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Older adults (≥65 yr) account for the majority of emergency laparotomies in the UK and are well characterised with reported outcomes. In contrast, there is limited knowledge on those patients that require emergency laparotomy but do not undergo surgery (NoLaps). A multicentre cohort study (n =64 UK surgical centres) recruited 750 consecutive NoLap patients (February 15th - November 15th 2021, inclusive of a 90-day follow up period). Each patient was admitted to hospital with a surgical condition treatable by an emergency laparotomy (defined by The National Emergency Laparotomy Audit (NELA) criteria), but a decision was made not to undergo surgery (NoLap). NoLap patients were predominately female (452 patients, 60%), of advanced age (median age 83.0 yr, interquartile range 77.0–88.8), frail (523 patients, 70%), and had severe comorbidity (750 patients, 100%); 99% underwent CT scanning. The commonest diagnoses were perforation (26%), small bowel obstruction (17%), and ischaemic bowel (13%). The 90-day mortality was 79% and influencing factors were >80 yr, underweight BMI, elevated serum lactate or creatinine concentration. The majority of patients died in hospital (77%), with those with ischaemic bowel dying early. For the 21% of NoLap patients that survived to 90 days, 77% returned home with increased care requirements. This study reports that the NoLap patient population present significant medical challenges because of their extreme levels of comorbidity, frailty, and physiology. Despite these complexities a fifth remained alive at 90 days. Further work is underway to explore this high-risk decision-making process. ISRCTN14556210. [ABSTRACT FROM AUTHOR]

In the first year of the COVID pandemic, 2020, in the US, the disproportionate deaths of nursing-facility residents, mostly indigent older women, were primarily due to abandonment by the Trump administration and the states, here defined as an Eldercide. The Eldercide that occurred in most of the 15,477 and others, aiming to transform the public-health system that had long failed the residents and their bereaved families. This essay provides an overview of the residents' situations during the pandemic, their social characteristics, and their psychological needs. Members of government, like the populace, suffer from compound ageism, learned starting young. The bias is accompanied by a range of emotions toward residents – from indifference to avoidance and, since COVID, an erroneous sense of futility about keeping residents alive. Experts have long known what policies would be necessary to transform the industry and the public-health system, but politics, corruption, and the influence of the industry's lobby may interfere, even in the wake of the catastrophe. [ABSTRACT FROM AUTHOR]

This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients. This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database. A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001). FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center. [ABSTRACT FROM AUTHOR]

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

AbstractBackgroundMethodsResultsConclusionsSome have hypothesized that talk about suffering can be used by clinicians to motivate difficult decisions, especially to argue for reducing treatment at the end of life. We examined how talk about suffering is related to decision-making for critically ill patients, by evaluating transcripts of conversations between clinicians and patients’ families.We conducted a secondary qualitative content analysis of audio-recorded family meetings from a multicenter trial conducted in the adult intensive care units of five hospitals from 2012–2017 to look at how the term “suffering” and its variants were used. A coding guide was developed by consensus-oriented discussion by four members of the research team. Two coders independently evaluated each transcript. We followed an inductive approach to data analysis in reviewing transcripts; findings were iteratively discussed among study authors until consensus on key themes was reached.Of 146 available transcripts, 34 (23%) contained the word “suffer” or “suffering” at least once, with 58 distinct uses. Clinicians contributed 62% of first uses. Among uses describing the suffering of persons, 57% (n = 24) were related to a decision, but only 42% (n = 10) of decision-relevant uses accompanied a proposal to limit treatment, and only half of treatment-limiting uses (n = 5) were initiated by clinicians. The target terms had a variety of implicit meanings, including poor prognosis, reduced functioning, pain, discomfort, low quality of life, and emotional distress. Suffering was frequently attributed to persons who were unconscious.Our results did not support the claim that the term “suffering” and its variants are used primarily by clinicians to justify limiting treatment, and the terms were not commonly used in our sample when decisions were requested. Still, when these terms were used, they were often used in a decision-relevant fashion. [ABSTRACT FROM AUTHOR]

