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

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Decisions to withdraw life sustaining treatment in the ICU are common, but there is little information about how treatment should be withdrawn. A pilot study showed that doctors withdraw life sustaining treatment in different ways even in identical cases. This variation can cause stress for ICU staff and relatives.  Our study investigated the decisions of doctors working in ICUs in Sweden regarding the withdrawal of life sustaining treatment for two fictitious patients. There was variation in if and how drug treatments should be withdrawn, as well as how ventilatory support should be withdrawn. Less experienced doctors tended to choose to prolong the dying process by weaning, even if it is unclear if that is preferable for the staff or for relatives.  Our study could be used in discussions in ICUs to try to understand how individual doctors make decisions about withdrawing life sustaining treatment.

BACKGROUND: The Patient Right to Autonomy Act (PRAA), implemented in Taiwan in 2019, enables the creation of advance decisions (AD) through advance care planning (ACP). This legal framework allows for the withholding and withdrawal of life-sustaining treatment (LST) or artificial nutrition and hydration (ANH) in situations like irreversible coma, vegetative state, severe dementia, or unbearable pain. This study aims to investigate preferences for LST or ANH across various clinical conditions, variations in participant preferences, and factors influencing these preferences among urban residents.
METHODS: Employing a survey of legally structured AD documents and convenience sampling for data collection, individuals were enlisted from Taipei City Hospital, serving as the primary trial and demonstration facility for ACP in Taiwan since the commencement of the PRAA in its inaugural year. The study examined ADs and ACP consultation records, documenting gender, age, welfare entitlement, disease conditions, family caregiving experience, location of ACP consultation, participation of second-degree relatives, and the intention to participate in ACP.
RESULTS: Data from 2337 participants were extracted from electronic records. There was high consistency in the willingness to refuse LST and ANH, with significant differences noted between terminal diseases and extremely severe dementia. Additionally, ANH was widely accepted as a time-limited treatment, and there was a prevalent trend of authorizing a health care agent (HCA) to make decisions on behalf of participants. Gender differences were observed, with females more inclined to decline LST and ANH, while males tended towards accepting full or time-limited treatment. Age also played a role, with younger participants more open to treatment and authorizing HCA, and older participants more prone to refusal.
CONCLUSIONS: Diverse preferences in LST and ANH were shaped by the public\'s current understanding of different clinical states, gender, age, and cultural factors. Our study reveals nuanced end-of-life preferences, evolving ADs, and socio-demographic influences. Further research could explore evolving preferences over time and healthcare professionals\' perspectives on LST and ANH decisions for neurological patients..

UNASSIGNED: Bystander cardiopulmonary resuscitation (CPR) reduces mortality from out.of.hospital cardiac arrest. The willingness to perform CPR (W-CPR) is also critical. Uncertain effects of the coronavirus disease 2019 (COVID-19) pandemic on W-CPR were reported. Our objectives aim to examine W-CPR during the COVID-19 pandemic, including the influence of the bystander-victim relationship, bystander characteristics, and CPR background on the W-CPR of laypeople and healthcare providers (HCPs).
UNASSIGNED: A cross-sectional online survey was conducted between August 2020 and November 2020 among Thai laypeople and HCPs. A structured questionnaire was given to volunteers as an online survey. We recorded W-Conventional CPR (W-C-CPR), W-Compression.only CPR (W-CO-CPR), chest compression, automated external defibrillator (AED), mouth.to.mouth, face shield, and pocket mask ventilation on family members (FMs), acquaintances, and strangers during the study (pandemic) and in nonpandemic situation and analyzed.
UNASSIGNED: We included 419 laypeople and 716 HCPs. During the pandemic, laypeople expressed less willingness in all interventions (P < 0.05) except W-CO-CPR in FMs and AED in FMs and acquaintances. HCPs were less willing to any interventions (P < 0.05). Laypeople showed comparable W-C-CPR and W-CO-CPR between FMs and acquaintances but less among strangers (P < 0.05). HCPs\' W-CPR differed significantly depending on their relationship (P < 0.05), except W-CO-CPR between FMs and acquaintances. CPR self.efficacy, single marital status, CPR experience, and HCPs reported higher W-CO-CPR in FMs.
UNASSIGNED: Participants were less W-CPR during the COVID-19 pandemic on all recipients (laypeople: 2.8%-21.0%, HCPs: 7.6%-31.2%), except for laypeople with FMs. The recipient\'s relationship was more critical in W-C-CPR than in W-CO-CPR, especially in HCPs.

