both unnecessary and duplicate medication (30%). 35 patients were encountered with 48 medication duplications of the different pharmacological class of medications mostly opioids (33%). According to multivariate logistic regression analysis, the number of drugs and the average time to death were related with the prevalence of medication futility. Conclusion: Palliative cancer patients were exposed to taking futile medications. More different prospective studies are warranted to evaluate the clinical and economic impact of futile medication use in oncology practice.

Objective: Literature shows high in-hospital mortality rates following end-of-life decisions in patients with traumatic spinal cord injury. This study investigated 2-year mortality and end-of-life decisions in patients with traumatic spinal cord injury. Design: Explorative retrospective study in a Dutch level 1 trauma centre. Patients: All consecutive patients between 2015 and 2020 with new traumatic spinal cord injury were selected from the trauma registry. Patients were excluded if myelopathy, cauda equina, or conus medullaris injury was absent or if they were referred to another level 1 trauma centre. Methods: Mortality and end-of-life decisions (i.e. withdrawal and withholding of treatment, and euthanasia) within 2 years were analysed. Demographics, injury and clinical characteristics, and hospital treatment outcomes were compared with survivors. Motivations and critical morbidities concerning end-of-life decisions were assessed. Results: The sample included 219 patients. Two-year mortality was 26% (n = 56), in-hospital mortality was 16%. The deceased were older, had more comorbidities and more severe injuries. end-of-life decisions concerned 42 patients (75%), mostly motivated by loss of independence or poor outcomes. Three patients received euthanasia (5%). The largest group with end-of-life decisions also sustained moderate-severe traumatic brain injuries (n = 11; 26%). Conclusion: Most patients with traumatic spinal cord injury died following an end-of-life decision, with the largest group sustaining concomitant traumatic brain injuries. The incidence of euthanasia was low.

Ultrasound-guided percutaneous liver biopsy (UPLB) is currently performed mainly to determine if new hepatic space occupying lesions (SOL) represent benign, primary malignant, or metastatic disease. This study sought to investigate the outcome of UPLB in this setting. In a retrospective study, patients with a new hepatic SOL who underwent UPLB during 1/2006-12/2016 were included and followed to 12/2018. Clinical data and pathology reports were reviewed. Mortality within 60 days and no change in patients' management following UPLB were defined as medically futile. Included 140 patients, 50% male, mean age 68.8 ± 11.5 years; 112 patients died, all of malignant disease. 32 patients (23%) died within 60 days of UPLB. Median post-UPLB survival was 151 days. Survival was significantly shorter in patients with >1 hepatic lesion (n = 108) or an extrahepatic malignant lesion (n = 77) (p = 0.0082, p = 0.0301, respectively). On Cox Proportional Hazards analysis, significant predictors of mortality within 60 days of UPLB were: age as a continuous variable, (HR 1.070, 95% CI 1.011–1.131, p = 0.018), serum albumin <2.9 g/dL, (HR 4.822 95% CI 1.335–17.425, p = 0.016) and serum LDH >1500 U/L (HR 9.443, 95% CI 3.404–26.197, p < 0.0001). In patients with these features or with disseminated disease, liver biopsy should be carefully reconsidered. • Percutaneous liver biopsy is mainly perforemd to find if new hepatic lesions are benign, malignant, or metastatic diseaese • We investigated the medical contribution of ultrasound-guided percutaneous liver biopsy in the diagnosis of hepatic lesions. • Clinical, laboratory and imaging data were combined with patients' outcome. • Thus, we were able to outline states in which ultrasound-guided percutaneous liver biopsy becomes medically futile. • In elders with disseminated malignancy, low albumin and high LDH, liver biopsy has no contribution to patients' outcome. [ABSTRACT FROM AUTHOR]

We aimed to evaluate the characteristics, resource use and outcomes of critically ill patients with cancer according to appropriateness of ICU admission. This was a retrospective cohort study of patients with cancer admitted to ICU from January 2017 to December 2018. Patients were classified as appropriate, potentially inappropriate, or inappropriate for ICU admission according to the Society of Critical Care Medicine guidelines. The primary outcome was ICU length of stay (LOS). Secondary outcomes were one-year, ICU, and hospital mortality, hospital LOS and utilization of ICU organ support. We used logistic regression and competing risk models accounting for relevant confounders in primary outcome analyses. From 6700 admitted patients, 5803 (86.6%) were classified as appropriate, 683 (10.2%) as potentially inappropriate and 214 (3.2%) as inappropriate for ICU admission. Potentially inappropriate and inappropriate ICU admissions had lower likelihood of being discharged from the ICU than patients with appropriate ICU admission (sHR 0.55, 95% CI 0.49–0.61 and sHR 0.65, 95% CI 0.53–0.81, respectively), and were associated with higher 1-year mortality (OR 6.39, 95% CI 5.60–7.29 and OR 11.12, 95% CI 8.33–14.83, respectively). Among patients with appropriate, potentially inappropriate, and inappropriate ICU admissions, ICU mortality was 4.8%, 32.6% and 35.0%, and in-hospital mortality was 12.2%, 71.6% and 81.3%, respectively (p < 0.01). Use of organ support was more common and longer among patients with potentially inappropriate ICU admission. The findings of our study suggest that inappropriateness for ICU admission among patients with cancer was associated with higher resource use in ICU and higher one-year mortality among ICU survivors. [ABSTRACT FROM AUTHOR]

