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S J Youngner

Publications and source records attributed to S J Youngner.

At least 19 recordsLinked to original sources
PubMed2001

Philosophical debates about the definition of death: who cares?

Since the Harvard Committee's bold and highly successful attempt to redefine death in 1968 (Harvard Ad Hoc committee, 1968), multiple controversies have arisen. Stimulated by several factors, including the inherent conceptual weakness of the Harvard Committee's proposal, accumulated clinical experience, and the incessant push to expand the pool of potential organ donors, the lively debate about the definition of death has, for the most part, been confined to a relatively small group of academics who have created a large body of literature of which this issue of the Journal of Medicine and Philosophy is an example. Law and public policy, however, have remained essentially unaffected. This paper will briefly review the multiple controversies about defining death in an attempt to explain why they have and will remain unresolved in the academic community and have even less chance of being understood and resolved by politicians, legislators, and the general public. Considering this, we will end by suggesting the probable course of public policy and clinical practice in the decades ahead.

Bioethics↗
PubMed2000

Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation.

Patients, families, and health care providers have a right to expect that ethics consultants can deal competently with the complex issues that they are asked to address. The Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation explored core competencies and related issues in ethics consultation. This position paper summarizes the content of the resulting Task Force Report, which included nine general conclusions: 1) U.S. societal context makes "ethics facilitation" an appropriate approach to ethics consultation; 2) ethics facilitation requires certain core competencies; 3) core competencies can be acquired in various ways; 4) individual consultants, teams, or committees should have the core competencies for ethics consultation; 5) consult services should have policies that address access, patient notification, documentation, and case review; 6) abuse of power and conflicts of interest must be avoided; 7) ethics consultation must have institutional support; 8) evaluation of process, outcomes, and competencies is needed; and 9) certification of individuals and accreditation of programs are rejected.

Bioethics↗
PubMed1999

Prosecutors and end-of-life decision making.

OBJECTIVE: To examine personal beliefs and professional behavior of state criminal prosecutors toward end-of-life decisions. DESIGN: Mail survey. SETTING: District attorney offices nationwide. PARTICIPANTS: All prosecuting attorneys who are members of the National District Attorneys Association. A total of 2844 surveys were mailed with 2 follow-up mailings at 6-week intervals; 761 surveys were returned for a response rate of 26.8%. The majority of respondents were white men, Protestant, and served in rural areas. INTERVENTIONS: None. MAIN OUTCOME MEASURES: On the basis of 4 case scenarios, (1) professional behavior as determined by respondents' willingness to prosecute and what criminal charges they would seek; and (2) personal beliefs as determined by whether prosecutors believed the physicians' actions were morally wrong and whether they would want the same action taken if they were in the patient's condition. RESULTS: Most respondents would not seek prosecution in 3 of the 4 cases. In the fourth case, involving physician-assisted suicide, only about one third of the respondents said that they definitely would prosecute. Those who would prosecute would most often seek a charge of criminal homicide. A majority of respondents believed that the physicians' actions were morally correct in each of the 4 cases and would want the same action taken if they were in the patient's position. There was a strong correlation between personal beliefs and professional behaviors. CONCLUSIONS: A large majority of responding prosecutors were unwilling to prosecute physicians in cases that clearly fall within currently accepted legal and professional boundaries. In the case of physician-assisted suicide, results reflected a surprisingly large professional unwillingness to prosecute and an even greater personal acceptance of physician-assisted suicide.

Attitude to Death↗
PubMed1999

Increased risk of death in patients with do-not-resuscitate orders.

BACKGROUND: Whereas studies have shown higher mortality rates in patients with do-not-resuscitate (DNR) orders, most have not accounted for confounding factors related to the use of DNR orders and/or factors related to the risk of death. OBJECTIVE: To determine the relationship between the use of DNR orders and in-hospital mortality, adjusting for severity of illness and other covariates. DESIGN: Retrospective cohort study. PATIENTS: There were 13,337 consecutive stroke admissions to 30 hospitals in 1991 to 1994. MEASURES: To decrease selection bias, propensity scores reflecting the likelihood of a DNR order were developed. Scores were based on nine demographic and clinical variables independently related to use of DNR orders. The odds of death in patients with DNR orders were then determined using logistic regression, adjustment for propensity scores, severity of illness, and other factors. RESULTS: DNR orders were used in 22% (n = 2,898) of patients. In analyses examining DNR orders written at any time during hospitalization, unadjusted in-hospital mortality rates were higher in patients with DNR orders than in patients without orders (40% vs. 2%, P<0.001); the adjusted odds of death was 33.9 (95% CI, 27.4-42.0). The adjusted odds of death remained higher in analyses that only considered orders written during the first 2 days (OR 3.7; 95% CI, 3.2-4.4) or the first day (OR 2.4; 95% CI, 2.0-2.9). In stratified analyses, adjusted odds of death tended to be higher in patients with lower propensity scores. CONCLUSION: The risk of death was substantially higher in patients with DNR orders after adjusting for propensity scores and other covariates. Whereas the increased risk may reflect patient preferences for less intensive care or unmeasured prognostic factors, the current findings highlight the need for more direct evaluations of the quality and appropriateness of care of patients with DNR orders.

