Understanding the treatment preferences of seriously ill patients

Attitudes of Patients With Incurable Cancer Toward Medical Treatment in the Last Phase of Life

Purpose

When cancer has advanced to a stage in which cure becomes unlikely, patients may have to consider the aim of further treatment. We studied the relationship of patients' attitudes toward treatment with advance care planning and the development of these attitudes after diagnosis of incurable cancer.

Patients and Methods

Patients with incurable cancer were interviewed and asked to fill out a written questionnaire about their attitudes concerning life-prolonging treatment and end-of-life decision making. These questions were repeated after 6 and 12 months.

Results

One hundred twenty-two patients (mean age, 64 years; standard deviation, 10.5 years; 53% women) participated in the study. Patients' attitudes toward treatment could be categorized into the following three different profiles: striving for quality of life, striving for length of life, and no clear preference. Patients who were older, more tired, or had less positive feelings and patients who had more often taken initiatives to engage in advance care planning were more inclined to strive for quality of life than others. Patients with a history of cancer of less than 6 months were more inclined to prefer life prolongation than patients with a longer history of cancer. During follow-up, no changes in attitudes toward treatment were found, except for patients with a short history of cancer in whom the inclination to strive for length decreased.

Conclusion

Patients who appreciate advance care planning were more inclined to strive for quality of life than other patients. Shortly after the diagnosis of cancer, patients typically seem to prefer life-prolonging treatment, whereas quality of life becomes more important when death is nearing.

When critical illness becomes chronic: informational needs of patients and families

PURPOSE

A large and growing group of intensive care unit survivors are "chronically critically ill," with ongoing respiratory failure and poor outcomes for postdischarge survival and functional recovery. In this qualitative study, we investigated what information is relevant and important for clinician-patient/family communication when critical illness becomes chronic, as indicated by tracheotomy for prolonged mechanical ventilation.

METHODS

We conducted focus groups and structured interviews of patients who survived chronic critical illness, of surrogates of such patients and of nonsurvivors, and of clinicians with relevant experience. Discussions were audiotaped, transcribed, and analyzed using grounded theory.

RESULTS

Twenty-five subjects participated (4 survivors, 7 survivors' surrogates, 4 nonsurvivors' surrogates, 10 clinicians). We found broad agreement on 6 major domains of information that are relevant and important: (1) nature of illness/treatments, (2) prognosis, (3) impact of treatment, (4) potential complications, (5) expected care needs after hospitalization, and (6) alternatives to continuation of treatment. Participants endorsed the multidisciplinary family meeting as an effective communication strategy.

CONCLUSIONS

Given poor outcomes for most patients and high costs and burdens of treatment, effective communication is essential when critical illness enters a chronic phase. Our findings provide a framework for such communication and a basis for further research.

Patients' understanding of advance directives and cardiopulmonary resuscitation

OBJECTIVE

To describe understanding of end-of-life issues and compare characteristics of patients with and without advance directives.

SETTING

A 325-bed community teaching hospital.

MEASUREMENTS

Questionnaires were administered to all patients admitted to the medical-surgical wards.

RESULTS

Of 755 patients admitted during the study period, 264 patients participated in the study, and 82 (31%) had living wills. Patients with living wills were more likely to be white, Protestant, and highly educated. Most (76%) created them with a lawyer or family member, whereas only 7% involved physicians. Although these patients were able to identify some components of cardiopulmonary resuscitation (CPR), few (19%) understood the prognosis after CPR. After explaining CPR, 37% of those with living wills did not want it, which was not stated in their directive or hospital record. If life-sustaining therapies were already started, 39% of these patients stated that they would not want CPR or mechanical ventilation if the likelihood of recovery was < or =10%. Patients without living wills either had not heard (18%) or did not know enough (51%) about them. After education, 5% did not want CPR, and 32% would terminate life-sustaining therapies if the likelihood of recovery was < or =10%. Seventy percent of these patients expressed interest in creating a living will.

CONCLUSIONS

Patients with living wills understand poorly "life-sustaining therapies" and the implications of their advance directives. Most fail to involve physicians in creating directives. A significant number of those without living wills have end-of-life wishes that could be addressed by and appear open to the idea of creating advance directives.