Rationale: Medical interventions that prolong life without achieving an effect that the patient can appreciate as a benefit are often considered futile or inappropriate by healthcare providers. In recent years, a multicenter guideline has been released with recommendations on how to resolve conflicts between families and clinicians in these situations and to increase public engagement. Although laypeople are acknowledged as important stakeholders, their perceptions and understanding of the terms "potentially inappropriate" or "futile" treatment have received little formal evaluation.Objectives: To evaluate the community perspective about the meaning of futile treatment.Methods: Six focus groups (two groups each of ages 75 yr) were convened to explore what constitutes futile treatment and who should decide in situations of conflict between doctors and families. Focus group discussions were analyzed using grounded theory.Results: There were 39 participants aged 18 or older with at least one previous hospitalization (personal or by immediate relative). When asked to describe futile or inappropriate treatment, community members found the concept difficult to understand and the terminology inadequate, though when presented with a case describing inappropriate treatment, most participants recognized it as the provision of inappropriate treatment. Several themes emerged regarding participant difficulty with the concept, including inadequate physician-patient communication, lack of public emphasis on end-of-life issues, skepticism that medical treatment can be completely inappropriate, and doubts and fears that medical futility could undermine patient and/or family autonomy. Participants also firmly believed that in situations of conflict families should be the ultimate decision-makers.Conclusions: Public engagement in policy development and discourse around medical futility will first require intense education to familiarize the lay public about use of inappropriate treatment at the end of life.

Abstract Background Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life. Aim To define and understand determinants of non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life. Design Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles. Data sources Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science. Results Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences. Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’. Conclusion A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool. Trial registration PROSPERO Protocol CRD42021214137 .

Background: The determination of what makes a medical treatment inappropriate is unclear with a small likelihood of consensus. Objectives: This study aimed to explore how clinicians in cardiology perceive "inappropriate treatment" and to collate the common profiles of cardiology patients receiving likely "inappropriate treatment" as perceived by clinicians in a multiethnic Asian context. Methods: A qualitative study was conducted using semistructured in-depth interviews with 32 clinicians involved in the care for cardiology patients at a large national cardiology center in Singapore. Results: Clinicians' accounts indicated that elements of potentially inappropriate treatment encompass patient-related treatment elements as well as quantitative and probability-based elements such as resource use and probability of treatment benefit. Patient prognostic profiles, characterized as likely to have received inappropriate treatment by clinicians, were organized into six categories according to demographic, clinical, and functional factors. Conclusions: The perception of inappropriateness of treatments among clinicians in cardiology was primarily focused on patient-related outcomes. Collated patient profiles may serve as meaningful indicators of patient cases receiving potentially inappropriate treatment for further research and intervention. [ABSTRACT FROM AUTHOR]

Background: In Colombia, cancer incidence is increasing, as is the demand for end-of-life care. Understanding how patients who die from cancer experience this phase will allow the identification of factors associated with greater suffering and actions to improve end-of-life care. We aimed to explore associations between the level of suffering of patients who died from cancer and were cared for in three Colombian hospitals with patient, tumor, treatment, and care characteristics and provided information. Methods: Data on the last week of life and level of suffering were collected through proxies: Bereaved caregivers of patients who died from cancer in three participating Colombian hospitals. Bereaved caregivers participated in a phone interview and answered a series of questions regarding the last week of the patient's life. An ordinal logistic regression model explored the relationship between the level of suffering reported by bereaved caregivers with the patient's demographic and clinical characteristics, the bereaved caregivers, and the care received. Multivariate analyses were adjusted for place of death, treatments to prolong of life, prolongation of life during the dying process, suffering due to prolongation of life, type of cancer, age, if patient had partner, rural/urban residence of patient, importance of religion for the caregiver, caregivers´ relationship with the patient, and co-living with the patient. Results: A total of 174 interviews were included. Median age of the deceased patients was 64 years (IQR 52–72 years), and 93 patients were women (53.4%). Most caregivers had rated the level of suffering of their relative as "moderately to extremely" (n = 139, 80%). In multivariate analyses, factors associated with a higher level of suffering were: unclear information about the treatment and the process before death Odds Ratio (OR) 2.26 (90% CI 1.21–4.19), outpatient palliative care versus home care OR 3.05 (90% CI 1.05–8.88), procedures inconsistent with the patient's wishes OR 2.92 (90% CI 1.28–6.70), and a younger age (18–44 years) at death versus the oldest age group (75–93 years) OR 3.80 (90% CI 1.33–10.84, p = 0.04). Conclusion: End-of-life care for cancer patients should be aligned as much as possible with patients´ wishes, needs, and capacities. A better dialogue between doctors, family members, and patients is necessary to achieve this. [ABSTRACT FROM AUTHOR]

