今日の臨床サポート

集中治療における倫理

著者: 鍋島正慶 東京ベイ・浦安市川医療センター 救急集中治療科 集中治療部門

著者: 則末泰博 東京ベイ・浦安市川医療センター 救急集中治療科 集中治療部門

監修: 藤谷茂樹 聖マリアンナ医科大学 救急医学

著者校正/監修レビュー済:2020/07/30
参考ガイドライン:
  1. 厚⽣労働省 人生の最終段階における医療の普及・啓発の在り方に関する検討会編:人生の最終段階における医療・ケアの決定プロセスに関するガイドライン 解説編(改訂 平成30年3⽉)、2018:0-6.
  1. 日本集中治療医学会日本救急医学会日本循環器学会編:救急・集中治療における終末期医療に関するガイドライン ~3学会からの提⾔~、2014:1-4.
  1. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med. 2015 Jun 1;191(11):1318-30.
  1. 日本集中治療医学会倫理委員会:DNAR(Do Not Attempt Resuscitation)の考え方. 日集中医誌 2017; 24: 210-215.
  1. 日本小児科学会、倫理委員会小児終末期医療ガイドラインワーキンググループ:重篤な疾患を持つ子どもの医療をめぐる話し合いのガイドライン. 2012.
  1. 宗教的輸血拒否に関する合同委員会:宗教的輸血拒否に関するガイドライン. 宗教的輸血拒否に関する合同委員会報告. 2008: 1-7.

概要・推奨   

  1. 治療方針の不一致があった場合、法的、倫理的、社会的な対立や医学的解釈の違いがないかを考えることが推奨される。
  1. 終末期の治療方針の決定には、共有意思決定を前提とし、主治医だけでなく医療チームによって十分な話し合いを行い、その経過を文章にまとめておくことが推奨される。
  1. 本人に意思決定能力がある場合や推定意思が確認できる場合には、本人の意向に沿った治療方針が推奨される。小児においても同様のことが推奨される。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
鍋島正慶 : 特に申告事項無し[2021年]
則末泰博 : 特に申告事項無し[2021年]
監修:藤谷茂樹 : 特に申告事項無し[2021年]

病態・疫学・診察

はじめに  
  1. 医療従事者-患者(家族)間、医療従事者間などで時に治療方針をめぐっての意見の不一致を抱えることがある[1][2][3]
  1. 集中治療領域においては、以下のような複数の要因が起きやすく、患者(家族)、医療従事者ともにジレンマを抱えやすい。
  1. 患者の意思を確認することが難しいこと
  1. 発症が突然であり現状を受け入れる精神的余裕が失われ、また信頼関係を築く時間がないこと
  1. 診断や治療、予後に対する不確実性が多いこと
  1. 重症であるがゆえに治療方針などの決定までの時間的猶予がないこと
  1. 医療技術の進歩、治療と終末期治療を同時に進めていかなければいけない複雑性
  1. 超高齢化社会に伴う複数の基礎疾患をもつ患者の増加
  1. 核家族化や単独世帯の増加などで本人の事前指示や本人の意向を推定することが困難であること
  1. 生死に関わる重大な決定となるため患者(家族)が決定を下しにくいこと
  1. 倫理的苦悩はICUの医療従事者のメンタルヘルスを害す原因となり、バーンアウト症候群の一因となりうる[4][5]
医療倫理の四原則・臨床倫理の四分割表  
  1. ビーチャムとチルドレスが『生命医学倫理の諸原則』で提唱した医療倫理の四原則は、医療従事者が倫理的な問題に直面した時に、どのように解決すべきかを判断する指針となっている[6]
  1. 四原則とは、「自律Autonomy」、「善行Beneficence」、「無危害Non-maleficence」、「公正Justice」である。

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文献 

著者: J Randall Curtis, Jean-Louis Vincent
雑誌名: Lancet. 2010 Oct 16;376(9749):1347-53. doi: 10.1016/S0140-6736(10)60143-2. Epub 2010 Oct 11.
Abstract/Text The intensive care unit (ICU) is where patients are given some of the most technologically advanced life-sustaining treatments, and where difficult decisions are made about the usefulness of such treatments. The substantial regional variability in these ethical decisions is a result of many factors, including religious and cultural beliefs. Because most critically ill patients lack the capacity to make decisions, family and other individuals often act as the surrogate decision makers, and in many regions communication between the clinician and family is central to decision making in the ICU. Elsewhere, involvement of the family is reduced and that of the physicians is increased. End-of-life care is associated with increased burnout and distress among clinicians working in the ICU. Since many deaths in the ICU are preceded by a decision to withhold or withdraw life support, high-quality decision making and end-of-life care are essential in all regions, and can improve patient and family outcomes, and also retention of clinicians working in the ICU. To make such a decision requires adequate training, good communication between the clinician and family, and the collaboration of a well functioning interdisciplinary team.

Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID 20934213  Lancet. 2010 Oct 16;376(9749):1347-53. doi: 10.1016/S01・・・
著者: Jae Young Moon, Ju-Ock Kim
雑誌名: Tuberc Respir Dis (Seoul). 2015 Jul;78(3):175-9. doi: 10.4046/trd.2015.78.3.175. Epub 2015 Jun 30.
Abstract/Text The intensive care unit (ICU) is the most common place to die. Also, ethical conflicts among stakeholders occur frequently in the ICU. Thus, ICU clinicians should be competent in all aspects for ethical decision-making. Major sources of conflicts are behavioral issues, such as verbal abuse or poor communication between physicians and nurses, and end-of-life care issues including a lack of respect for the patient's autonomy. The ethical conflicts are significantly associated with the job strain and burn-out syndrome of healthcare workers, and consequently, may threaten the quality of care. To improve the quality of care, handling ethical conflicts properly is emerging as a vital and more comprehensive area. The ICU physicians themselves need to be more sensitive to behavioral conflicts and enable shared decision making in end-of-life care. At the same time, the institutions and administrators should develop their processes to find and resolve common ethical problems in their ICUs.

PMID 26175769  Tuberc Respir Dis (Seoul). 2015 Jul;78(3):175-9. doi: 1・・・
著者: Jonathan R Gavrin
雑誌名: Crit Care Med. 2007 Feb;35(2 Suppl):S85-94. doi: 10.1097/01.CCM.0000252909.52316.27.
Abstract/Text Intensive care units (ICUs) confront the healthcare system with end-of-life situations and ethical dilemmas surrounding death. It is necessary for all providers who treat dying patients to have a working knowledge of the philosophical principles that are fundamental to biomedical ethics. Those principles, however, are insufficient for compassionate care. To function well in the intensive care unit, one also must appreciate the behaviors that surround mortality. Human conduct is not predicated solely on rules; complex, unpredictable interactions are the norm. Palliative care, moving forward as a discipline, will become the perfect complement to intensive medical care, rather than being seen as an embodiment of its failures. We need to be as aggressive about respecting patient dignity as we are about using the technology that is central to health care. This article will outline end-of-life ethical principles, explore the sociology that influences human interactions in intensive care units, and show how palliative care should guide behaviors to improve how we deal with death.

PMID 17242609  Crit Care Med. 2007 Feb;35(2 Suppl):S85-94. doi: 10.109・・・
著者: Marc Moss, Vicki S Good, David Gozal, Ruth Kleinpell, Curtis N Sessler
雑誌名: Am J Crit Care. 2016 Jul;25(4):368-76. doi: 10.4037/ajcc2016133.
Abstract/Text Burnout syndrome (BOS) occurs in all types of health care professionals and is especially common in individuals who care for critically ill patients. The development of BOS is related to an imbalance of personal characteristics of the employee and work-related issues or other organizational factors. BOS is associated with many deleterious consequences, including increased rates of job turnover, reduced patient satisfaction, and decreased quality of care. BOS also directly affects the mental health and physical well-being of the many critical care physicians, nurses, and other health care professionals who practice worldwide. Until recently, BOS and other psychological disorders in critical care health care professionals remained relatively unrecognized. To raise awareness of BOS, the Critical Care Societies Collaborative (CCSC) developed this call to action. The present article reviews the diagnostic criteria, prevalence, causative factors, and consequences of BOS. It also discusses potential interventions that may be used to prevent and treat BOS. Finally, we urge multiple stakeholders to help mitigate the development of BOS in critical care health care professionals and diminish the harmful consequences of BOS, both for critical care health care professionals and for patients.