When Written Advance Directives are not Enough

Advance directives have been promoted as being the best device for making decisions on behalf of patients who are unable to speak for themselves. It is believed that an advance directive would tell the health care professionals what to do. Conflicts would dissolve and the course would become clear. Such hopes and expectations probably exceed the capacity of these documents to provide context-based, real-time decisions. This article reviews the research on advance directives, including proxy and instructional documents, and discusses the strengths and limitations of each. Advance directives are often thought of as static, binding documents. Recommendations will be offered on how to use these documents as tools to facilitate patient-centered, dynamic decisions.

Under what conditions is euthanasia acceptable to lay people and health professionals?

Euthanasia is legal only in the Netherlands and Belgium, but it is on occasion performed by physicians elsewhere. We recruited in France two convenience samples of 221 lay people and of 189 professionals (36 physicians, 92 nurses, 48 nurse's aides, and 13 psychologists) and asked them how acceptable it would be for a patient's physician to perform euthanasia in each of 72 scenarios. The scenarios were all combinations of three levels of the patient's life expectancy (3 days, 10 days, or 1 month), four levels of the patient's request for euthanasia (no request, unable to formulate a request because in a coma, some form of request, repeated formal requests), three of the family's attitude (do not uselessly prolong care, no opinion, try to keep the patient alive to the very end), and two of the patient's willingness to undergo organ donation (willing or not willing). We found that most lay people and health care professionals structure the factors in the patient scenarios in the same way: they assign most importance to the extent of requests for euthanasia by the patient and least importance (the lay people) or none (the health professionals) to the patient's willingness to donate organs. They also integrate the information from the different factors in the same way: the factors of patient request, patient life expectancy, and (for the lay people) organ donation are combined additively, and the family's attitude toward prolonging care interacts with patient request (playing a larger role when the patient can make no request). Thus we demonstrate a common cognitive foundation for future discussions, at the levels of both clinical care and public policy, of the conditions under which physician-performed euthanasia might be acceptable.

Perspectives, Preferences, Care Practices, and Outcomes Among Older and Middle-Aged Patients With Late-Stage Cancer

Purpose

To evaluate relationships among physician and cancer patient survival estimates, patients' perceived quality of life, care preferences, and outcomes, and how they vary across middle-aged and older patient groups.

Patients and Methods

Subjects were from the Study to Understand Prognoses and Preferences for Risks of Treatments (SUPPORT) prospective cohort studied in five US teaching hospitals (from 1989 to 1994), and included 720 middle-aged (45 to 64 years) and 696 older (≥ 65 years) patients receiving care for advanced cancer. Perspectives were assessed in physician and patient/surrogate interviews; care practices and outcomes were determined from hospital records and the National Death Index. General linear models were used within age groups to obtain adjusted estimates.

Results

Although most patients had treatment goals to relieve pain, treatment preferences and care practices were linked only in the older group. For older patients, preference for life-extending treatment was associated with more therapeutic interventions and more documented discussions; cardiopulmonary resuscitation (CPR) preference was linked to more therapeutic interventions and longer survival. For middle-aged patients, better perceived quality of life was associated with preferring CPR. In both groups, patients' higher survival estimates were associated with preferences for life-prolonging treatment and CPR; physicians' higher survival estimates were associated with patients' preferences for CPR, fewer documented treatment limitation discussions about care, and actual 6-month survival. More discussions were associated with readmissions and earlier death. More aggressive care was not related to outcomes.

Conclusion

Fewer older patients preferred CPR or life-prolonging treatments. Although older patients’ goals for aggressive treatment were related to care, this was not so for middle-aged patients. Aggressive care was not related to prolonged life in either group.

Preferences in end-of-life care of older persons: after-death interviews with proxy respondents

This population-based study employing after-death interviews with proxies describes older persons' preferences regarding medical care at the end of life. Interviews were held with 270 proxy respondents of 342 deceased persons (age range 59-91) in the Netherlands, The deceased were respondents to the Longitudinal Aging Study Amsterdam. The prevalence of advance directives (ADs), preferences for medical decisions at the end of life (i.e. withholding treatment, physician-assisted suicide euthanasia) and preferences about the focus of treatment in the last week of life (i.e. comfort care versus extending life) were examined. Written ADs were present in 14% of the sample. A quarter had designated a surrogate decision-maker. Co-morbidity and perceived self-efficacy (PSE) were positively associated with ADs. About half the sample had expressed a preference in favour or against one or more medical decisions at the end of life. Predictors positively associated with expressing a preference were co-morbidity, dying from cancer, and PSE. Being religious was negatively associated with expressing a preference. The knowledge of the proxy regarding the older person's preference for the focus of treatment was dependent on the patient's symptom burden as perceived by the proxy. The majority of older persons had died without either an AD, or having expressed preferences for end-of-life care. Stimulating the formulation of ADs may help professionals who work with older people to understand these preferences better, especially in the case of non-cancer patients and those with low PSE.