Background: Palliative cancer patients suffer from a condition which needs to take many medications for supportive care and comorbid illnesses management. Therefore, they are at risk of drug-rated problems, such as futile medications. We aimed to discover the futile medication occurrence and identification as well as medication futility associated predictor factors. Method: In a prospective cross-sectional study, we included patients with advanced/incurable malignancies admitted to Ala palliative clinic, a charity clinic affiliated to Omid Hospital in Isfahan, Iran, between June 2018 and April 2019. To identify the use of fruitless medicine towards the end of life, we conducted a thorough analysis of the demographic information and prescription lists of terminally ill patients. The phrase "futile drugs" refers to those that are superfluous or redundant, have no significant benefits in terms of illness symptom management or survival time extension, or have a long-term chronic usage. Results: From 133 involved patients, 114 (85.7%) were considered to use at least one futile medication (including only administration of unnecessary medications (70%) or both unnecessary and duplicate medication (30%). 35 patients were encountered with 48 medication duplications of the different pharmacological class of medications mostly opioids (33%). According to multivariate logistic regression analysis, the number of drugs and the average time to death were related with the prevalence of medication futility. Conclusion: Palliative cancer patients were exposed to taking futile medications. More different prospective studies are warranted to evaluate the clinical and economic impact of futile medication use in oncology practice. [ABSTRACT FROM AUTHOR]

The provision of intensive care enables the lives of neonates, infants and children to be sustained or extended in circumstances previously regarded as impossible. However, as well as benefits, such care may confer burdens that resultingly frame continuation of certain interventions as futile, conferring more harm than or any, benefit. Subsequently, clinicians and families in the paediatric intensive care unit are often faced with decisions to withdraw, withhold or limit intensive care in order to act in the best interests of the child. An integral consideration in respect of these decisions is that futility is a concept that has to be contextualised for all those involved. Recent high-profile legal cases highlight the professional, clinical, legal and social conflicts that can arise when parents and clinicians have different interpretations of futility. In acknowledging the complexity of these conflicts for clinicians, this paper aims to support a better understanding of futility as an integral concept in such difficult and emotive decisions within professional practice. We utilise the concept of futility to frame how these decisions to withdraw or withhold certain invasive life-prolonging interventions are ethically and legally justifiable, even when they disagree or conflict with parental views. To support clinicians in understanding these decisions, we in part use the familiar bioethical framework of Principlism developed by Beauchamp and Childress. We suggest that understanding legal and ethical analysis of futility ultimately will help clinicians in approaching and reflecting on such decision-making. [ABSTRACT FROM AUTHOR]

BackgroundInvasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients' goals of care.ObjectiveThe aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality.MethodsThis study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization.ResultsThe study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020.ConclusionsThe successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses.International registered report identifier (irrid)DERR1-10.2196/16301.

BackgroundIron from haemolysed blood is implicated in secondary injury after intracerebral haemorrhage. We aimed to assess the safety of the iron chelator deferoxamine mesylate in patients with intracerebral haemorrhage and to establish whether the drug merits investigation in a phase 3 trial.MethodsWe did a multicentre, futility-design, randomised, placebo-controlled, double-blind, phase 2 trial at 40 hospitals in Canada and the USA. Adults aged 18-80 years with primary, spontaneous, supratentorial intracerebral haemorrhage were randomly assigned (1:1) to receive deferoxamine mesylate (32 mg/kg per day) or placebo (saline) infusions for 3 consecutive days within 24 h of haemorrhage onset. Randomisation was done via a web-based trial-management system centrally in real time, and treatment allocation was concealed from both participants and investigators. The primary outcome was good clinical outcome, which was defined as a modified Rankin Scale score of 0-2 at day 90. We did a futility analysis: if the 90% upper confidence bound of the absolute risk difference between the two groups in the proportion of participants with a good clinical outcome was less than 12% in favour of deferoxamine mesylate, then to move to a phase 3 efficacy trial would be futile. Primary outcome and safety data were analysed in the modified intention-to-treat population, comprising only participants in whom the study infusions were initiated. This trial is registered with ClinicalTrials.gov, number NCT02175225, and is completed.FindingsWe recruited 294 participants between Nov 23, 2014, and Nov 10, 2017. The modified intention-to-treat population consisted of 144 patients assigned to the deferoxamine mesylate group and 147 assigned to the placebo group. At day 90, among patients with available data for the primary outcome, 48 (34%) of 140 participants in the deferoxamine mesylate group, and 47 (33%) of 143 patients in the placebo group, had modified Rankin Scale scores of 0-2 (adjusted absolute risk difference 0·6% [90% upper confidence bound 6·8%]). By day 90, 70 serious adverse events were reported in 39 (27%) of 144 patients in the deferoxamine mesylate group, and 78 serious adverse events were reported in 49 (33%) of 147 patients in the placebo group. Ten (7%) participants in the deferoxamine mesylate and 11 (7%) in the placebo group died. None of the deaths were judged to be treatment related.InterpretationDeferoxamine mesylate was safe. However, the primary result showed that further study of the efficacy of deferoxamine mesylate with anticipation that the drug would significantly improve the chance of good clinical outcome (ie, mRS score of 0-2) at day 90 would be futile.FundingUS National Institutes of Health and US National Institute of Neurological Disorders and Stroke.