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility. [ABSTRACT FROM AUTHOR]

We consider several industry group sequential trials and associated issues over the last 30 years. Generally, group sequential design has provided a great deal of flexibility to overcome many challenges in a relatively straightforward way compared to more complex adaptive designs. Among the issues considered are the timing of and boundaries for interim and final analyses, dealing with multiple hypotheses created by dose groups, populations and endpoints. Tools for design and execution will also be discussed. [ABSTRACT FROM AUTHOR]

Abstract Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a ‘terminal’ illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED ‘staging’ discourse. Conceptually, ‘terminality’ interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual’s eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a ‘terminal’ ED to a variety of definitions of ‘recovery’. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them.

Eating disorders (EDs) are complex, multifaceted conditions that significantly impact quality-of-life, often co-occur with multiple medical and psychiatric diagnoses, and are associated with a high risk of medical sequelae and mortality. Fortunately, many people recover even after decades of illness, although there are different conceptualisations of recovery and understandings of how recovery is experienced. Differences in these conceptualisations influence categorisations of ED experiences (e.g., longstanding vs. short-duration EDs), prognoses, recommended treatment pathways, and research into treatment outcomes. Within recent years, the proposal of a 'terminal' illness stage for a subset of individuals with anorexia nervosa and arguments for the prescription of end-of-life pathways for such individuals has ignited debate. Semantic choices are influential in ED care, and it is critical to consider how conceptualisations of illness and recovery and power dynamics influence outcomes and the ED 'staging' discourse. Conceptually, 'terminality' interrelates with understandings of recovery, efficacy of available treatments, iatrogenic harm, and complex co-occurring diagnoses, as well as the functions of an individual's eating disorder, and the personal and symbolic meanings an individual may hold regarding suffering, self-starvation, death, health and life. Our authorship represents a wide range of lived and living experiences of EDs, treatment, and recovery, ranging from longstanding and severe EDs that may meet descriptors of a 'terminal' ED to a variety of definitions of 'recovery'. Our experiences have given rise to a shared motivation to analyse how existing discourses of terminality and recovery, as found in existing research literature and policy, may shape the conceptualisations, beliefs, and actions of individuals with EDs and the healthcare systems that seek to serve them. [ABSTRACT FROM AUTHOR]

The authors consider the legal and ethical considerations of offering a time-limited trial of a potentially non-beneficial intervention in the setting of patient or surrogate requests to pursue aggressive treatment. The likelihood of an intervention's success is rarely a zero-sum game, and an intervention's risk-to-benefit ratio may be indiscernible without further information (often, a matter of time). [ABSTRACT FROM AUTHOR]

A group sequential design allows investigators to sequentially monitor efficacy and safety as part of interim testing in phase III trials. Literature is well developed in the case of continuous and binary outcomes, however, in case of trials with a time-to-event outcome, popular methods of sample size calculation often assume proportional hazards. In situations where the proportional hazards assumption is inappropriate as indicated by historical data, these popular methods are very restrictive. In this paper, a novel simulation-based group sequential design is proposed for a two-arm randomized phase III clinical trial with a survival endpoint for the non-proportional hazards scenario. By assuming that the survival times for each treatment arm follow two different Weibull distributions, the proposed method utilizes the concept of Relative Time to calculate the efficacy and safety boundaries at selected interim testing points. The test statistic used to generate these boundaries is asymptotically normal, allowing p-value calculation at each boundary. Many design features specific to time-to-event data can be incorporated with ease. Additionally, the proposed method allows the flexibility of having the accelerated failure time model and the proportional hazards model as constrained special cases. Real life applications are discussed demonstrating the practicality of the proposed method.

