- Email: [email protected]
Palliative Care, Spiritual Care, and Clinical Ethics
declined to 96,005 in 2014, a -25.9% decline or 6.7% compounded yearly decrease (range, -5.4% to -9.3%) (Fig 1). This occurred despite stable and increased rates of DVT and pulmonary embolism diagnosed in this period. The FDA advisory regarding filter use in 2010, updates to American Heart Association in 2011 and ACCP in 2012 societal guidelines, and the consolidation of IVC filter lawsuits into multidistrict litigations in 2014 occurred during this period. Interrupted time series analysis of filter placements demonstrated a significant difference in trends between the pre-2010 and post-2010 periods (P ¼ .0002) that were significant across subgroups of age, gender, and other studied variables. Decreased use was observed across all geographic regions of the United States (Table 1). Since 2010, annual IVC filter use has declined by compound and overall rates of -6.7% and -25.9%, respectively. In evaluating the events that occurred since 2010, it remains likely that the FDA advisory, incorporation of legal cases into multidistrict litigations, and updated American Heart Association and ACCP guidelines recommending only therapeutic placements have contributed to temper the number of filters placed annually in the United States. Osman Ahmed, MD Ketan Patel, MD, FCCP Mikin V. Patel, MD Amanjit S. Baadh, MD Sreekumar Madassery, MD Ulku Cenk Turba, MD Chicago, IL Thomas J. Ward, MD Orlando, FL AFFILIATIONS: From the Department of Radiology (Drs Ahmed, K. Patel, Baadh, Madassery, and Turba), Section of Interventional Radiology, Rush University Medical Center; Department of Radiology (Dr M. V. Patel), University of Chicago Medicine; and the Department of Radiology (Dr Ward), Section of Interventional Radiology, University of Central Florida College of Medicine, Florida Hospital. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: A. S. B. is a speaker and advisory board member for Penumbra and Medtronic/Covidien and speaker for Cook, W.L. Gore, Guerbet, and CR Bard. O. A. is a speaker for Cook and shareholder of Penumbra. None declared (K. P., M. V. P., S. M., U. C. T., T. J. W.). CORRESPONDENCE TO: Osman Ahmed, MD, Rush University Medical Center, 1725 W Harrison St, Ste 450, Chicago, IL 60612; e-mail: [email protected] Published by Elsevier Inc. under license from the American College of Chest Physicians. DOI: http://dx.doi.org/10.1016/j.chest.2017.03.038
1404 Correspondence
References 1. Antevil JL, Sise MJ, Sack DI, et al. Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale. J Trauma. 2006;60(1):35-40. 2. IN RE COOK MEDICAL, INC., IVC FILTERS MARKETING, 53F. Supp.3d (J.P.M.L 2014). 3. IN RE BARD IVC FILTERS PRODUCTS LIBABILITY LITIGATION (J.P.M.L 2015).
Palliative Care, Spiritual Care, and Clinical Ethics Widely Available, but Underused To the Editor:
With expansion of hospital-based care come increasingly complex needs inviting palliative care (PC), clinical ethics (CE), and spiritual care (SC) collaboration. Commonly encountered situations include withdrawal of life-sustaining therapies, surrogate decision-making, provider conflict, and spiritual/ religious distress, all of which overlap among PC, CE, and SC domains of expertise. Nevertheless, although hospitals commonly use these three clinical services, little guidance exists regarding which service to consult, how they might best collaborate, and their effect on quality benchmarks.1-4 To learn more about consultation preferences in critical care settings, we conducted an institutional review board–approved 22-question online survey to members of the American College of Chest Physicians in August 2015. The survey presented three cases in critical care settings and elicited responses regarding consultation needs preferences. The survey yielded 72 responses (6% response rate, 100% completion rate). Respondents (88% physicians, 83% intensivists, 63% male) reported high availability of PC (81%), CE (74%), and SC (79%) at their institutions. Despite high availability of all these services, only 14% of respondents reported “routinely” or “often” consulting CE, compared with 72% for PC and 63% for SC. In hypothetical cases, most respondents expressed preference to consult PC for a patient with stage IV lung cancer admitted to their ICU for hypoxemic respiratory failure (case 1) or for a patient with an estimated prognosis of weeks who wants “everything done” (case 2) (Fig 1). For a mechanically ventilated patient with multisystem organ failure and no available surrogate decision-maker, 40.3% of respondents would consult CE first (case 3),
[
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70.0% 63.9% 60.0%
Percentage Respondents
50.0% 43.1% 40.3% 40.0%
30.0% 25.0%
25.0% 20.0%
10.0%
16.7% 9.7%
13.9% 11.1%
13.9%
12.5%
11.1% 6.9%
5.6%
1.4% 0.0%
Stage IV lung cancer with progressive respiratory failure
Spiritual Care
Prognosis of weeks-months, existential distress, family wants “everything done”
Palliative Care
Clinical Ethics
None
Multi-organ failure with mechanical ventilation, no surrogate decision maker All three simultaneously
Figure 1 – Survey responses to hypothetical ICU cases followed by the question, “Which consultant would you contact first?”
compared with 25% for PC and 5.6% for SC (P < .05). No association was found between responses and clinician age or sex.