Purpose: Adjusting therapeutic efforts is an evidence-based clinical decision that aims to avoid medical futility. Varied factors that can influence this decision-making have been pointed out, related to the patient, the medical professional who makes the decisions, system barriers, culture, and the economy, among others. The present study aims to identify those factors that help the specialists working in a cancer referral institution in Colombia to plan actions that improve the approach to decision-making regarding the adequacy of therapeutic efforts in cancer patients. Methodology: This qualitative design is based on 13 in-depth interviews with Colombia's National Cancer Institute specialists. Results: Three women and ten men participated, with an average age of 36 years; seven belonged to the specialty of adult oncology, two to pediatric oncohematology, one to adult intensive care, and three to pediatric intensive care. The factors found were grouped into four categories: 1) knowledge, 2) aspects related to decision-making, 3) the decision-maker, and 4) the type of decision made. These categories were clustered into themes that allude to the factors swaying specialists' decision-making to adjust therapeutic efforts. Conclusion: Adjusting therapeutic actions is vital to avoid futile medical procedures that prolong suffering. Some factors that influence the specialists' decision-making were noted: lack of preparation of health professionals on end-of-life decision-making, reduced use of scales to improve prognostic information, and ignorance about advance directives. These factors must be strengthened to improve the approach to this issue. [ABSTRACT FROM AUTHOR]

Background and purpose: Futile medical care is referred to any medical intervention or activity that bring no benefit to patients. The aim of this study was to evaluate the frequency of futile treatment and its cost in neonates with a probable diagnosis of inherited metabolic disorder. Materials and methods: In this cross-sectional study, hospitalization records of all admitted neonates in Children's Medical Center, Tehran were evaluated between 2013 and 2016. Demographic characteristics of the patients, duration of hospitalization, diagnostic and therapeutic management, and costs were investigated. Results: In the period studied, 1668 neonates were hospitalized of whom 20 (1.2%) died in neonatal intensive care unite with a probable diagnosis of inherited metabolic disorder. Six (30%) cases had deceased siblings. The total duration of hospitalization was 290 day-patient ranging from 20 hours to 37 days. The costs of hospitalization and medical treatments were calculated. Despite disagreement of eight (40%) parents with any futile treatments, the medical team discontinued the futile care in only one case who received palliative care. In other patients futile treatment continued before death. Conclusion: Futile medical treatments in neonates with inherited metabolic disorders are not uncommon. Lack of a comprehensive guideline about this issue leads to continuation of futile medical care.

Background: Despite the progress made in recent decades on the phenomenon of futility in adult intensive care, recognizing it during clinical care practice remains a complex and sensitive process, during which questions are often raised for which concrete answers are difficult to find. Aims: To analyze the frequency with which futile nursing interventions are implemented in critically ill patients admitted to adult intensive care in specific situations and how often futile autonomous and interdependent nursing interventions are implemented in the same population, as perceived by adult intensive care nurses. Research design: Cross-sectional, quantitative, and descriptive study, which employed a questionnaire constructed specifically for this research to assess the perception of therapeutic futility in nursing in adult intensive care. Following an evaluation of the psychometric properties, the questionnaire was made available in an electronic format on the EUSurvey platform between August and October 2024. The data was analyzed between November 2023 and March 2024 using the statistical software packages SPSS and R. Participants and research context: A simple random sample of nurses working in level II and level III intensive care units in Portugal. Ethical considerations: Research ethical approvals were obtained, and the participants provided informed consent. Findings/results: Four hundred and fourteen valid questionnaires were obtained. The results allow the identification of thirty-three statistically significant associations, the inference of intervals for the mean and median for the perception of futility of nursing interventions with a 95% confidence interval, and enable the hierarchization of nursing interventions implemented in critically ill patients admitted to adult intensive care units according to the nurses’ perception of their futility. Conclusion: There is a balance in nurses' perception of the futility of their interventions in the specific situations analyzed. There is statistically significant evidence that interdependent nursing interventions are, in general, more frequently perceived as futile when compared to autonomous nursing interventions. [ABSTRACT FROM AUTHOR]