Background: Cardiopulmonary resuscitation (CPR) is considered an essential intervention in unanticipated cardiac arrest, but in the out-of-hospital setting it is often the default treatment for many patients dying of chronic and incurable disease who experience this. The Clinical Frailty Scale (CFS) can predict an individual's vulnerability to adverse health outcomes and might be a useful tool in prognostication in the prehospital setting. Aims: The primary aim was to assess if the CFS can be used for prognostication in cardiac arrest and whether UK paramedics would be able to use the CFS in the context of an out-of-hospital cardiac arrest. Methods: A rapid review of the literature was undertaken to identify research relating to frailty's influence on cardiac arrest outcomes. Five primary research articles were identified and were included. Findings: All the primary research focused on in-hospital cardiac arrest and demonstrated that an higher clinical frailty score was associated with increased mortality following cardiac arrest, with a significant reduction in survival at CFS ≥6. Conclusion: Research could assess whether these findings would be replicated in the out-of-hospital cardiac arrest context and whether paramedics could use the CFS to aid in prognostication in this situation. [ABSTRACT FROM AUTHOR]

Objective. This paper examines two aspects of treatment decision making: withdrawal of treatment decisions made by a patient; and decisions to not proceed with treatment by a health professional. The paper aims to provide an overview of the law relating to the provision of treatment, then highlight the uncertainty as to the meaning of and costs associated with futile treatment. Methods. The paper reviews the current legal and medical literature on futile treatment. Results. Continuing treatment which is futile is not in the patient's best interests. Futility may be understood in both quantitative and qualitative terms. Recent legal cases have expanded the definition of futility to focus not on the nature of the treatment itself, but also on the health of the patient to whom treatment is provided. Conclusions. As Australia's population ages, there is likely to be an increased focus on the allocation of scarce health resources. This will, inevitably, place constraints on the number and variety of treatments offered to patients. The level of constraint will be felt acutely where a proposed treatment offers little clinical efficacy. It is time to try to understand and agree on a workable definition of futility. [ABSTRACT FROM AUTHOR]

Background: Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer. Methods: We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18 years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24 h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further. Results: A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24 h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31–8.28), anticoagulation use (OR 2.11, CI 1.09–4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29–1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26–1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32–9.29), hydrocephalus (OR 9.30, CI 4.56–18.96), and intraventricular extension (OR 5.27, CI 2.60–10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942). Conclusions: Early death or WOLST after ICH within 24 h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers. [ABSTRACT FROM AUTHOR]

Liver retransplantation (reLT) yields poorer outcomes than primary liver transplantation, necessitating careful patient selection to avoid futile reLT. We conducted a retrospective analysis to assess reLT outcomes and identify associated risk factors. All adult patients who underwent a first reLT at the Medical University of Innsbruck from 2000 to 2021 (N = 111) were included. Graft- and patient survivalwere assessed via Kaplan-Meier plots and log-rank tests. Uni- and multivariate analyses were performed to identify independent predictors of graft loss. Five-year graft- and patient survival rates were 64.9% and 67.6%, respectively. The balance of risk (BAR) score was found to correlate with and be predictive of graft loss and patient death. The BAR score also predicted sepsis (AUC 0.676) and major complications (AUC 0.720). Multivariate Cox regression analysis identified sepsis [HR 5.179 (95% CI 2.575-10.417), p < 0.001] as the most significant independent risk factor for graft loss. At a cutoff of 18 points, the 5 year graft survival rate fell below 50%. The BAR score, a simple and easy to use score available at the time of organ acceptance, predicts and stratifies clinically relevant outcomes following reLT and may aid in clinical decision-making. [ABSTRACT FROM AUTHOR]

