Lyons, Patrick G.

This cross-sectional study evaluates US state regulation of clinician decisions about life-sustaining treatment for adults, including justifications and regulatory requirements.

Abstract Rationale: Disparities in unilateral clinician decisions to decline initiating or maintaining life-sustaining treatment (LST) exist. We aimed to determine 1) which US state statutes support unilateral clinician decisions to decline initiating or maintaining LST; 2) what requirements, if any, must be met for these unilateral clinician decisions to occur; and 3) which state statutes address concerns for sociodemographic disparities associated with these decisions. Methods: Between September and October 2024, we used Fastcase, Casetext and official US state government websites to identify statutes for all US states and Washington, DC that addressed clinician decisions to decline to initiate or maintain LST. We defined reason of conscience as explicit mention of conscience, religion, ethics or moral reasons supporting unilateral clinician decision-making. Two reviewers independently analyzed each statute resolving disagreements with consensus adjudication. Results: Almost all (98%, n=50/51) statutes explicitly support unilateral clinician decisions to decline initiating or maintaining at least one form of LST. Reasons supporting these decisions varied across states including medical reasons only (16%), reasons of conscience only (22%), both medical reasons and reasons of conscience (35%), or no medical or conscience reason explicitly provided (25%). Medical reasons supporting unilateral clinician decisions included if LST was “medically ineffective” (24%), “contrary to medical standards” (14%), “medically inappropriate” (10%), or “nonbeneficial” (8%). For states supporting unilateral clinician decisions if LST was medically ineffective, 75% also supported LST to be declined for reason of conscience while 25% did not. When using medical reasons to support unilateral clinician decisions to decline LST, many statutes require that clinicians must first inform patient/surrogate of this decision (37%) and cooperate with transferring the patient to another clinician or institution (75%). Statutes rarely directly required clinicians to obtain a second medical opinion (8%), pursue a medical ethics committee review (6%), or address conflict (2%) in these situations. Although no state statutes explicitly acknowledged the existence of sociodemographic disparities associated with unilateral clinician decisions to initiate or maintain LST, 27% included guidance that addressed decisions to withhold or withdraw LST in specific marginalized groups. Conclusions: While almost all US state statutes allowed clinicians to decline to initiate or maintain LST, the reasons supporting and actions required to pursue these decisions varied. No statute explicitly addressed sociodemographic disparities associated with these decisions, which may perpetuate these disparities across the US.

OBJECTIVES: To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19. DESIGN: Retrospective observational study. SETTING: Multicenter, international COVID-19 registry. Subjects: Adult hospitalized COVID-19 patients on antihypertensive agents (AHAs) prior to admission, admitted from March 31, 2020, to March 10, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were compared between three groups: patients on RAASIs only, other AHAs only, and those on both medications. Multivariable logistic and linear regressions were performed after controlling for prehospitalization characteristics to estimate the effect of RAASIs on mortality and other outcomes during hospitalization. Of 26,652 patients, 7,975 patients were on AHAs prior to hospitalization. Of these, 1,542 patients (19.3%) were on RAASIs only, 3,765 patients (47.2%) were on other AHAs only, and 2,668 (33.5%) patients were on both medications. Compared with those taking other AHAs only, patients on RAASIs only were younger (mean age 63.3 vs 66.9 yr; p < 0.0001), more often male (58.2% vs 52.4%; p = 0.0001) and more often White (55.1% vs 47.2%; p < 0.0001). After adjusting for age, gender, race, location, and comorbidities, patients on combination of RAASIs and other AHAs had higher in-hospital mortality than those on RAASIs only (odds ratio [OR] = 1.28; 95% CI [1.19–1.38]; p < 0.0001) and higher mortality than those on other AHAs only (OR = 1.09; 95% CI [1.03–1.15]; p = 0.0017). Patients on RAASIs only had lower mortality than those on other AHAs only (OR = 0.87; 95% CI [0.81–0.94]; p = 0.0003). Patients on ACEIs only had higher mortality compared with those on ARBs only (OR = 1.37; 95% CI [1.20–1.56]; p < 0.0001). CONCLUSIONS: Among patients hospitalized for COVID-19 who were taking AHAs, prior use of a combination of RAASIs and other AHAs was associated with higher in-hospital mortality than the use of RAASIs alone. When compared with ARBs, ACEIs were associated with significantly higher mortality in hospitalized COVID-19 patients.

Objectives: Multicenter data on the characteristics and outcomes of children hospitalized with coronavirus disease 2019 are limited. Our objective was to describe the characteristics, ICU admissions, and outcomes among children hospitalized with coronavirus disease 2019 using Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: Coronavirus Disease 2019 registry. Design: Retrospective study. Setting: Society of Critical Care Medicine Viral Infection and Respiratory Illness Universal Study (Coronavirus Disease 2019) registry. Patients: Children (< 18 yr) hospitalized with coronavirus disease 2019 at participating hospitals from February 2020 to January 2021. Interventions: None. Measurements and Main Results: The primary outcome was ICU admission. Secondary outcomes included hospital and ICU duration of stay and ICU, hospital, and 28-day mortality. A total of 874 children with coronavirus disease 2019 were reported to Viral Infection and Respiratory Illness Universal Study registry from 51 participating centers, majority in the United States. Median age was 8 years (interquartile range, 1.25–14 yr) with a male:female ratio of 1:2. A majority were non-Hispanic (492/874; 62.9%). Median body mass index (n = 817) was 19.4 kg/m2 (16–25.8 kg/m2), with 110 (13.4%) overweight and 300 (36.6%) obese. A majority (67%) presented with fever, and 43.2% had comorbidities. A total of 238 of 838 (28.2%) met the Centers for Disease Control and Prevention criteria for multisystem inflammatory syndrome in children, and 404 of 874 (46.2%) were admitted to the ICU. In multivariate logistic regression, age, fever, multisystem inflammatory syndrome in children, and pre-existing seizure disorder were independently associated with a greater odds of ICU admission. Hospital mortality was 16 of 874 (1.8%). Median (interquartile range) duration of ICU (n = 379) and hospital (n = 857) stay were 3.9 days (2–7.7 d) and 4 days (1.9–7.5 d), respectively. For patients with 28-day data, survival was 679 of 787, 86.3% with 13.4% lost to follow-up, and 0.3% deceased. Conclusions: In this observational, multicenter registry of children with coronavirus disease 2019, ICU admission was common. Older age, fever, multisystem inflammatory syndrome in children, and seizure disorder were independently associated with ICU admission, and mortality was lower among children than mortality reported in adults.