©2016 American Association of Critical-Care Nurses.
PMID 27369038  Am J Crit Care. 2016 Jul;25(4):368-76. doi: 10.4037/ajc・・・
著者: Christiane S Hartog, Konrad Reinhart
雑誌名: Curr Opin Anaesthesiol. 2018 Apr;31(2):195-200. doi: 10.1097/ACO.0000000000000557.
Abstract/Text PURPOSE OF REVIEW: End-of-life (EOL) care can be stressful for clinicians as well as patients and their relatives. Decisions to withhold or withdraw life-sustaining therapy vary widely depending on culture, beliefs and organizational norms. The following review will describe the current understanding of the problem and give an overview over interventional studies.
RECENT FINDINGS: EOL care is a risk factor for clinician burnout; poor work conditions contribute to emotional exhaustion and intent to leave. The impact of EOL care on families is part of the acute Family Intensive Care Unit Syndrome (FICUS) and the Post Intensive Care Syndrome-Family (PICS-F). Family-centered care (FCC) acknowledges the importance of relatives in the ICU. Several interventions have been evaluated, but evidence for their effectiveness is at best moderate. Some interventions even increased family stress. Interventional studies, which address clinician burnout are rare.
SUMMARY: EOL care is associated with negative outcomes for ICU clinicians and relatives, but strength of evidence for interventions is weak because we lack understanding of associated factors like work conditions, organizational issues or individual attitudes. In order to develop complex interventions that can successfully mitigate stress related to EOL care, more research is necessary, which takes into account all potential determinants.

PMID 29493551  Curr Opin Anaesthesiol. 2018 Apr;31(2):195-200. doi: 10・・・
著者: Lee Daugherty Biddison, Kenneth A Berkowitz, Brooke Courtney, Col Marla J De Jong, Asha V Devereaux, Niranjan Kissoon, Beth E Roxland, Charles L Sprung, Jeffrey R Dichter, Michael D Christian, Tia Powell, Task Force for Mass Critical Care, Task Force for Mass Critical Care
雑誌名: Chest. 2014 Oct;146(4 Suppl):e145S-55S. doi: 10.1378/chest.14-0742.
Abstract/Text BACKGROUND: Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients' vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.
METHODS: We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.
RESULTS: We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns.
CONCLUSIONS: Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide health-care decisions during disasters.

PMID 25144262  Chest. 2014 Oct;146(4 Suppl):e145S-55S. doi: 10.1378/ch・・・
著者: Ezekiel J Emanuel, Govind Persad, Ross Upshur, Beatriz Thome, Michael Parker, Aaron Glickman, Cathy Zhang, Connor Boyle, Maxwell Smith, James P Phillips
雑誌名: N Engl J Med. 2020 May 21;382(21):2049-2055. doi: 10.1056/NEJMsb2005114. Epub 2020 Mar 23.
Abstract/Text
PMID 32202722  N Engl J Med. 2020 May 21;382(21):2049-2055. doi: 10.10・・・
著者: Govind Persad, Alan Wertheimer, Ezekiel J Emanuel
雑誌名: Lancet. 2009 Jan 31;373(9661):423-31. doi: 10.1016/S0140-6736(09)60137-9.
Abstract/Text Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system-the complete lives system-which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

PMID 19186274  Lancet. 2009 Jan 31;373(9661):423-31. doi: 10.1016/S014・・・
著者: Timothy E Quill, Robert Arnold, Anthony L Back
雑誌名: Ann Intern Med. 2009 Sep 1;151(5):345-9. doi: 10.7326/0003-4819-151-5-200909010-00010.
Abstract/Text When asked about setting limits on medical treatment in the face of severe illness, patients and their families often respond that they want "everything." Clinicians should not take this request at face value, but should instead use it as the basis for a broader discussion about what "doing everything" means to the patient. The discussion might include questions about what balances of treatment burden and benefit the patient can tolerate and about emotional, cognitive, spiritual, and family factors that underlie the request. After this initial exploration, the clinician can propose a philosophy of treatment and make recommendations that capture the patient's values and preferences in light of the medical condition. Clinicians should respond to emotional reactions, directly negotiate disagreements, and use harm-reduction strategies for the relatively infrequent instances in which patients continue to request burdensome therapy that is unlikely to help. By using this approach, patients, families, and clinicians will be better able to understand each other and join together to develop a treatment approach that best respects patient and family values in light of what is medically achievable.