Questions about when to limit unhelpful treatments are often raised in general medicine but are less commonly considered in psychiatry. Here we describe a survey of U.S. psychiatrists intended to characterize their attitudes about the management of suicidal ideation in patients with severely treatment-refractory illness. Respondents (n = 212) received one of two cases describing a patient with suicidal ideation due to either borderline personality disorder or major depressive disorder. Both patients were described as receiving all guideline-based and plausible emerging treatments. Respondents rated the expected helpfulness and likelihood of recommending each of four types of intervention: hospitalization, additional medication changes, additional neurostimulation, and additional psychotherapy. Across both cases, most respondents said they were likely to provide each intervention, except for additional neurostimulation in borderline personality disorder, while fewer thought each intervention would be helpful. Substantial minorities of respondents indicated that they would provide an intervention they did not think was likely to be helpful. Our results suggest that while most psychiatrists recognize the possibility that some patients are unlikely to be helped by available treatments, many would continue to offer such treatments. [ABSTRACT FROM AUTHOR]

Background: patients with cancer are one of the main group of patients on home parenteral nutrition (HPN). Patients with malignant bowel obstruction (MBO) represent a challenging group when considering HPN. At the Ethics Working Group of SENPE ethical considerations on this subject were reviewed and a guidelines proposal was made. Methods: a literature search was done and a full set of questions arose: When, if ever, is HPN indicated for patients with MBO? How should the training program be? When withdrawal of HPN should be considered? Other questions should be also taken into consideration. May any Oncologist send home a patient with HPN? The educational program could be shortened? When considering to withdraw parenteral nutrition? Results: HPN in MBO has better outcomes when patients have a good functional status (Karnofsky ≥ 50 or ECOG ≤ 2), expected survival > 2-3 months, and low inflammatory markers. Very few data have been reported on quality of life, but HPN allows a valuable time at home albeit with a considerable burden for both patients and their families. Proposal: once a patient is considered for HPN, there is a need for a deep talk on the benefits, complications and risks. In this initial talk, when HNP should be stopped needs to be included. The palliative care team with the help of the nutrition support team should follow the patient, whose clinical status must be assessed regularly. HPN should be withdrawn when no additional benefits are achieved. Conclusion: HPN may be considered an option in patients with MBO when they have a fair or good functional status and a desire to spend their last days at home. [ABSTRACT FROM AUTHOR]

Aim. This study aims to conduct a comprehensive analysis of the absurdities inherent in combat events as depicted in Joseph Heller's novel, Catch-22. The study seeks to explore how Heller utilizes literary techniques such as sarcasm, black humor, and surrealism to portray the contradictions, irrationality, and overall absurd nature of war. Additionally, the study aims to unfold the deeper societal implications, including dehumanization and moral degradation, presented in the novel. Method. The research method employed in this study is primarily a qualitative literary analysis. The analysis involves a close examination of the text of Catch-22, focusing on the novel's characters, plot structure, narrative techniques, and the use of literary devices. It engages in critical interpretation and evaluation of how Heller employs sarcasm, black humor to convey the absurdities of war. Results. The study reveals that Joseph Heller employs a unique set of literary techniques, including non-sequential narrative, broken chronology, and cyclical motifs, to vividly capture the chaotic and absurd nature of combat events. The analysis uncovers recurring themes such as bureaucratic absurdities, loss of personal agency, dehumanization, and the existential toll of war. The study highlights the significance of the Catch-22 paradox as a central motif, illustrating the circular and illogical nature of bureaucratic processes during war. Conclusion. Joseph Heller's Catch-22 serves as a powerful critique of the absurdities prevalent in wartime. The Catch-22 paradox emerges as a symbolic representation of bureaucratic folly, encapsulating the struggle of individuals caught in the machinery of conflict. [ABSTRACT FROM AUTHOR]

It is often claimed that Ecclesiastes constitutes an irremediable enigma which flies in the face of traditional Hebrew cosmology, making the author's intended meaning not much more than a bewildering speculative task. Biblical scholars disagree on just about every aspect of this ancient Hebraic work: authorship, date, structure, narrative framework, and even its connection to a Creator God. This essay utilizes Ballantine's strategic rhetorical perspective to introduce and wade through some of the central controversies and debates about the meaning of Ecclesiastes: Is earthly life meaningful or meaningless ? Is there eternal meaning to earthly life or not? Is the earthly life of human beings pointless and futile or not? If the simple pleasures of earthly life are gifts from God, then how can earthly life itself be 'hevel'? and more. Somewhat surprisingly, it concludes that Ecclesiastes is anything but an enigma when viewed rhetorically, and certainly not in contravention of basic Hebraic and Christian biblical principles about the sovereign importance of believing in God and obeying the Commandments, even despite all the trials and tribulations offered by earthly life. [ABSTRACT FROM AUTHOR]