Scott Howard Snyder, MD Baltimore, MD Nneka Sederstrom, PhD, FCCP Minneapolis, MN
Provider preference for PC over CE or SC is notable, despite high availability of all three services. Lower rates of SC consultation may reflect that PC teams frequently engage chaplain services themselves, that chaplains visit patients without specific requests, or that clinicians limit SC involvement to end-of-life rituals. Lower preference for CE may indicate less bedside CE consult availability or respondents’ belief that they can handle ethical issues alone. Low response rate may reflect survey fatigue but respondents are likely invested in engaging PC, CE, and/or SC. How and when we invite and assimilate experts in supportive care to the critical care setting affects patient and family experience. Future research should further investigate relationships among critical care providers and PC, SC, and CE consultants.
journal.publications.chestnet.org
J. Keith Mansel, MD, FCCP Jackson, MS Hunter Groninger, MD Washington, DC AFFILIATIONS: From the Division of Geriatric Medicine and Gerontology (Dr Snyder), Johns Hopkins University School of Medicine; the Clinical Ethics Department (Dr Sederstrom), Children’s Hospitals and Clinics of Minnesota; the University of Mississippi Medical Center (Dr Mansel); and Palliative Care (Dr Groninger), MedStar Washington Hospital Center. This work was presented as a poster at the 2016 International Conference on Clinical Ethics Consultation, May 2016, in Washington, DC. FINANCIAL/NONFINANCIAL DISCLOSURES: None declared. CORRESPONDENCE TO: Scott Howard Snyder, MD, Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, 5200 Eastern Ave, MFL-C, 2nd Floor, Ste 2200, Baltimore, MD 21224; e-mail: [email protected] Published by Elsevier Inc. under license from the American College of Chest Physicians. DOI: http://dx.doi.org/10.1016/j.chest.2017.03.034
1405
References 1. Morrison W, Derrington SF. Stories and the longitudinal patient relationship: what can clinical ethics consultants learn from palliative care? J Clin Ethics. 2012;23(3):224-230. 2. Maung AA, Toevs CC, Kayser JB, Kaplan LJ. Conflict management teams in the intensive care unit: a concise definitive review. J Trauma Acute Care Surg. 2015;79(2):314-320. 3. Carter BS, Wocial LD. Ethics and palliative care: which consultant and when? Am J Hosp Palliat Care. 2012;29(2):146-150. 4. Aulisio MP, Chaitin E, Arnold RM. Ethics and palliative care consultation in the intensive care unit. Crit Care Clin. 2004;20(3): 505-523. x-xi.
Association Between Attention-Deficit/ Hyperactivity Disorder and Asthma Among Adults A Case-Control Study To the Editor:
Recently, we showed in a meta-analysis that in children there is an association between attention-deficit/ hyperactivity disorder (ADHD) and atopic diseases, especially asthma.1 The nature of this relationship is still
TABLE 1
unknown, although findings suggest links with environmental and/or genetic risk factors contributing to inflammatory mechanisms.2 Not much is known about this association among adults. The aim of the present study was to investigate associations between the presence of ADHD and the presence and severity of asthma in adults. As a secondary aim we investigated the association between ADHD and the presence of eczema and allergic rhinitis. We conducted a case-control study using the University of Groningen pharmacy prescription database, which is representative of the Netherlands. Case subjects were defined as adults aged between 18 and 50 years with at least two prescriptions for ADHD medication within the past 12 months. Control subjects were defined as adults without any history of ADHD medication prescriptions and were matched (4:1) on age and sex for each case. The presence of asthma, eczema, and allergic rhinitis, and asthma severity, were based on the type and frequency of the prescription of drugs used to treat the specific atopic allergy (e-Appendix 1). Multivariable logistic regression analyses were applied to control for urbanization and the presence of two of the other atopic
] Cohort Characteristics of Patients With ADHD and the Matched Comparator Group
Sex (female) Age, mean (SD), y Urbanization level
Patients With ADHD Medication (3,987)
Control Subjects Without ADHD Medication (15,948)
1,652 (41.4)
6,608 (41.4)
32.4 (8.2)
32.8 (8.3)
.147a < .001c
b
1
1,248 (31.3)
2
1,123 (28.2)
3,823 (24.0)
3
811 (20.3)
3,260 (20.4)
4
437 (11.0)
1,868 (11.7)
5
323 (8.1)
2,124 (13.3)
Missing
P Value
4,610 (28.9)
45 (1.1)
263 (1.6)
Rhinitis
310 (7.8)
651 (4.1)
< .001c
Eczema
222 (5.6)
534 (3.3)
< .001c
387 (9.7)
499 (3.1)
< .001c
45 (1.1)
64 (0.4)
< .001c
Persistent mild
129 (3.2)
193 (1.2)
< .001c
Persistent moderate-severe
137 (3.4)
168 (1.1)
< .001c
Asthma Asthma severity
d
Intermittent
Data are presented as No. (%) unless otherwise indicated. ADHD ¼ attention-deficit/hyperactivity disorder. a Student t test. b 1 ¼ 2,500 or more addresses per km2; 2 ¼ 1,500-2,500 addresses per km2; 3 ¼ 1,000-1,500 addresses per km2; 4 ¼ 500-1,000 addresses per km2; and 5 ¼ fewer than 500 addresses per km2. c Pearson c2 test. d Asthma severity was estimated on the basis of various medication proxies (e-Appendix 1).