Background: Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life. Aim: To define and understand determinants of non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life. Design: Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles. Data sources: Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science. Results: Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences. Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to 'Motivation to Address Conflict & Seek Agreement' helped to lessen uncertainty around decision-making. Establishing agreement was reliant on 'Valuing Clear Communication and Sharing of Information'. Reaching consensus was dependent on 'Choices around Timing & Documenting of end-of-life Decisions'. Conclusion: A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool. Trial registration: PROSPERO Protocol CRD42021214137. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary Resuscitation (CPR) causes significant injuries and increased cost among transiently resuscitated patients that do not survive their hospitalizations. Descriptive studies show zero and near-zero percent survival for CPR recipients with high Apache II scores. Despite these factors, no controlled studies exist in CPR to guide patient selection for CPR candidacy. Our objective was therefore to perform a controlled study in CPR to inform recommendations for CPR candidacy. We hypothesize that the protective effects of CPR decrease as illness severity increases, and that Full-Code status provides no survival benefit over Do-Not-Resuscitate (DNR) status for patients with the highest predicted mortality by Apache IV score. Methods: We performed propensity-score matched survival analyses between Full-Code and DNR patients after stratifying by predicted mortality quartiles using Apache IV scores. Primary outcomes were mortality hazard ratios. Secondary outcomes were Median Survival Differences, ICU LOS, and tracheostomy rates. Results: Among 17,710 propensity-score matched ICU encounters, DNR status was associated with greater mortality in the first through third predicted mortality quartiles. There was no difference in survival outcomes in the fourth quartile (HR 0.99, p=.96). There was a stepwise decrease in the mortality hazard ratio for DNR patients as quartiles increased. Conclusion: Full-Code status provides no survival benefit over DNR status in individuals with greater than 75% predicted mortality by Apache IV score. There is a stepwise decrease in survival benefit for Full-Code patients as predicted mortality increases. We propose that it is reasonable to consider a very high predicted mortality by Apache IV score a contraindication to CPR given the lack of survival benefit seen in these patients. Larger studies with similar methods should be performed to reinforce or refute these findings. [ABSTRACT FROM AUTHOR]

Background. Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood. Aim. This study aimed to explore clinicians' perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting. Design. We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed. Results. A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment. Conclusion. Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment. [ABSTRACT FROM AUTHOR]

Purpose: To explore whether the failure of early neurological improvement can predict futile recanalization after successful interventional recanalization of anterior circulation tandem lesions., Patients and Methods: A retrospective analysis was conducted on the clinical data of patients who received successful interventional recanalization treatment of anterior circulation tandem lesions from January 2019 to November 2023. The failure of early neurological improvement is defined as a decrease of less than 4 points in NIHSS score compared to preoperative score at 24 h after surgery. Statistical analysis was conducted using SPSS 26.0 software, and a forest plot and Receiver Operating Characteristic curve related to futile recanalization were drawn., Results: A total of 120 patients received successful interventional recanalization of anterior circulation tandems lesion were included, including 68 cases of futile recanalization (56.67 %) and 52 cases of effective recanalization (43.33 %). The rate of failure of early neurological improvement in the futile recanalization group was higher than that in the effective recanalization group (94.12 % vs 34.62 %, P < 0.001). After adjusting for confounding factors, the rate of failure of early neurological improvement in the futile recanalization group was higher than that in the effective recanalization group (adjusted OR: 39.925; 95 % CI: 4.110-387.864; P = 0.001). The area under the Receiver Operating Characteristic curve using failure of neurological improvement for predicting futile recanalization was 0.800., Conclusion: Failure of early neurological improvement is an effective indicator for predicting futile recanalization after successful interventional recanalization in anterior circulation tandem lesions., Competing Interests: Declaration of Competing Interest The authors declare that there are no conflicts of financial or non-financial interests that are directly or indirectly related to the work., (Copyright © 2024. Published by Elsevier B.V.)