[Display omitted] [ABSTRACT FROM AUTHOR]

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

Liver retransplantation (reLT) yields poorer outcomes than primary liver transplantation, necessitating careful patient selection to avoid futile reLT. We conducted a retrospective analysis to assess reLT outcomes and identify associated risk factors. All adult patients who underwent a first reLT at the Medical University of Innsbruck from 2000 to 2021 (N = 111) were included. Graft- and patient survival were assessed via Kaplan-Meier plots and log-rank tests. Uni- and multivariate analyses were performed to identify independent predictors of graft loss. Five-year graft- and patient survival rates were 64.9% and 67.6%, respectively. The balance of risk (BAR) score was found to correlate with and be predictive of graft loss and patient death. The BAR score also predicted sepsis (AUC 0.676) and major complications (AUC 0.720). Multivariate Cox regression analysis identified sepsis [HR 5.179 (95% CI 2.575–10.417), p < 0.001] as the most significant independent risk factor for graft loss. At a cutoff of 18 points, the 5 year graft survival rate fell below 50%. The BAR score, a simple and easy to use score available at the time of organ acceptance, predicts and stratifies clinically relevant outcomes following reLT and may aid in clinical decision-making.

It is often claimed that Ecclesiastes constitutes an irremediable enigma which flies in the face of traditional Hebrew cosmology, making the author’s intended meaning not much more than a bewildering speculative task. Biblical scholars disagree on just about every aspect of this ancient Hebraic work: authorship, date, structure, narrative framework, and even its connection to a Creator God. This essay utilizes Ballantine’s strategic rhetorical perspective to introduce and wade through some of the central controversies and debates about the meaning of Ecclesiastes: Is earthly life meaningful or meaningless ? Is there eternal meaning to earthly life or not? Is the earthly life of human beings pointless and futile or not? If the simple pleasures of earthly life are gifts from God, then how can earthly life itself be ‘hevel’? and more. Somewhat surprisingly, it concludes that Ecclesiastes is anything but an enigma when viewed rhetorically, and certainly not in contravention of basic Hebraic and Christian biblical principles about the sovereign importance of believing in God and obeying the Commandments, even despite all the trials and tribulations offered by earthly life.

Background: Endoscopic prostate surgery is an established treatment for male lower urinary tract symptoms (LUTS) and is recognized to have low mortality rates. We aimed to describe factors that may have contributed to death following endoscopic prostate surgery using data from the Australia and New Zealand Audits of Surgical Mortality (ANZASM). Methods: All urological related deaths reported to ANZASM from January 1 2012 to December 31 2019 were reviewed. Deaths related to endoscopic prostate resection (transurethral resection of prostate – TURP, laser procedures) were included. Peer reviewers identified up to three clinical management issues (CMIs), and these were analysed. CMIs were classified in order of least to most concerning: area of consideration, area of concern and adverse events. Results: Of 1127 total urological deaths, 77 deaths were related to endoscopic prostate surgery (7.0%). Most procedures were monopolar TURP. The mean age of patients was 80.9 years (range 57.0–96.2). Leading causes of death were cardiovascular events 23/77 (29.9%) and respiratory failure 14/77 (18.2%). Assessors identified 39 CMIs in 26/77 (33.8%) patients. Twenty‐three were areas of consideration, nine were areas of concern and seven identified adverse events. The most common CMIs were regarding post‐operative care (14/39) and the decision to operate (13/39). Conclusion: Most deaths did not elicit concerns from the ANZASM peer assessors. However, the main concerns identified were surrounding decision making and rationale for operating. This highlights the importance of clear counselling and documentation during the treatment decision process. [ABSTRACT FROM AUTHOR]