PMID 19721022  Ann Intern Med. 2009 Sep 1;151(5):345-9. doi: 10.7326/0・・・
著者: Scott A Murray, Marilyn Kendall, Kirsty Boyd, Aziz Sheikh
雑誌名: BMJ. 2005 Apr 30;330(7498):1007-11. doi: 10.1136/bmj.330.7498.1007.
Abstract/Text
PMID 15860828  BMJ. 2005 Apr 30;330(7498):1007-11. doi: 10.1136/bmj.33・・・
著者: Shelley R Salpeter, Esther J Luo, Dawn S Malter, Brad Stuart
雑誌名: Am J Med. 2012 May;125(5):512.e1-6. doi: 10.1016/j.amjmed.2011.07.028. Epub 2011 Oct 24.
Abstract/Text PURPOSE: We report on clinical indicators of 6-month mortality in advanced noncancer illnesses and the effect of treatment on survival.
METHODS: The MEDLINE database was searched comprehensively to find studies evaluating survival for common advanced noncancer illnesses. We retrieved and evaluated studies that reported a median survival of ≤1 year and evaluated prognostic factors or effect of treatment on survival. We extracted data on presentations with median survivals of ≤6 months for heart failure, chronic obstructive pulmonary disease, dementia, geriatric failure to thrive, cirrhosis, and end-stage renal failure. Independent risk factors for survival were combined and included if their combination was associated with a 6-month mortality of ≥50%.
RESULTS: The search identified 1000 potentially relevant studies, of which 475 were retrieved and evaluated, and 74 were included. We report the common clinical presentations that are consistently associated with a 6-month median survival. Even though advanced noncancer syndromes differ clinically, a universal set of prognostic factors signals progression to terminal disease, including poor performance status, advanced age, malnutrition, comorbid illness, organ dysfunction, and hospitalization for acute decompensation. Generally, a 6-month median survival is associated with the presence of 2-4 of these factors. With few exceptions, these terminal presentations are quite refractory to treatment.
CONCLUSION: This systematic review summarizes prognostic factors common to advanced noncancer illness. There is little evidence at present that treatment prolongs survival at these terminal stages.

Copyright © 2012 Elsevier Inc. All rights reserved.
PMID 22030293  Am J Med. 2012 May;125(5):512.e1-6. doi: 10.1016/j.amjm・・・
著者: Meghan A Brown, Elizabeth L Sampson, Louise Jones, Anna M Barron
雑誌名: Palliat Med. 2013 May;27(5):389-400. doi: 10.1177/0269216312465649. Epub 2012 Nov 22.
Abstract/Text BACKGROUND: For end-of-life dementia patients, palliative care offers a better quality of life than continued aggressive or burdensome medical interventions. To provide the best care options to dementia sufferers, validated, reliable, sensitive, and accurate prognostic tools to identify end-of-life dementia stages are necessary.
AIM: To identify accurate prognosticators of mortality in elderly advanced dementia patients consistently reported in the literature.
DESIGN: Systematic literature review.
DATA SOURCES: PubMed, Embase, and PsycINFO databases were searched up to September 2012. Reference lists of included studies were also searched. Inclusion criteria were studies measuring factors specifically related to 6-month outcome in patients diagnosed with dementia in any residential or health-care setting.
RESULTS: Seven studies met the inclusion criteria, five of which were set in the United States and two in Israel. Methodology and prognostic outcomes varied greatly between the studies. All but one study found that Functional Assessment Staging phase 7c, currently widely used to assess hospice admission eligibility in the United States, was not a reliable predictor of 6-month mortality. The most common prognostic variables identified related to nutrition/nourishment, or eating habits, followed by increased risk on dementia severity scales and comorbidities.
CONCLUSIONS: Although the majority of studies agreed that the Functional Assessment Staging 7c criterion was not a reliable predictor of 6-month mortality, we found a lack of prognosticator concordance across the literature. Further studies are essential to identify reliable, sensitive, and specific prognosticators, which can be applied to the clinical setting and allow increased availability of palliative care to dementia patients.

PMID 23175514  Palliat Med. 2013 May;27(5):389-400. doi: 10.1177/02692・・・
著者: Grant V Chow, Matthew J Czarny, Mark T Hughes, Joseph A Carrese
雑誌名: Chest. 2010 Feb;137(2):421-7. doi: 10.1378/chest.09-1133.
Abstract/Text The evaluation of medical decision-making capacity and provision of emergency treatment in the acute care setting may present a significant challenge for both physicians-in-training and attending physicians. Although absolutely essential to the proper care of patients, recalling criteria for decision-making capacity may prove cumbersome during a medical emergency. Likewise, the requirements for providing emergency treatment must be fulfilled. This article presents a mnemonic (CURVES: Choose and Communicate, Understand, Reason, Value, Emergency, Surrogate) that addresses the abilities a patient must possess in order to have decision-making capacity, as well as the essentials of emergency treatment. It may be used in conjunction with, or in place of, lengthier capacity-assessment tools, particularly when time is of the essence. In addition, the proposed tool assists the practitioner in deciding whether emergency treatment may be administered, and in documenting medical decisions made during an acute event.