Aim: Prehospital termination of resuscitation (ToR) rules are used to predict medical futility in adult out-of-hospital cardiac arrest (OHCA), however, the available evidence for pediatric patients is limited. The primary aim of this study is to derive a Pediatric Termination of Resuscitation (PToR) prediction rule for use in pediatric non-traumatic OHCA patients., Methods: We analyzed a retrospective cohort of pediatric OHCA patients within the CARES database over a 10-year period (2013-2022). We split the dataset into training and test datasets and fit logistic regressions with Least Absolute Shrinkage and Selection Operator (LASSO) to select predictor variables and estimate predictive test characteristics for the primary outcome of death and a secondary composite outcome of death or survival to hospital discharge with unfavorable neurologic status., Results: We analyzed a sample of 21,240 children where 2,326 (11.0%) survived to hospital discharge, and 1,894 (8.9%) survived to hospital discharge with favorable neurologic status. We derived a PToR rule for death demonstrating a specificity of 99.1% and a positive predictive value (PPV) of 99.8% and a PToR rule for death or survival with poor neurologic status with a specificity of 99.7% and PPV of 99.9% within the test dataset., Conclusion: We derived a clinical prediction rule with high specificity and positive predictive value in prehospital settings utilizing Advanced Life Support (ALS) providers which may inform termination of resuscitation considerations in pediatric patients. Further prospective and validation studies will be necessary to define the appropriateness and applicability of these PToR criteria for routine use., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Despite successful recanalization after Mechanical Thrombectomy (MT), approximately 25 % of patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) show unfavorable clinical outcomes, namely Futile Recanalization (FR). We aimed to use a Machine Learning (ML) Non-Contrast brain CT (NCCT) imaging predictive model to identify FR in patients undergoing MT., Materials & Methods: Between July 2022 and December 2022, 70 consecutive patients with LVO undergoing a complete recanalization (eTICI 3) with MT within 8 h from onset at our Centre were analyzed. Two NCCT images per patient of middle cerebral artery vascular territory and patients' clinical characteristics were classified by the presence of ischemic features on 24 h NCCT after MT. Each slice was segmented with "Mazda" software ver.4.6 by placing a Region Of Interest (ROI) on the whole brain by two radiologists in consensus. A total of 381 features were extracted for each slice. The dataset was split into train and test set with a 70:30 ratio., Results: Eleven classification models were trained. An Ensemble Machine Learning (EML) model was obtained by averaging the predictions of models with accuracy on a test set >70 %, with and without patients' clinical characteristics. The EML model combined with clinical data showed an accuracy of 0.76, a sensitivity of 0.88, a specificity of 0.69 with a NPV of 0.90, a PPV of 0.64, with AUC of 0.84., Conclusion: NCCT and ML analysis shows promise in predicting FR after complete recanalization following MT in AIS patients. Larger studies are required to confirm these preliminary results., Competing Interests: Declaration of competing interest The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Despite its prevalence today, the practice of purely performative resuscitation (PPR)-paradigmatically, the "slow code"-has attracted more critics in bioethics than defenders. The most common criticism of the slow code is that it's fundamentally deceptive or harmful, while the most common justification offered is that it may benefit the patient's loved ones, by symbolically honoring the patient or the care team's relationship with the family. I argue that critics and defenders of the slow code each have a point. Advocates of the slow code are right that not all PPR is wrongly deceptive or harmful to the patient or his family and that the symbolic aspect of medicine is itself morally significant. But the critics are also correct: slow codes are prima facie wrong. I argue that pursuing a slow code amounts to treating the patient as a tool for others' benefit-hence, treating him as an object-and that this instrumentalizing quality constitutes one core prima facie wrong of the practice. I also build a case for the idea that the slow code may not always be all-things-considered wrong, specifying certain limited conditions under which acts of PPR might ultimately be permissible. Thus, the symbolic dimension of medical treatment is indeed morally important, both in morally favorable and in morally problematic respects-namely, in its symbolic denial of the patient's humanity., (© 2024 John Wiley & Sons Ltd.)

Background and Purpose: We aimed to investigate the association between critical perfusion delay and poor outcome among recanalized stroke patients with anterior large-vessel occlusion, and to use pretreatment hypoperfusion biomarkers on CT to predict futile recanalization even after successful thrombectomy., Methods: An ischemic region with time-to-maximum (Tmax) > 12s-10s was defined as critical hypoperfusion, Tmax > 8s as moderate hypoperfusion, and hypoperfusion intensity ratio (HIR, volumetric ratio of Tmax > 10s / Tmax > 6s) represented for severity of critical hypoperfusion and rCBF < 30% for ischemic core. The associations between these CT perfusion characteristics and favorable or unfavorable outcome (mRS 0-2 versus 3-6) were analyzed in univariable regression, and a multivariable model was then used to predict futile recanalization., Results: Seventy-nine stroke patients were included and had good grades of instant recanalization. Forty-two patients (53%) had poor outcomes, and they had a significantly larger volume of critical hypoperfusion as seen with Tmax > 10s and > 12s (P = 0.032 and 0.008, respectively), a larger volume of ischemic core (P = 0.011) and a higher HIR (P = 0.002) than those patients achieving good outcomes. In the univariable analysis, a lower HIR (OR, 0.008; 95%CI, 0.001-0.254, P = 0.006) was associated with favorable outcome. The volume size of Tmax > 12s was significantly and positively correlated with the size of ischemic core. A HIR value higher than 0.491 might predict a futile recanalization and poor outcome (AUC = 0.701)., Conclusions: The critical hypoperfusion biomarkers on CTP could be useful in triaging endovascular treatment and identifying stroke patients at risk of futile recanalization., (© 2024. The Author(s).)