Abstract Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of “futility”, but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve implantation (TAVI) has caused a significant change in the treatment of aortic stenosis. It has expanded treatment to include patients not previously indicated for surgical intervention. Despite the tremendous benefit of this method, there are patients who do not benefit from treatment and in whom TAVI is considered unnecessary. In pivotal studies of high-risk patients, one-third either died, or their quality of life failed to improve and their symptoms persisted. The futility of TAVI in such patients thus leads to their unnecessary exposure to risk. Factors that lead to poor outcomes after TAVI and increase the risk of death despite successful implantation include patient frailty and certain cardiac and non-cardiac diseases. These comorbidities may prevent improvement in symptoms and quality of life. On the other hand, some comorbidities may be reversible after the TAVI procedure. This article provides an overview of the main associated comorbidities that may contribute to poor outcomes, identifying reversible factors and looking at frailty assessment. The latter is crucial for TAVI futility. The paper also highlights the need for a systematic approach to patient assessment so that the potential futility of TAVI could be assessed more accurately and comprehensively. [ABSTRACT FROM AUTHOR]

Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) is rapidly becoming a common treatment strategy for patients with refractory cardiac arrest. Despite its benefits, ECPR raises a variety of ethical concerns when the treatment is discontinued. There is little information about the decision to withhold/withdraw life-sustaining therapy (WLST) for out-of-hospital cardiac arrest (OHCA) patients after ECPR. Methods We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter study of ECPR in Japan. Adult patients who underwent ECPR for OHCA with medical causes were included. The prevalence, reasons, and timing of WLST decisions were recorded. Outcomes of patients with or without WLST decisions were compared. Further, factors associated with WLST decisions were examined. Results We included 1660 patients in the analysis; 510 (30.7%) had WLST decisions. The number of WLST decisions was the highest on the first day and WSLT decisions were made a median of two days after ICU admission. Reasons for WLST were perceived unfavorable neurological prognosis (300/510 [58.8%]), perceived unfavorable cardiac/pulmonary prognosis (105/510 [20.5%]), inability to maintain extracorporeal cardiopulmonary support (71/510 [13.9%]), complications (10/510 [1.9%]), exacerbation of comorbidity before cardiac arrest (7/510 [1.3%]), and others. Patients with WLST had lower 30-day survival (WLST vs. no-WLST: 36/506 [7.1%] vs. 386/1140 [33.8%], p

IntroductionThe COVID-19 pandemic has had a profoundly detrimental impact on the emotional wellbeing of health care workers. Numerous studies have shown that their rates of the various forms of work-related distress, which were already high before the pandemic, have worsened as the demands on health care workers intensified. Yet much less is known about the specific social processes that have generated these outcomes. This study adds to our collective knowledge by focusing on how one specific social process, the act of treating critically ill COVID-19 patients, contributed to emotional pain among health care workers.MethodsThis article draws from 40 interviews conducted with intensive care unit (ICU) staff in units that were overwhelmed with COVID-19 patients. The study participants were recruited from two suburban community hospitals in Massachusetts and the interviews were conducted between January and May 2021.ResultsThe results show that the uncertainty over how to treat critically ill COVID-19 patients, given the absence of standard protocols combined with ineffective treatments that led to an unprecedented number of deaths caused significant emotional pain, characterized by a visceral, embodied experience that signaled moral distress, emotional exhaustion, depersonalization, and burnout. Furthermore, ICU workers’ occupational identities were undermined as they confronted the limits of their own abilities and the limits of medicine more generally.DiscussionThe inability to save incurable COVID-19 patients while giving maximal care to such individuals caused health care workers in the ICU an immense amount of emotional pain, contributing to our understanding of the social processes that generated the well-documented increase in moral distress and related measures of work-related psychological distress. While recent studies of emotional socialization among health care workers have portrayed clinical empathy as a performed interactional strategy, the results here show empathy to be more than dramaturgical and, in this context, entailed considerable risk to workers’ emotional wellbeing.