PMID 20133288  Chest. 2010 Feb;137(2):421-7. doi: 10.1378/chest.09-113・・・
著者: Laura L Sessums, Hanna Zembrzuska, Jeffrey L Jackson
雑誌名: JAMA. 2011 Jul 27;306(4):420-7. doi: 10.1001/jama.2011.1023.
Abstract/Text CONTEXT: Evaluation of the capacity of a patient to make medical decisions should occur in the context of specific medical decisions when incapacity is considered.
OBJECTIVE: To determine the prevalence of incapacity and assessment accuracy in adult medicine patients without severe mental illnesses.
DATA SOURCES: MEDLINE and EMBASE (from their inception through April 2011) and bibliographies of retrieved articles.
STUDY SELECTION: We included high-quality prospective studies (n = 43) of instruments that evaluated medical decision-making capacity for treatment decisions.
DATA EXTRACTION: Two authors independently appraised study quality, extracted relevant data, and resolved disagreements by consensus.
DATA SYNTHESIS: Incapacity was uncommon in healthy elderly control participants (2.8%; 95% confidence interval [CI], 1.7%-3.9%) compared with medicine inpatients (26%; 95% CI, 18%-35%). Clinicians accurately diagnosed incapacity (positive likelihood ratio [LR+] of 7.9; 95% CI, 2.7-13), although they recognized it in only 42% (95% CI, 30%-53%) of affected patients. Although not designed to assess incapacity, Mini-Mental State Examination (MMSE) scores less than 20 increased the likelihood of incapacity (LR, 6.3; 95% CI, 3.7-11), scores of 20 to 24 had no effect (LR, 0.87; 95% CI, 0.53-1.2), and scores greater than 24 significantly lowered the likelihood of incapacity (LR, 0.14; 95% CI, 0.06-0.34). Of 9 instruments compared with a gold standard, only 3 are easily performed and have useful test characteristics: the Aid to Capacity Evaluation (ACE) (LR+, 8.5; 95% CI, 3.9-19; negative LR [LR-], 0.21; 95% CI, 0.11-0.41), the Hopkins Competency Assessment Test (LR+, 54; 95% CI, 3.5-846; LR-, 0; 95% CI, 0.0-0.52), and the Understanding Treatment Disclosure (LR+, 6.0; 95% CI, 2.1-17; LR-, 0.16; 95% CI, 0.06-0.41). The ACE was validated in the largest study; it is freely available online and includes a training module.
CONCLUSIONS: Incapacity is common and often not recognized. The MMSE is useful only at extreme scores. The ACE is the best available instrument to assist physicians in making assessments of medical decision-making capacity.

PMID 21791691  JAMA. 2011 Jul 27;306(4):420-7. doi: 10.1001/jama.2011.・・・
著者: Gabriel T Bosslet, Thaddeus M Pope, Gordon D Rubenfeld, Bernard Lo, Robert D Truog, Cynda H Rushton, J Randall Curtis, Dee W Ford, Molly Osborne, Cheryl Misak, David H Au, Elie Azoulay, Baruch Brody, Brenda G Fahy, Jesse B Hall, Jozef Kesecioglu, Alexander A Kon, Kathleen O Lindell, Douglas B White, American Thoracic Society ad hoc Committee on Futile and Potentially Inappropriate Treatment, American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, Society of Critical Care
雑誌名: Am J Respir Crit Care Med. 2015 Jun 1;191(11):1318-30. doi: 10.1164/rccm.201505-0924ST.
Abstract/Text BACKGROUND: There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered.
PURPOSE: This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units.
METHODS: The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care).
MAIN RESULTS: The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term "potentially inappropriate" should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan they believe is appropriate. Conflicts regarding potentially inappropriate treatments that remain intractable despite intensive communication and negotiation should be managed by a fair process of conflict resolution; this process should include hospital review, attempts to find a willing provider at another institution, and opportunity for external review of decisions. When time pressures make it infeasible to complete all steps of the conflict-resolution process and clinicians have a high degree of certainty that the requested treatment is outside accepted practice, they should seek procedural oversight to the extent allowed by the clinical situation and need not provide the requested treatment. (3) Use of the term "futile" should be restricted to the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal. Clinicians should not provide futile interventions. (4) The medical profession should lead public engagement efforts and advocate for policies and legislation about when life-prolonging technologies should not be used.
CONCLUSIONS: The multisociety statement on responding to requests for potentially inappropriate treatments in intensive care units provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.