Admission to intensive care unit at the end-of-life: is it an informed decision?

There is a major deficiency in the end-of-life care offered to patients dying in the intensive care unit (ICU).

HYPOTHESIS

Hospitalized dying patients had informed discussions on end-of-life and palliative care options before admission to ICU.

PATIENTS AND METHODS

A descriptive non-interventional study was performed at a teaching hospital to examine if patients who died in hospital had informed discussions on end-of-life care before admission to ICU. The impact of these discussions on subsequent patient care: aggressive therapy in the ICU, the quality of palliation, use of hospice care services and utilization of hospital resources were examined. Data were collected from medical records for all hospital deaths over 24 months.

RESULTS

Of 252 hospital deaths, 196 (78%) were treated and subsequently 165 (65%) died in the ICU. Patients treated either in the ICU or general hospital wards had similar frequency of ultimately or rapidly fatal pre-existing disease (47% versus 62%, P: ns) and readmission to hospital within one year before death (43% versus 57%, P, ns). The median age (10-90% percentile) was slightly younger for the ICU than hospital wards patients: 73 (45-85) versus 76 (55-91) years, P < 0.01. Of the 156 patients who were transferred to ICU from hospital wards: 136 (87%) were managed by house staff on teaching services and 20 (13%) were managed by attending staff hospitalists, P < 0.01. None of those transferred to the ICU who subsequently died had discussion of palliation or end-of-life care as an alternative treatment. Of those who died who were treated on general wards, 14 (25%) patients had discussion of palliation as an alternative treatment option before death. Do-not-resuscitate decisions were made in 48% of cases two days before death. Patients who were treated in the ICU had more invasive tests performed on them and were less likely to have adequate pain control or referral to hospice care services than on a general ward. Median hospital charge was much higher for patients who received ICU versus general ward care (33,252 dollars versus 8549 dollars, P < 0.001).

CONCLUSIONS

Patients who died in the ICU did not have informed discussions of end-of-life or palliative care as an alternative treatment option before admission. The quality of end-of-life care was disrupted for patients with fatal pre-existing chronic disease who were admitted to the ICU before death. Lack of clinical experience, knowledge and competency with end-of-life care influenced admission of patients to ICU regardless of poor prognosis. Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources.

Morbidity in hospitalized patients receiving human albumin: a meta-analysis of randomized, controlled trials

OBJECTIVE

To determine the effect of albumin administration on morbidity in acutely ill hospitalized patients.

DATA SOURCE

Computer searches of MEDLINE, EMBASE, and the Cochrane Library; hand searches of journals and Index Medicus; inquiries with investigators and fluid product suppliers; and examination of reference lists. No language or time period restrictions were adopted.

STUDY SELECTION

Randomized, controlled trials comparing the administration of albumin with that of crystalloid, no albumin, or lower-dose albumin.

DATA EXTRACTION

Two investigators independently extracted data. The primary endpoint for the meta-analysis was morbidity, defined as the incidence of complications, including death. Trial quality was evaluated by blinding, allocation concealment, presence of morbidity as a study endpoint, and individual patient crossover.

DATA SYNTHESIS

Seventy-one trials were included in the categories of surgery or trauma, burns, hypoalbuminemia, high-risk neonates, ascites, and other indications. The 3,782 randomized patients in the included trials experienced a total of 3,287 complications, including 515 deaths and 2,772 cardiovascular, gastrointestinal, hepatic, infectious, renal, respiratory, and other complications. Albumin significantly reduced overall morbidity, with a risk ratio of 0.92 (confidence interval [CI], 0.86-0.98). Control group albumin dose significantly affected the incidence of complications (p = .002). In 32 trials with no albumin administered to the control group, the risk ratio was 0.77 (CI, 0.67-0.88) compared with 0.89 (CI, 0.80-1.00) in 20 trials with control patients receiving low-dose albumin and 1.07 (CI, 0.96-1.20) in 19 trials with moderate-dose control group albumin.

CONCLUSIONS

Albumin reduces morbidity in acutely ill hospitalized patients. Concomitant administration of albumin in the control group can obscure the effects of albumin on clinical outcome in randomized trials.

Post-ICU mortality in critically ill infected patients: an international study

OBJECTIVE

To determine the incidence and risk factors for post-ICU mortality in patients with infection.