Background: Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. Methods: A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013–December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. Results: Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65–81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22–1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50–2.85). Conclusions: Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients. [ABSTRACT FROM AUTHOR]

Acute-on-chronic liver failure (ACLF), which was described relatively recently (2013), is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g. , proven microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and because of this, should be urgently stabilised for transplantation by receiving appropriate treatment of identified precipitants, and full general management, including support of organ systems in the intensive care unit (ICU). The objective of the present Clinical Practice Guidelines is to provide recommendations to help clinicians recognise ACLF, make triage decisions (ICU vs. no ICU), identify and manage acute precipitants, identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation. Based on an in-depth review of the relevant literature, we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with ACLF. [ABSTRACT FROM AUTHOR]

Objective: To review the recent literature on the proposed entity of "terminal anorexia nervosa." Method: Review of recent literature on the concept of "terminal AN" as well as past and supporting work. Results: The cases and proposed definitions are reviewed, as is the growing literature on this topic. Problems exist with predicting outcomes and thus, determining futility, as well as about capacity for decision‐making. Discussion: To make decisions about treatment futility, the existing database for predicting AN course and treatment response must expand greatly. In addition, while decisional capacity is central to the debate, its determination may be unusually complex in this situation. The gaps identified point to extensive needs for future research, but they also indicate that the concept of "terminal AN" cannot be defined at present and should not be used. Public Significance: Anorexia nervosa is challenging to treat, and it often lasts for years. There is debate about whether palliative care or medical aid in dying should be considered. Identifying who has a terminal case of AN is important for this question, but we have limited ability to predict a given individual's outcome at present, and there are concerns about the ability of those with AN to make treatment decisions. This means the concept of "terminal AN" should not currently be used. [ABSTRACT FROM AUTHOR]

In The Rhetoric of Reaction, published in 1991, Albert Hirschman identified three standard objections to reform proposals: perversity, futility and jeopardy. In Hirschman's account, these objections define reactionary rhetoric. A proposal would be "perverse" if it would aggravate the very problem it is meant to solve; it would be "futile" if it would not even dent the problem; it would produce "jeopardy" if it would endanger some other goal or value (such as liberty or economic growth). The rhetoric of reaction comes from both left and right, though in Hirschman's account, it is a special favorite of the right. In recent years, the perversity, futility and jeopardy theses have often been invoked to challenge reforms, including nudges. While the three theses are sometimes supported by the evidence, they are often evidence-free speculations, confirming Hirschman's suggestion that the rhetoric of reaction has "a certain elementary sophistication and paradoxical quality that carry conviction for those who are in search of instant insights and utter certainties." [ABSTRACT FROM AUTHOR]

Time is man's element as it flows ceaselessly to bring about changes in life. For Larkin, time is a double-edged weapon. It has destroying forces and devastating powers to bring changes in life against human wish. In time's flow, life, that starts with birth and traverses through childhood, youth, manhood, old age, and decrepitude to culminate in death, turns mortal on one side. It turns life futile or void and fills life with disappointments and frustrations by shattering dreams, expectations, hopes, wants etc in its flow. It has a dual goal as the double-edged weapon to turn life to mortality and futility. Man fails miserably as it conquers him by turning life into mortality and futility: so he concurs with it as a double-edged weapon. Life exists in linear time-dimension and time with invincible powers governs life. It is the mystery or the riddle of time. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) has strikingly progressed over the last 20 years in the management of adult and pediatric severe respiratory and cardiac dysfunctions refractory to conventional management. In this review, we will discuss the weaning strategies of veno-venous and veno-arterial ECMO including the bridge to recovery and bridge to transplant along with post-ECMO care. We will also discuss the futility and the management of bridge to nowhere from Indian perspectives. [ABSTRACT FROM AUTHOR]