PMID 25978438  Am J Respir Crit Care Med. 2015 Jun 1;191(11):1318-30. ・・・
著者: Deborah Cook, Graeme Rocker
雑誌名: N Engl J Med. 2014 Jun 26;370(26):2506-14. doi: 10.1056/NEJMra1208795.
Abstract/Text
PMID 24963569  N Engl J Med. 2014 Jun 26;370(26):2506-14. doi: 10.1056・・・
著者: Timothy E Quill, Robert Holloway
雑誌名: JAMA. 2011 Oct 5;306(13):1483-4. doi: 10.1001/jama.2011.1413.
Abstract/Text
PMID 21972312  JAMA. 2011 Oct 5;306(13):1483-4. doi: 10.1001/jama.2011・・・
著者: Eva E Vink, Elie Azoulay, Arthur Caplan, Erwin J O Kompanje, Jan Bakker
雑誌名: Intensive Care Med. 2018 Sep;44(9):1369-1377. doi: 10.1007/s00134-018-5339-x. Epub 2018 Aug 22.
Abstract/Text In critically ill patients, it is frequently challenging to identify who will benefit from admission to the intensive care unit and life-sustaining interventions when the chances of a meaningful outcome are unclear. In addition, the acute illness not only affects the patients but also family members or surrogates who often are overwhelmed and unable to make thoughtful decisions. In these circumstances, a time-limited trial (TLT) of intensive care treatment can be helpful. A TLT is an agreement to initiate all necessary treatments or treatments with clearly delineated limitations for a certain period of time to gain a more realistic understanding of the patient's chances of a meaningful recovery or to ascertain the patient's wishes and values. In this article, we discuss current research on different aspects of TLTs in the intensive care unit. We propose how and when to use TLTs, discuss how much time should be taken for a TLT, give an overview of the potential impact of TLTs on healthcare resources, describe ethical challenges concerning TLTs, and discuss how to evaluate a TLT.

PMID 30136140  Intensive Care Med. 2018 Sep;44(9):1369-1377. doi: 10.1・・・
樋口範雄編:C-2. 生命維持治療の差し控え、中止、医の倫理の基礎知識 2018年版、日本医師会、2018.
著者: Charles L Sprung, Fathima Paruk, Niranjan Kissoon, Christiane S Hartog, Jeffrey Lipman, Bin Du, Andrew Argent, R Eric Hodgson, Bertrand Guidet, A B Johan Groeneveld, Charles Feldman
雑誌名: J Crit Care. 2014 Dec;29(6):890-5. doi: 10.1016/j.jcrc.2014.06.022. Epub 2014 Jun 30.
Abstract/Text INTRODUCTION: Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees.
METHODS: Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared.
RESULTS: Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent.
CONCLUSIONS: Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.

Copyright © 2014 Elsevier Inc. All rights reserved.
PMID 25151218  J Crit Care. 2014 Dec;29(6):890-5. doi: 10.1016/j.jcrc.・・・
著者: So Young Park, Jason Phua, Masaji Nishimura, Yiyun Deng, Yan Kang, Keiichi Tada, Younsuck Koh, Asian Collaboration for Medical Ethics (ACME) Study Collaborators and the Asian Critical Care Clinical Trials (ACCCT) Group
雑誌名: Crit Care Med. 2018 Jul;46(7):1114-1124. doi: 10.1097/CCM.0000000000003138.
Abstract/Text OBJECTIVES: To compare physicians' perceptions and practice of end-of-life care in the ICU in three East Asian countries cultures similarly rooted in Confucianism.
DESIGN: A structured and scenario-based survey of physicians who managed ICU patients from May 2012 to December 2012.
SETTING: ICUs in China, Korea, and Japan.
SUBJECTS: Specialists who are either intensivists or nonintensivist primary attending physicians in charge of patients (195 in China, 186 in Korea, 224 in Japan).
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Country was independently associated with differences in the practice of limiting multiple forms of life-sustaining treatments on multivariable generalized linear model analysis. Chinese respondents were least likely to apply do-not-resuscitate orders, even if they existed (p < 0.001). Japanese respondents were most likely to practice do not resuscitate for terminally ill patients during cardiac arrest, even when no such prior order existed (p < 0.001). Korean respondents' attitudes were in between those of Chinese and Japanese respondents as far as withdrawing total parenteral nutrition, antibiotics, dialysis, and suctioning was concerned. Chinese respondents were most uncomfortable discussing end-of-life care issues with patients, while Japanese respondents were least uncomfortable (p < 0.001). Chinese respondents were more likely to consider financial burden when deciding on limiting life-sustaining treatment (p < 0.001). Japanese respondents felt least exposed to personal legal risks when limiting life-sustaining treatment (p < 0.001), and the Korean respondents most wanted legislation to guide this issue (p < 0.001). The respondents' gender, religion, clinical experience, and primary specialty were also independently associated with the different perceptions of end-of-life care.
CONCLUSIONS: Despite similarities in cultures and a common emphasis on the role of family, differences exist in physician perceptions and practices of end-of-life ICU care in China, Korea, and Japan. These findings may be due to differences in the degree of Westernization, national healthcare systems, economic status, and legal climate.