DESIGN AND SETTING

International observational cohort study including 28 ICUs in eight countries.

PATIENTS

All 1,872 patients discharged alive from the ICU over a 1-year period were screened for infection at ICU admission and daily throughout the ICU stay. Outcomes at ICU and hospital discharge were recorded.

MEASUREMENTS AND RESULTS

Post-ICU death occurred in 195 (10.4%) patients and was associated in the multivariable analysis with age, chronic respiratory failure, immunosuppression, cirrhosis, Simplified Acute Physiology Score II on the first day with infection, and LOD score at ICU discharge. Post-ICU death was more common among medical patients and patients with hospital-acquired infection or microbiologically documented infection and was less common in patients with pneumonia.

CONCLUSIONS

Post-ICU death in patients with infection was within previously reported ranges in overall ICU populations. The main risk factors were patient and infection characteristics, severity at ICU admission, and persistent organ dysfunction at ICU discharge. Further interventions such as further ICU management, discharge to a step-down unit, or follow-up by intensivists on the ward should be evaluated in patients with a high risk of post-ICU mortality.

Family-physician interactions in the intensive care unit

Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.

Management of severe COPD

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, and the burden of the disorder will continue to increase over the next 20 years despite medical intervention. Apart from smoking cessation, no approach or agent affects the rate of decline in lung function and progression of the disease. Especially in the later phase, COPD is a multicomponent disorder, and various integrated intervention strategies are needed as part of the optimum management programme. This seminar describes largely non-pharmacological interventions aimed at improving health status and function of disabled patients. Exacerbations become progressively more troublesome as baseline lung function declines, commonly necessitating hospital admission and associated with the development of acute respiratory failure.

Thoughts of patients with advanced heart failure on dying

OBJECTIVE

To explore, over a one-year period, the ideas and attitudes of patients with end-stage cardiac failure concerning dying.

DESIGN

Prospective longitudinal multiple case study using qualitative interview techniques.

PARTICIPANTS

Thirty-one patients from two hospitals who fulfilled one or more of the following criteria: NYHA III or IV, ejection fraction < 25%, at least one hospitalization for heart failure.

MAIN OUTCOMES

Statements of patients with advanced heart failure, expressed in semi-structured interviews, concerning the quality of dying and medical decisions at the end of life.

RESULTS

Many respondents only thought about death during exacerbations. Mentioned aspects of appropriate dying include: a degree of usefulness, prognostic knowledge, appropriate duration and mental awareness. Few respondents were in favour of euthanasia or suicide, but all wanted life-prolonging treatment to be withheld or withdrawn when appropriate.

CONCLUSIONS

Our study found some elements of 'appropriate dying' that differ from other studies and that are relatively specific for advanced heart failure. The tendency of patients not to think about death raises ethical concerns.

Value and role of intensive care unit outcome prediction models in end-of-life decision making

In the United States, intensive care unit (ICU) admission at the end of life is commonplace. What is the value and role of ICU mortality prediction models for informing the utility of ICU care?In this article, we review the history, statistical underpinnings,and current deployment of these models in clinical care. We conclude that the use of outcome prediction models to ration care that is unlikely to provide an expected benefit is hampered by imperfect performance, the lack of real-time availability, failure to consider functional outcomes beyond survival, and physician resistance to the use of probabilistic information when death is guaranteed by the decision it informs. Among these barriers, the most important technical deficiency is the lack of automated information systems to provide outcome predictions to decision makers, and the most important research and policy agenda is to understand and address our national ambivalence toward rationing care based on any criterion.

Advance care planning in elderly chronic dialysis patients

Despite the usefulness of advance directives, most dialysis patients do not complete them. Current views of the advance care planning process emphasize that development of a specific written advance directive is only one small part of the process. Patients and families use advance care planning discussions to plan for death, achieve control over their health care, and strengthen relationships. Studies of chronic dialysis patients have shown that discussions about end-of-life care occur within the patient-family and not the patient-physician relationship. Successful advance care planning requires that dialysis care providers incorporate end-of-life care wishes and palliative care into the overall health care plans for their patients. This review focuses on the past impediments to achieving useful advance directives among dialysis patients and their families and provides some suggestions to improving this important aspect of dialysis patient care.

Quality of death: assessing the importance placed on end-of-life treatment in the intensive-care unit

CONTEXT

The value of good end-of-life (EOL) care could be underestimated if its effects are assessed using the standard metric of quality-adjusted survival, especially if the time horizon is limited to the duration of the EOL care. This issue is particularly problematic in the intensive-care unit (ICU) where death is frequent, care is difficult, and costs are high.