The experience and self-confidence of healthcare professionals play critical roles in reducing anxiety levels during emergencies. It is important to recognize the potential impact of anxiety on performance. To enhance preparedness and confidence in managing emergencies, healthcare professionals benefit from regular training and simulations. Additionally, repeated exposure to emergency scenarios can help modulate physiological responses. Managing anxiety effectively is key, as heightened sympathetic stimulation associated with anxiety can adversely affect performance. This study aimed to investigate nurses\' self-assessed ability to manage emergency guidelines and their self-confidence in performing tasks in critical care settings. A questionnaire was provided to 1097 nurses. We compared the self-confidence of experienced nurses (ENs) and newly licensed nurses (NLNs) in managing emergency department shifts or critical patients, and found that ENs are more confident in these scenarios. This phenomenon was also observed in subjects who had taken simulation courses, although they were still a low percentage. Most NLNs feel sufficiently ready to work in medium-intensity wards. Attending advanced training courses enhances nurses\' self-confidence and may improve patient safety management., improving patient recovery, and minimizing errors. Attending courses improves the perception of autonomy of nurses in different scenarios.

Comatose survivors of cardiac arrest may die following withdrawal of life-sustaining therapy (WLST) due to poor neurologic prognosis. Family members, acting as surrogate decision makers, are frequently asked to decide whether the patient should continue to receive ongoing life-sustaining therapy such as mechanical ventilation in this context of risk of death following removal. Sometimes, physicians and family members disagree about what is in the patient\'s best interest, and this conflict causes distress for both families and medical personnel.This article examines themes recorded in the medical records of 24 cardiac arrest patients at Columbia University Medical Center (CUMC) whose families chose to pursue continued life support despite physician recommendations for withdrawal. In documented conversations between patients\' families and their providers, the most prominent themes included faith in miracles, the inappropriateness of \"playing God,\" the value of more time with the patient, and differences in how providers and family members perceived the patient\'s status.

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BACKGROUND: Despite being one of the fastest growing ethnic groups in the U.S., there exists a gap in how treatment preferences among Chinese Americans are expressed and enacted upon in inpatient settings.
OBJECTIVE: To compare the rates of advance care documentation and life-sustaining treatment between Chinese American and White American ICU decedents.
METHODS: In this matched retrospective decedent cohort study, we included four ICUs within a tertiary medical center located in a Chinatown neighborhood. The Chinese American cohort included adult patients during the terminal admission in the ICU with primary language identified as Chinese (Mandarin, Cantonese, Taishanese). The White American cohort was matched according to age, sex, year of death, and admitting diagnosis.
RESULTS: We identified 154 decedents in each cohort. Despite similar odds on admission, Chinese American decedents had higher odds of DNR completion (OR 1.82; 95%CI 0.99-3.40) and DNI completion (OR 1.81; 95%CI, 1.07-1.57) during the terminal ICU admission. Although Chinese American decedents had similar odds of intubation (aOR 0.90; 95%CI, 0.55-1.48), a higher proportion signed a DNI after intubation (41% vs 25%). Chinese American decedents also had higher odds of CPR (aOR 2.03; 95%CI, 1.03-41.6) with three Chinese American decedents receiving CPR despite a signed DNR order (12% vs 0%).
CONCLUSIONS: During terminal ICU admissions, Chinese American decedents were more likely to complete advance care documentation and to receive CPR than White American decedents. Changes in code status were more common for Chinese Americans after intubation. Further research is needed to understand these differences and identify opportunities for goal-concordant care.

OBJECTIVE: Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA).
METHODS: This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world.
RESULTS: LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients\' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients\' best-interest, with the need for an ICU bed only rarely considered.
CONCLUSIONS: Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.