1406 Correspondence
[
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]
1404 Correspondence
References 1. Antevil JL, Sise MJ, Sack DI, et al. Retrievable vena cava filters for preventing pulmonary embolism in trauma patients: a cautionary tale. J Trauma. 2006;60(1):35-40. 2. IN RE COOK MEDICAL, INC., IVC FILTERS MARKETING, 53F. Supp.3d (J.P.M.L 2014). 3. IN RE BARD IVC FILTERS PRODUCTS LIBABILITY LITIGATION (J.P.M.L 2015).
Palliative Care, Spiritual Care, and Clinical Ethics Widely Available, but Underused To the Editor:
With expansion of hospital-based care come increasingly complex needs inviting palliative care (PC), clinical ethics (CE), and spiritual care (SC) collaboration. Commonly encountered situations include withdrawal of life-sustaining therapies, surrogate decision-making, provider conflict, and spiritual/ religious distress, all of which overlap among PC, CE, and SC domains of expertise. Nevertheless, although hospitals commonly use these three clinical services, little guidance exists regarding which service to consult, how they might best collaborate, and their effect on quality benchmarks.1-4 To learn more about consultation preferences in critical care settings, we conducted an institutional review board–approved 22-question online survey to members of the American College of Chest Physicians in August 2015. The survey presented three cases in critical care settings and elicited responses regarding consultation needs preferences. The survey yielded 72 responses (6% response rate, 100% completion rate). Respondents (88% physicians, 83% intensivists, 63% male) reported high availability of PC (81%), CE (74%), and SC (79%) at their institutions. Despite high availability of all these services, only 14% of respondents reported “routinely” or “often” consulting CE, compared with 72% for PC and 63% for SC. In hypothetical cases, most respondents expressed preference to consult PC for a patient with stage IV lung cancer admitted to their ICU for hypoxemic respiratory failure (case 1) or for a patient with an estimated prognosis of weeks who wants “everything done” (case 2) (Fig 1). For a mechanically ventilated patient with multisystem organ failure and no available surrogate decision-maker, 40.3% of respondents would consult CE first (case 3),
[
151#6 CHEST JUNE 2017
]
70.0% 63.9% 60.0%
Percentage Respondents
50.0% 43.1% 40.3% 40.0%
30.0% 25.0%
25.0% 20.0%
10.0%
16.7% 9.7%
13.9% 11.1%
13.9%
12.5%
11.1% 6.9%
5.6%
1.4% 0.0%
Stage IV lung cancer with progressive respiratory failure
Spiritual Care
Prognosis of weeks-months, existential distress, family wants “everything done”
Palliative Care
Clinical Ethics
None
Multi-organ failure with mechanical ventilation, no surrogate decision maker All three simultaneously
Figure 1 – Survey responses to hypothetical ICU cases followed by the question, “Which consultant would you contact first?”
compared with 25% for PC and 5.6% for SC (P < .05). No association was found between responses and clinician age or sex.