OBJECTIVES

The objectives of this study were to test whether people would trade healthy life expectancy for better EOL care, to understand how much life expectancy they would trade relative to domains of good care, and to determine the association of respondent characteristics to time traded.

DESIGN AND SUBJECTS

We used a computerized survey instrument describing hypothetical patient experiences in the ICU used to assess attitudes of a general population sample (n = 104) recruited in Pittsburgh, Pennsylvania.

MEASURES

We used life expectancy traded (from a baseline of 80 healthy years followed by a 1-month fatal ICU stay) for improving ICU care in 4 domains: pain and discomfort, daily surroundings, treatment decisions, and family support.

RESULTS

Three fourths of respondents (n = 78) were prepared to shorten healthy life for better EOL care. Median time traded in individual domains ranged from 7.2 to 7.7 months overall and 9.6 to 11.4 months when restricted to those willing to trade. Median time traded for improvement in all domains was 8.3 months overall and 24.0 months by those willing to trade. In multivariable analyses, respondents who were older, nonwhite, or had children traded significantly less time, whereas those who did not perceive the ICU to be a caring environment traded more time.

CONCLUSIONS

Good EOL care is highly valued, both in terms of medical and nonmedical domains, as suggested by previous work and confirmed by our data showing respondents trading quantities of healthy life several times longer than the duration of the EOL period itself. The considerable interperson variation highlights the importance of soliciting individual preferences about EOL care.

Too Old to Care?

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH (http://www.theschwarzcenter.org/rounds.asp). The Schwartz Center is a nonprofit organization dedicated to supporting and advancing compassionate health care delivery, which provides hope to the patient and support to caregivers, and encourages the healing process. The center sponsors the Schwartz Center Rounds, a monthly multidisciplinary forum where caregivers reflect on important psychosocial issues faced by patients, their families, and their caregivers, and gain insight and support from fellow staff members. Ageism is a pervasive problem throughout society. It is rooted in language, attitudes, beliefs, behaviors, and policies. Aging profoundly influences physiology, challenging the medical community to accommodate but not discriminate. The elderly are at an increased risk of disease and disability. Sixty percent of cancer occurs in people aged 65 and older, and the population is aging. The treatment of cancer in the elderly is complicated by comorbidities and other physiological factors, particularly renal, bone marrow, and metabolic reserve. Caregivers have to treat patients in a manner that optimizes treatment and avoids anticipated harm. However, the caregiver is often faced with situations where they must balance their personal beliefs, professional values, and knowledge of medicine with their patients' preferences and needs. Discussion in the Rounds focused on age bias, drug toxicity, life prolongation, and symptom relief, with the role of the caregiver, and the relationship to the patient, being pivotal.

Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors Study

OBJECTIVES

To examine the relationship between worsening physical function and depression and preferences for life-sustaining treatment.

DESIGN

Mailed survey of older physicians.

SETTING

Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University.

PARTICIPANTS

Physicians who completed the life-sustaining treatment questionnaire in 1998 and provided information about health status in 1992 and 1998 (n=645, 83% of respondents to the 1998 questionnaire; mean age 68).

MEASUREMENTS

Preferences for life-sustaining treatment, assessed using a checklist questionnaire in response to a standard vignette.

RESULTS

Of 645 physicians, 11% experienced clinically significant decline in physical functioning, and 18% experienced worsening depression over the 6-year period. Physicians with clinically significant functional decline were more likely (adjusted odds ratio (AOR)=2.14, 95% confidence interval (CI)=1.18-3.88) to prefer high-burden life-sustaining treatment. Worsening depression substantially modified the association between declining functioning and treatment preferences. Physicians with declining functioning and worsening depression were more likely (AOR=5.33, 95% CI=1.60-17.8) to prefer high-burden treatment than respondents without declining function or worsening depression.

CONCLUSION

This study calls attention to the need for clinical reassessment of preferences for potentially life-sustaining treatment when health has declined to prevent underestimating the preferences of older patients.

Consciousness monitoring in ventilated patients: bispectral EEG monitors arousal not delirium

OBJECTIVE

Bispectral index (BIS) is being evaluated as a monitor of consciousness, yet it is unclear what components of consciousness (i.e., arousal vs. content of consciousness) the BIS measures. This study compared BIS levels to well-validated clinical measures of arousal and the presence or absence of delirium.