Aged↗
PubMed1997

Variation in the use of do-not-resuscitate orders in patients with stroke.

OBJECTIVES: To identify sociodemographic and clinical characteristics associated with the use of do-not-resuscitate (DNR) orders in hospitalized patients with stroke. To examine whether the use of DNR orders varies across hospitals. METHODS: This observational cohort study used data collected for 13337 consecutive eligible patients with a primary diagnosis of stroke. These patients were discharged in 1991 through 1994 from 30 hospitals in a large metropolitan area. Study data were abstracted from patients' hospital records using standard forms. Admission severity of illness was measured using a validated multivariable model. Sociodemographic and clinical factors independently associated with the use of DNR orders were identified using stepwise logistic regression. RESULTS: Do-not-resuscitate orders were written for 2898 patients (22%). Patient characteristics independently (P < .01) associated with increased use of DNR orders included increasing age (odds ratio [OR], 1.06 per year); admission from a skilled nursing facility (OR, 2.44) or through the emergency department (OR, 1.49); cancer (OR, 2.73), intracerebral hemorrhage (OR, 2.12), coma (OR, 7.47), or lethargy or stupor on admission neurological assessment (OR, 3.38); and increasing admission severity (OR; 1.29 per decile). In contrast, African American race was associated with lower use of DNR orders (OR, 0.54). Although substantial variation in the use of DNR orders was observed across hospitals, with rates ranging from 12% to 32%, adjusting for the above patient characteristics eliminated much of this variation, including differences between major teaching and other hospitals and between hospitals with and without religious affiliations. CONCLUSIONS: In our community-based analysis of patients with stroke, the use of DNR orders was common and was strongly related to several patient characteristics. These factors explained much of the variation across hospitals. While our analysis did not account for differences in patient preferences for treatment, the differences we observed in the use of DNR orders across sociodemographic groups are suggestive of variations in care and may have important implications for the cost and quality of hospital care.

Aged↗
PubMed1997

Dialysis patient attitudes toward financial incentives for kidney donation.

Offering financial incentives to families of brain-dead individuals has been proposed as a way to increase the supply of organs for transplantation. However, such incentives may lead to weakening of altruism and exploitation of poor families. We investigated dialysis patient attitudes toward the potential benefits and problems of incentives. Using a structured questionnaire, we interviewed 60 randomly selected patients at three chronic hemodialysis units. Subjects were asked to make an explicit trade-off between maintaining altruism versus increasing the supply of kidneys. They were also asked to make a trade-off between protecting poor families versus increasing the supply of kidneys. In addition, we asked subjects how they thought incentives would affect donation by different types of families. We found that 37% of all subjects placed more emphasis on maintaining altruism, 42% placed more emphasis on increasing the supply of kidneys, and 22% placed an equal emphasis on maintaining altruism and on increasing the supply of kidneys. Similarly, 35% of all subjects placed more emphasis on protecting poor families, 33% placed more emphasis on increasing the supply of kidneys, and 32% placed an equal emphasis on protecting poor families and on increasing the supply of kidneys. Subjects thought financial incentives would greatly increase donation by poor families while having little impact on rich families. In conclusion, even though dialysis patients are likely to benefit from increasing the supply of kidneys, many of them want to maintain altruism and protect poor families even if that means fewer kidneys. These concerns should be addressed in proposals to modify the transplant system.

Adolescent↗
PubMed1996

Medical futility.

Recent discussions about futility have been useful in elucidating health professionals' responsibility to communicate, to establish trust, and to collaborate with patients and families about end-of-life decisions. They have highlighted the often impersonal and fragmented care that patients receive in today's large medical centers. Futility also has been a stalking horse for the much more important and problematic issue of rationing. The latter must be discussed on its own merits, however painful that may be.

Disclosure↗
PubMed1995

Physician burnout in pediatric critical care medicine.