Background: Endovascular therapy (EVT) is the treatment of choice for acute ischemic stroke (AIS) with large vessel occlusion. However, in many patients, successful EVT recanalization does not correspond to a clinical improvement, called futile recanalization (FR). We aimed to identify stroke risk factors and patient characteristics associated with FR in AIS with large core infarct (LCI)., Methods: A total of 137 patients with AIS with LCI treated by EVT at a single stroke center were retrospectively included from January 2016 to June 2023. LCI was defined by Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECT) < 6. Patient age, sex, modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), time to treatment, risk factors, and radiologic findings were collected, and potential associations with FR were analyzed. FR was defined as successful reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) ≥ 2b but without functional independence at 90 days (mRS ≥ 3). A multivariate logistic regression analysis was conducted on the clinical characteristics of patients, based on the presence or absence of FR, and the factors influencing FR., Results: Of 137 patients, 120 showed successful recanalization (mTICI ≥ 2b). All patients were divided into FR (n = 80) and no FR (n = 40) groups. Older age (odds ratio [OR] 1.052, 95% confidence interval [CI] 1.002-1.105; p = 0.041), the higher the initial NIHSS score (OR 1.181, 95% CI 1.037-1.344; p = 0.012), and prior intravenous plasminogen activator (OR 0.310, 95% CI 0.118-0.813, p = 0.017) were independent influencing factors of FR., Conclusions: The older age, the higher the initial NIHSS, and not receiving intravenous plasminogen activator were independently associated with FR in AIS with LCI. These factors could identify poor responders to EVT recanalization., (© 2024. The Author(s).)

Background: Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care., Methods: We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors., Results: Of 41,029 patients, 5589 (13.6 ​%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 ​% CI,3.5-26.8, p ​< ​0.001), septic shock (aOR 4.9, 95 ​% CI,4.5-5.4, p ​< ​0.001), and dialysis (aOR 2.1, 95 ​% CI,1.8-2.4, p ​< ​0.001). Without risk factors, mortality rates were 11.9 ​% after colectomy and 10.2 ​% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 ​% and 100 ​% following colectomy and small bowel resection, respectively., Conclusions: In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: There are currently no clinically relevant criteria to predict a futile up-front pancreatectomy in patients with anatomically resectable pancreatic ductal adenocarcinoma., Objectives: To develop a futility risk model using a multi-institutional database and provide unified criteria associated with a futility likelihood below a safety threshold of 20%., Design, Setting, and Participants: This retrospective study took place from January 2010 through December 2021 at 5 high- or very high-volume centers in Italy. Data were analyzed during April 2024. Participants included consecutive patients undergoing up-front pancreatectomy at the participating institutions., Exposure: Standard management, per existing guidelines., Main Outcomes and Measures: The main outcome measure was the rate of futile pancreatectomy, defined as an operation resulting in patient death or disease recurrence within 6 months. Dichotomous criteria were constructed to maintain the futility likelihood below 20%, corresponding to the chance of not receiving postneoadjuvant resection from existing pooled data., Results: This study included 1426 patients. The median age was 69 (interquartile range, 62-75) years, 759 patients were male (53.2%), and 1076 had head cancer (75.4%). The rate of adjuvant treatment receipt was 73.7%. For the model construction, the study sample was split into a derivation (n = 885) and a validation cohort (n = 541). The rate of futile pancreatectomy was 18.9% (19.2% in the development and 18.6% in the validation cohort). Preoperative variables associated with futile resection were American Society of Anesthesiologists class (95% CI for coefficients, 0.68-0.87), cancer antigen (CA) 19.9 serum levels (95% CI, for coefficients 0.05-0.75), and tumor size (95% CI for coefficients, 0.28-0.46). Three risk groups associated with an escalating likelihood of futile resection, worse pathological features, and worse outcomes were identified. Four discrete conditions (defined as CA 19.9 levels-adjusted-to-size criteria: tumor size less than 2 cm with CA 19.9 levels less than 1000 U/mL; tumor size less than 3 cm with CA 19.9 levels less than 500 U/mL; tumor size less than 4 cm with CA 19.9 levels less than 150 U/mL; and tumor size less than 5 cm with CA 19.9 levels less than 50 U/mL) were associated with a futility likelihood below 20%. Both disease-free survival and overall survival were significantly longer in patients fulfilling the criteria., Conclusions and Relevance: In this study, a preoperative model (MetroPancreas) and dichotomous criteria to determine the risk of futile pancreatectomy were developed. This might help in selecting patients for up-front resection or neoadjuvant therapy.