PMID 29629982  Crit Care Med. 2018 Jul;46(7):1114-1124. doi: 10.1097/C・・・
著者: Alexander A Kon, Eric K Shepard, Nneka O Sederstrom, Sandra M Swoboda, Mary Faith Marshall, Barbara Birriel, Fred Rincon
雑誌名: Crit Care Med. 2016 Sep;44(9):1769-74. doi: 10.1097/CCM.0000000000001965.
Abstract/Text OBJECTIVES: The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units) provides examples of potentially inappropriate treatments; however, no clear definition is provided. This statement was developed to provide a clear definition of inappropriate interventions in the ICU environment.
DESIGN: A subcommittee of the Society of Critical Care Medicine Ethics Committee performed a systematic review of empirical research published in peer-reviewed journals as well as professional organization position statements to generate recommendations. Recommendations approved by consensus of the full Society of Critical Care Medicine Ethics Committees and the Society of Critical Care Medicine Council were included in the statement.
MEASUREMENTS AND MAIN RESULTS: ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient's neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. This definition should not be considered exhaustive; there will be cases in which life-prolonging interventions may reasonably be considered inappropriate even when the patient would survive outside the acute care setting with sufficient cognitive ability to perceive the benefits of treatment. When patients or surrogate decision makers demand interventions that the clinician believes are potentially inappropriate, the seven-step process presented in the multiorganization statement should be followed. Clinicians should recognize the limits of prognostication when evaluating potential neurologic outcome and terminal cases. At times, it may be appropriate to provide time-limited ICU interventions to patients if doing so furthers the patient's reasonable goals of care. If the patient is experiencing pain or suffering, treatment to relieve pain and suffering is always appropriate.
CONCLUSIONS: The Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement. This statement provides added guidance to clinicians in the ICU environment.

PMID 27525995  Crit Care Med. 2016 Sep;44(9):1769-74. doi: 10.1097/CCM・・・
著者: Lawrence J Schneiderman
雑誌名: J Bioeth Inq. 2011 Jun;8(2):123-131. doi: 10.1007/s11673-011-9293-3. Epub 2011 Mar 20.
Abstract/Text It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word "to suffer") is a person who seeks the healing (meaning "to make whole") powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions-comfort care-the physician's obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life.

PMID 21765643  J Bioeth Inq. 2011 Jun;8(2):123-131. doi: 10.1007/s1167・・・
著者: Bertrand Guidet, Eric Hodgson, Charles Feldman, Fathima Paruk, Jeffrey Lipman, Younsuck Koh, Jean Louis Vincent, Elie Azoulay, Charles L Sprung
雑誌名: J Crit Care. 2014 Dec;29(6):896-901. doi: 10.1016/j.jcrc.2014.08.004. Epub 2014 Aug 10.
Abstract/Text INTRODUCTION: Life-sustaining treatment (LST) limitation for elderly patients is highly controversial. In that context, it is useful to evaluate the attitudes to LST in the elderly among experienced intensive care unit (ICU) physicians with different backgrounds and cultures.
METHODS: A panel of 22 international ICU physicians from 13 countries responded to a questionnaire related to withholding (WH) and withdrawing (WD) LST in elderly patients using a semi-Likert scale.
RESULTS: Most experts disagree or strongly disagree (77%) that age should be used as the sole criterion for WH or WD LST, and almost all disagree (91%) that there should be a specific age for such decision making. However, the vast majority (91%) acknowledge that age should be an important consideration in conjunction with other factors. Disagreement for consideration of prioritizing the young over the old in normal ICU operations was reported in 68%, whereas in an emergency triage situation, disagreement dropped to 18%.
CONCLUSIONS: There is a consensus among ICU physicians that age cannot be the sole criterion on which health care decisions should be made. In that perspective, it is important to provide data showing that outcome differences between elderly and nonelderly patients are partly related to decisions to forgo LSTs.