OBJECTIVES: To determine the prevalence of, and factors associated with, burnout among pediatric intensivists across a variety of practice settings. DESIGN: A population-based survey, using a mailed questionnaire that included a previously validated Burnout Scale. SETTING: Private and academic pediatric critical care practices. PARTICIPANTS: Respondents from among all members of the Pediatric Section of the Society of Critical Care Medicine and all physicians certified in pediatric critical care medicine by the American Board of Pediatrics. MEASUREMENTS AND MAIN RESULTS: The questionnaire consisted of demographic items, variables noted in the literature as being associated with burnout (e.g., the individual's perception of how others valued their work, and the use of preventive measures such as regular exercise to relieve stress), and a validated Burnout Scale. The questionnaire also included questions pertaining to past training, practice of other primary specialties or subspecialties, practice settings, admission responsibilities, actual and preferred practice activities, total work effort, academic activities, and causes of stress at work. The Burnout Scale of Pines and Aronson is a self-diagnosis instrument, consisting of 21 questions using a 7-point frequency scale. The total Burnout Score represents an average of the scores for the individual components. Scores of < or = 3 in our study were classified as "not burned out." Scores of > 3 and < or = 4 were classified as "at risk." Scores of > 4 were classified as "burned out." A total of 883 questionnaires were mailed; 474 (56%) were respondent returns and 35 questionnaires could not be delivered. Primary analyses focused on the 389 respondent attending physicians presently practicing pediatric critical care medicine at the time of the survey. The average Burnout Score of these attending physicians was 3.1 +/- 0.8; 36% were classified as being at risk for burnout, and 14% were classified as burned out. There was no association between burnout status and the following work conditions: having fellows; having protected time for research and publications; frequency of being called at home; frequency of returning to the hospital when called at home; or call schedule. Respondents classified as burned out were significantly more likely than respondents who were classified as not burned out to feel that their work was not valued by others. Burned out respondents were less likely than respondents who were not burned out to give the following description: feeling very successful; feeling that their peers viewed them as very successful; feeling satisfied in their professional life; and routinely exercising or having some other outside interest. CONCLUSIONS: We found that a high degree of burnout exists in pediatric critical care medicine, with 50% of pediatric intensivists at risk or burned out. Overall, there was no association between Burnout Scores and training, practice specialties, or practice settings, nor was there an association with aspects of practice that are physically taxing. However, perceptions about the value of their work and feelings of success and satisfaction were highly associated with those respondents classified as burned out. Routine exercise (a strategy used by some for stress reduction) was associated with lower Burnout Scores. Further studies are necessary to evaluate the trends that we have reported and to identify causal factors.

Adult↗
PubMed1994

Evaluation of a treatment limitation policy with a specific treatment-limiting order page.

BACKGROUND: Concerns about misinterpretation, misunderstanding, poor communication, and lack of documentation prompted a revision of our hospital's treatment limitation policy. The revised policy was designed to explicate do-not-resuscitate (DNR) orders, structure the use of DNR and other treatment-limiting orders in a logical and standard way, and improve communication. Use of a Specific Treatment-Limiting Order Page (STOP) was required. METHODS: To evaluate the policy's effects, we conducted (1) a prospective cohort study (involving 2733 patients) of treatment limitation practices before and after the new policy and (2) cross-sectional surveys of 58 nurses and 62 physicians. Outcome measures included documented treatment-limiting orders, documented discussions of these decisions, and deaths. Staff opinions about effects on communication and patient care were elicited. RESULTS: Rates of death (5.4% before and 5.6% after the policy; P = .80) and rates of DNR orders (9.3% vs 9.2%, P = .9) did not change. The use of the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly increased the frequency of orders limiting 12 other specific treatments for conditions short of arrest. For example, before the policy, orders prohibited mechanical ventilation in 2% of DNR patients, compared with 66% after the policy (P < .001). Staff reported that the policy improved communication among health professionals, patients, and families. CONCLUSIONS: The treatment limitation policy with the STOP improved documentation and communication of treatment-limiting decisions. On the basis of our results, we offer a STOP for use and evaluation by others.

Aged↗
PubMed1994

Prior capacity of patients lacking decision making ability early in hospitalization: implications for advance directive administration. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

OBJECTIVE: To investigate the appropriateness of hospitalization as the time to elicit patients' medical care preferences, the authors evaluated the capability of seriously ill patients to participate in decision making early in hospitalization and their decision making capacity two weeks before hospital entry. DESIGN: Cross-sectional study with retrospective evaluation of preadmission decision making capacity. SETTING: Five acute care teaching hospitals. PATIENTS: Four thousand three hundred one acutely ill hospitalized adults meeting predetermined severity of illness criteria in nine specific disease categories. MEASUREMENTS: Surrogate decision makers' estimates of the prior mental capacities of patients unable to be interviewed early in hospitalization about care preferences due to intubation, coma, or cognitive impairment. Comparison of the demographics, degrees of sickness at admission, and outcomes of interviewable vs noninterviewable patients. MAIN RESULTS: Forty percent of the patients were not interviewable concerning preferences. Of these, 83% could have participated in treatment decisions two weeks prior to hospitalization. The patients who were not interviewable were more acutely ill, had less chronic disease, and were more likely to die during hospitalization than the interviewable patients. CONCLUSIONS: Many acutely ill patients likely to die in the hospital lost their ability to make medical care decisions around the time of hospital admission. Preferences for care and advance directives should be discussed in the outpatient setting or very early in hospital admission.

Advance Directives↗