Abstract Background Adaptive clinical trials may use conditional power (CP) to make decisions at interim analyses, requiring assumptions about the treatment effect for remaining patients. It is critical that these assumptions are understood by those using CP in decision-making, as well as timings of these decisions. Methods Data for 21 outcomes from 14 published clinical trials were made available for re-analysis. CP curves for accruing outcome information were calculated using and compared with a pre-specified objective criteria for original and transformed versions of the trial data using four future treatment effect assumptions: (i) observed current trend, (ii) hypothesised effect, (iii) 80% optimistic confidence limit, (iv) 90% optimistic confidence limit. Results The hypothesised effect assumption met objective criteria when the true effect was close to that planned, but not when smaller than planned. The opposite was seen using the current trend assumption. Optimistic confidence limit assumptions appeared to offer a compromise between the two, performing well against objective criteria when the end observed effect was as planned or smaller. Conclusion The current trend assumption could be the preferable assumption when there is a wish to stop early for futility. Interim analyses could be undertaken as early as 30% of patients have data available. Optimistic confidence limit assumptions should be considered when using CP to make trial decisions, although later interim timings should be considered where logistically feasible.

Abstract Background The number of older patients with multiple comorbidities in the emergency service is increasingly frequent, which implies the risk of incurring in futile surgical interventions. Some interventions generate false expectations of survival or quality of life in patients and families and represent a negligible therapeutic benefit in patients whose chances of survival are minimal. In order to address this dilemma, we describe mortality in a cohort of patients undergoing emergency laparotomy with a risk ≥ 75% per the ACS NSQIP Surgical Risk Calculator. Methods A retrospective observational study was designed to analyze postoperative mortality and factors associated with postoperative mortality in a cohort of patients undergoing emergency laparotomy between January 2018 and December 2021 in a high-complexity hospital who had a mortality risk ≥ 75% per the ACS NSQIP Surgical Risk Calculator. Results A total of 890 emergency laparotomies were performed during the study period, and 50 patients were included for the analysis. Patient median age was 82.5 (IQR: 18.25) years old and 33 (66.00%) were male. The most frequent diagnoses were mesenteric ischemia 21 (42%) and secondary peritonitis 18 (36%). Mortality in the series was 92%. Twenty-four (54.34%) died within the first 24 h of the postoperative period; 11 (23.91%) within 72 h and 10 (21.73%) within 30 days. APACHE II and SOFA scores were statistically significantly higher in patients who died. Conclusions All available tools should be used to make decisions, with the most reliable and objective information possible, and be particularly vigilant in patients at extreme risk (mortality risk greater than 75% according to ACS NSQIP Surgical Risk Calculator) to avoid futility and its consequences. The available information should be shared with the patient, the family, or their guardians through an assertive and empathetic communication strategy. It is necessary to insist on a culture of surgical ethics based on reflection and continuous improvement in patient care and to know how to accompany them in order to have a proper death.

Abstract The ethical approach to treatment non-response and treatment refusal in severe-enduring anorexia nervosa (SE-AN) is the source of significant ethical debate, particularly given the risk of death by suicide or medical complications. A recent article proposed criteria to define when anorexia nervosa (AN) can be diagnosed as ‘terminal’ in order to facilitate euthanasia or physician-assisted suicide (EAS), otherwise known as medical assistance in dying, for individuals who wish to be relieved of suffering and accept treatment as ‘futile’. This author utilises their personal lived experience to reflect on the issues raised, including: treatment refusal, iatrogenic harm, suicidality and desire to end suffering, impact of diagnosis/prognosis, schemas, alexithymia, countertransference, ambivalence, and holding on to hope. Within debates as critical as the bioethics of involuntary treatment, end-of-life and EAS in eating disorders, it is crucial that the literature includes multiple cases and perspectives of individuals with SE-AN that represent a wide range of experiences and explores the complexity of enduring AN illness, complex beliefs, communication patterns and relational dynamics that occur in SE-AN.