Copyright © 2014 Elsevier Inc. All rights reserved.
PMID 25216948  J Crit Care. 2014 Dec;29(6):896-901. doi: 10.1016/j.jcr・・・
著者: Donald R Sullivan, Christopher G Slatore
雑誌名: Ann Am Thorac Soc. 2015 Oct;12(10):1432-3. doi: 10.1513/AnnalsATS.201508-488ED.
Abstract/Text
PMID 26448348  Ann Am Thorac Soc. 2015 Oct;12(10):1432-3. doi: 10.1513・・・
著者: Jared Chiarchiaro, Praewpannarai Buddadhumaruk, Robert M Arnold, Douglas B White
雑誌名: Ann Am Thorac Soc. 2015 Oct;12(10):1528-33. doi: 10.1513/AnnalsATS.201504-253OC.
Abstract/Text RATIONALE: Although numerous studies have documented that family members in intensive care units struggle with end-of-life decisions for incapacitated patients, there is little information about whether prior advance care planning lessens the burden of decision making.
OBJECTIVES: We sought to measure decisional conflict in surrogates of critically ill patients and to examine whether prior advance care planning is associated with less decisional conflict.
METHODS: We performed a secondary data analysis of a multicenter, prospective cohort study done at five U.S. academic medical centers that included 471 surrogates of 257 patients with acute respiratory distress syndrome. The main outcome was surrogates' burden of decision making as measured using the Decisional Conflict Scale. Surrogates completed a questionnaire item addressing whether they had had any prior advance care planning conversations with their loved ones. We used multilevel linear regression modeling to measure the association between decisional conflict and advance care planning.
MEASUREMENTS AND MAIN RESULTS: Moderate or high levels of decisional conflict (Decisional Conflict Scale score≥25) were present in 48% of surrogates. After adjusting for potential confounders, surrogates who had engaged in prior advance care planning conversations had significantly lower levels of decisional conflict than those who had not (mean score 3.3 points lower on the Decisional Conflict Scale; 95% confidence interval, -6.4 to -0.2; P=0.03).
CONCLUSIONS: Nearly half of surrogates for critically ill patients have moderate or high levels of decisional conflict. Prior advance care planning was associated with less decisional conflict. These results suggest that the scope of the benefit of advance care planning may extend beyond respecting patients' wishes to also ameliorating the burden on patients' loved ones who act as surrogates.

PMID 26240996  Ann Am Thorac Soc. 2015 Oct;12(10):1528-33. doi: 10.151・・・
著者: Kei Ouchi, Naomi George, Jeremiah D Schuur, Emily L Aaronson, Charlotta Lindvall, Edward Bernstein, Rebecca L Sudore, Mara A Schonberg, Susan D Block, James A Tulsky
雑誌名: Ann Emerg Med. 2019 Aug;74(2):276-284. doi: 10.1016/j.annemergmed.2019.01.003. Epub 2019 Feb 13.
Abstract/Text During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID 30770207  Ann Emerg Med. 2019 Aug;74(2):276-284. doi: 10.1016/j.a・・・
著者: Aviva L Katz, Sally A Webb, COMMITTEE ON BIOETHICS
雑誌名: Pediatrics. 2016 Aug;138(2). doi: 10.1542/peds.2016-1485.
Abstract/Text Informed consent should be seen as an essential part of health care practice; parental permission and childhood assent is an active process that engages patients, both adults and children, in their health care. Pediatric practice is unique in that developmental maturation allows, over time, for increasing inclusion of the child's and adolescent's opinion in medical decision-making in clinical practice and research. This technical report, which accompanies the policy statement "Informed Consent in Decision-Making in Pediatric Practice" was written to provide a broader background on the nature of informed consent, surrogate decision-making in pediatric practice, information on child and adolescent decision-making, and special issues in adolescent informed consent, assent, and refusal. It is anticipated that this information will help provide support for the recommendations included in the policy statement.

Copyright © 2016 by the American Academy of Pediatrics.
PMID 27456510  Pediatrics. 2016 Aug;138(2). doi: 10.1542/peds.2016-148・・・
著者: Aryeh Shander, Lawrence Tim Goodnough
雑誌名: Am J Hematol. 2018 Sep;93(9):1183-1191. doi: 10.1002/ajh.25167. Epub 2018 Sep 3.
Abstract/Text Declining a treatment modality should not be considered the same as refusal of medical care as illustrated by the management of Jehovah's Witness patients who do not accept transfusions. Over the years, a comprehensive set of strategies have been developed to meet the specific needs of these patients and these strategies are collectively called "Bloodless Medicine and Surgery" (BMS). The focus in BMS is to optimize the patients' hematopoietic capacity to increase hemoglobin (Hgb) level, minimize blood loss, improve hemostasis, and provide supportive strategies to minimize oxygen consumption and maximize oxygen utilization. We present 3 case reports that illustrate some of the challenges faced and measures available to effectively treat these patients. Under BMS programs, patients with extremely low hemoglobin levels, not conducive to survival under ordinary conditions, have survived and recovered without receiving allogeneic transfusions. Additionally, the valuable experience gained from caring for these patients has paved the way to develop the concept of Patient Blood Management as a standard care to benefit all patients, and not only those for whom blood is not an option.

© 2018 Wiley Periodicals, Inc.
PMID 30033541  Am J Hematol. 2018 Sep;93(9):1183-1191. doi: 10.1002/aj・・・

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