Scott Howard Snyder, MD Baltimore, MD Nneka Sederstrom, PhD, FCCP Minneapolis, MN
Provider preference for PC over CE or SC is notable, despite high availability of all three services. Lower rates of SC consultation may reflect that PC teams frequently engage chaplain services themselves, that chaplains visit patients without specific requests, or that clinicians limit SC involvement to end-of-life rituals. Lower preference for CE may indicate less bedside CE consult availability or respondents’ belief that they can handle ethical issues alone. Low response rate may reflect survey fatigue but respondents are likely invested in engaging PC, CE, and/or SC. How and when we invite and assimilate experts in supportive care to the critical care setting affects patient and family experience. Future research should further investigate relationships among critical care providers and PC, SC, and CE consultants.
journal.publications.chestnet.org
J. Keith Mansel, MD, FCCP Jackson, MS Hunter Groninger, MD Washington, DC AFFILIATIONS: From the Division of Geriatric Medicine and Gerontology (Dr Snyder), Johns Hopkins University School of Medicine; the Clinical Ethics Department (Dr Sederstrom), Children’s Hospitals and Clinics of Minnesota; the University of Mississippi Medical Center (Dr Mansel); and Palliative Care (Dr Groninger), MedStar Washington Hospital Center. This work was presented as a poster at the 2016 International Conference on Clinical Ethics Consultation, May 2016, in Washington, DC. FINANCIAL/NONFINANCIAL DISCLOSURES: None declared. CORRESPONDENCE TO: Scott Howard Snyder, MD, Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, 5200 Eastern Ave, MFL-C, 2nd Floor, Ste 2200, Baltimore, MD 21224; e-mail: [email protected] Published by Elsevier Inc. under license from the American College of Chest Physicians. DOI: http://dx.doi.org/10.1016/j.chest.2017.03.034
1405
References 1. Morrison W, Derrington SF. Stories and the longitudinal patient relationship: what can clinical ethics consultants learn from palliative care? J Clin Ethics. 2012;23(3):224-230. 2. Maung AA, Toevs CC, Kayser JB, Kaplan LJ. Conflict management teams in the intensive care unit: a concise definitive review. J Trauma Acute Care Surg. 2015;79(2):314-320. 3. Carter BS, Wocial LD. Ethics and palliative care: which consultant and when? Am J Hosp Palliat Care. 2012;29(2):146-150. 4. Aulisio MP, Chaitin E, Arnold RM. Ethics and palliative care consultation in the intensive care unit. Crit Care Clin. 2004;20(3): 505-523. x-xi.
Association Between Attention-Deficit/ Hyperactivity Disorder and Asthma Among Adults A Case-Control Study To the Editor:
Recently, we showed in a meta-analysis that in children there is an association between attention-deficit/ hyperactivity disorder (ADHD) and atopic diseases, especially asthma.1 The nature of this relationship is still
TABLE 1
unknown, although findings suggest links with environmental and/or genetic risk factors contributing to inflammatory mechanisms.2 Not much is known about this association among adults. The aim of the present study was to investigate associations between the presence of ADHD and the presence and severity of asthma in adults. As a secondary aim we investigated the association between ADHD and the presence of eczema and allergic rhinitis. We conducted a case-control study using the University of Groningen pharmacy prescription database, which is representative of the Netherlands. Case subjects were defined as adults aged between 18 and 50 years with at least two prescriptions for ADHD medication within the past 12 months. Control subjects were defined as adults without any history of ADHD medication prescriptions and were matched (4:1) on age and sex for each case. The presence of asthma, eczema, and allergic rhinitis, and asthma severity, were based on the type and frequency of the prescription of drugs used to treat the specific atopic allergy (e-Appendix 1). Multivariable logistic regression analyses were applied to control for urbanization and the presence of two of the other atopic
] Cohort Characteristics of Patients With ADHD and the Matched Comparator Group
Sex (female) Age, mean (SD), y Urbanization level
Patients With ADHD Medication (3,987)
Control Subjects Without ADHD Medication (15,948)
1,652 (41.4)
6,608 (41.4)
32.4 (8.2)
32.8 (8.3)
.147a < .001c
b
1
1,248 (31.3)
2
1,123 (28.2)
3,823 (24.0)
3
811 (20.3)
3,260 (20.4)
4
437 (11.0)
1,868 (11.7)
5
323 (8.1)
2,124 (13.3)
Missing
P Value
4,610 (28.9)
45 (1.1)
263 (1.6)
Rhinitis
310 (7.8)
651 (4.1)
< .001c
Eczema
222 (5.6)
534 (3.3)
< .001c
387 (9.7)
499 (3.1)
< .001c
45 (1.1)
64 (0.4)
< .001c
Persistent mild
129 (3.2)
193 (1.2)
< .001c
Persistent moderate-severe
137 (3.4)
168 (1.1)
< .001c
Asthma Asthma severity
d
Intermittent
Data are presented as No. (%) unless otherwise indicated. ADHD ¼ attention-deficit/hyperactivity disorder. a Student t test. b 1 ¼ 2,500 or more addresses per km2; 2 ¼ 1,500-2,500 addresses per km2; 3 ¼ 1,000-1,500 addresses per km2; 4 ¼ 500-1,000 addresses per km2; and 5 ¼ fewer than 500 addresses per km2. c Pearson c2 test. d Asthma severity was estimated on the basis of various medication proxies (e-Appendix 1).
1406 Correspondence
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