Background: Despite the progress made in recent decades on the phenomenon of futility in adult intensive care, recognizing it during clinical care practice remains a complex and sensitive process, during which questions are often raised for which concrete answers are difficult to find. Aims: To analyze the frequency with which futile nursing interventions are implemented in critically ill patients admitted to adult intensive care in specific situations and how often futile autonomous and interdependent nursing interventions are implemented in the same population, as perceived by adult intensive care nurses. Research design: Cross-sectional, quantitative, and descriptive study, which employed a questionnaire constructed specifically for this research to assess the perception of therapeutic futility in nursing in adult intensive care. Following an evaluation of the psychometric properties, the questionnaire was made available in an electronic format on the EUSurvey platform between August and October 2024. The data was analyzed between November 2023 and March 2024 using the statistical software packages SPSS and R. Participants and research context: A simple random sample of nurses working in level II and level III intensive care units in Portugal. Ethical considerations: Research ethical approvals were obtained, and the participants provided informed consent. Findings/results: Four hundred and fourteen valid questionnaires were obtained. The results allow the identification of thirty-three statistically significant associations, the inference of intervals for the mean and median for the perception of futility of nursing interventions with a 95% confidence interval, and enable the hierarchization of nursing interventions implemented in critically ill patients admitted to adult intensive care units according to the nurses' perception of their futility. Conclusion: There is a balance in nurses' perception of the futility of their interventions in the specific situations analyzed. There is statistically significant evidence that interdependent nursing interventions are, in general, more frequently perceived as futile when compared to autonomous nursing interventions., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Avoiding futile treatment for patients at the end of life is among one of the care challenges of nurses in intensive care units (ICUs)., Aims: This study aimed to determine the attitude of intensive care unit nurses toward futile treatment and its relationship with missed care for patients at the end of life., Method: This cross-sectional study was conducted on 307 ICU nurses. Eleven teaching hospitals were selected from three Iranian provinces, Zanjan Province, East Azerbaijan and West Azerbaijan, in 2021. The data were collected using The Attitudes Toward Futile Treatment Scale (ATFTS) and The Missed Nursing Care Survey (MISSCARE Survey) as self-reports., Results: According to the obtained results, 94.8% of the nurses agreed that futile treatment should not be performed. However, 97.7% of the nurses reported that missed care occurs less for patients at the end of life. The correlation between the MISSCARE Survey's total scale and the ATFTS's total scale was positive and statistically significant (r =.11)., Conclusion: This research contributes to understanding nurses' attitudes toward futile treatment. Nurses oppose futile treatment, so obstacles to avoiding it should be eliminated. This attitude does not have a significant impact on nursing care quality or missed care for patients at the end of life, but it can lead to enduring distress for nurses. It is recommended to study the reasons for futile treatment, and its link to nurses' mental and physical health.

Introduction: The arbitrary geriatric age cutoff of 65 may not accurately define older adults at higher risk of mortality following massive transfusion (MT). We sought to redefine a new geriatric age threshold for MT and understand its association with outcomes., Material and Methods: The 2013-2018 Trauma Quality Improvement Program database was queried for all adults who received ≥10 units of packed red blood cells (pRBCs) within 24 h of admission. A bootstrap analysis using multiple logistic regression established transfusion futility thresholds (TTs), where additional pRBCs no longer improved mortality for various age cutoffs. The age cutoff at which the TT for those relatively older and relatively younger was statistically significant was used to define the new "geriatric" age for MT. Outcomes were then compared between the newly defined geriatric and nongeriatric patients., Results: The difference in TT first became significant when the age cutoff was 63 y. The TT for patients aged ≥63 y (new geriatric, n = 2870) versus <63 y (nongeriatric, n = 17,302) was 34 and 40 units of pRBCs, respectively (P = 0.04). Although geriatric patients had a higher Glasgow coma scale score (9 versus 6, P < 0.01) and lower abbreviated injury score-abdomen (3 versus 4, P < 0.01) than the nongeriatric, they suffered higher overall mortality (62% versus 45%, P < 0.01). A lower percentage of geriatric patients were discharged to home (7% versus 35%, P < 0.01)., Conclusions: The new geriatric age for MT is 63 y, with a TT of 34 units. Despite suffering less severe injuries, physiologically "geriatric" patients have worse outcomes following MT., (Copyright © 2024 Elsevier Inc. All rights reserved.)