DESIGN

A prospective, blinded, observational cohort study.

PATIENTS

124 mechanically ventilated, adult, medical ICU patients.

MEASUREMENTS AND RESULTS

Using BIS 3.4 and BIS-XP 4.0 algorithms, BIS values were calculated immediately prior to clinical assessments. The clinical assessments included the Richmond Agitation-Sedation Scale (RASS) and presence or absence of delirium using the Confusion Assessment Method for the ICU. A total of 484 assessments were collected among 124 patients. BIS-XP values demonstrated greater correlation with RASS than BIS 3.4 ( R(2)=0.36 vs. 0.20), although considerable overlap of BIS-XP scores remained across RASS levels. Median BIS-XP values for delirious and nondelirious observations were 74 and 96, respectively, while BIS 3.4 values were 91 and 96, respectively. However, neither BIS 3.4 nor BIS-XP were significantly associated with delirium after controlling for RASS value.

CONCLUSIONS

In comparison with clinical measures of arousal in mechanically ventilated patients, BIS-XP algorithm demonstrated stronger correlation with RASS levels than did BIS 3.4, yet marked overlap across different levels of arousal persist using both algorithms. After controlling for level of arousal, neither BIS-XP nor BIS 3.4 algorithms distinguished between the presence and absence of delirium.

Ethical issues in the perioperative management of neurologic patients

The perioperative care of patients who have diseases of the nervous system provides the setting for challenging ethical issues. In the preoperative period, these issues include obtaining informed consent for surgery and its complications, surrogate decision making for the neurologically incapacitated patient, the use of advance directives for medical care, and the temporary suspension of do-not-resuscitate orders during the perioperative period. During postoperative care, ethical issues include establishing and communicating prognosis in patients who are brain damaged, a trial of therapy when prognosis remains uncertain, surrogate consent and refusal of life-sustaining therapy in the neurologically impaired patient, and the management of brain death.

Hospice Admission Practices: Where Does Hospice Fit in the Continuum of Care?

OBJECTIVES

To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics.

DESIGN

From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices.

SETTING

California statewide.

PARTICIPANTS

One hundred of 149 (67%) operational licensed hospices.

MEASUREMENTS

Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions.

RESULTS

Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs.

CONCLUSION

Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

Patient-centered advance care planning in special patient populations: a pilot study

The purpose of this study was to assess the feasibility of a patient-centered advance care planning (PC-ACP) approach to patients with chronic illnesses and their surrogates with respect to promotion of shared decision-making outcomes-congruence between patient and surrogate, patient's decisional conflict, and knowledge of advance care planning. An experimental design was used. The settings were the heart failure, renal dialysis, and cardiovascular surgery clinics at Gundersen Lutheran Medical Center in La Crosse, WI. Twenty-seven patient-surrogate pairs participated. A 1-hour PC-ACP interview was provided to the experimental group. Only usual care was delivered to participants in the control group. Comparison of the composite scores of a Statement of Treatment Preferences indicated that congruence in decision-making for future medical treatment in patient-surrogate pairs in the treatment group was significantly higher than in the control group. Greater satisfaction with the decision-making process and less decisional conflict were demonstrated in the treatment group. The PC-ACP interview can be effective in promoting shared decision-making between patients and their surrogates and in producing greater satisfaction with the process of decision-making and less decisional conflict.

Albumin administration--what is the evidence of clinical benefit? A systematic review of randomized controlled trials

BACKGROUND AND OBJECTIVE

The advantages of albumin over less costly alternative fluids continue to be debated. Meta-analyses focusing on survival have been inconclusive, and other clinically relevant end-points have not been systematically addressed. We sought to determine whether albumin confers significant clinical benefit in acute illness compared with other fluid regimens.

METHODS

Database searches (MEDLINE, EMBASE, Cochrane Library) and other methods were used to identify randomized controlled trials comparing albumin with crystalloid, artificial colloid, no albumin or lower-dose albumin. Major findings for all end-points were extracted and summarized. A quantitative meta-analysis was not attempted.

RESULTS

Seventy-nine randomized trials with a total of 4755 patients were included. No significant treatment effects were detectable in 20/79 (25%) trials. In cardiac surgery, albumin administration resulted in lower fluid requirements, higher colloid oncotic pressure, reduced pulmonary oedema with respiratory impairment and greater haemodilution compared with crystalloid and hydroxyethylstarch increased postoperative bleeding. In non-cardiac surgery, fluid requirements, and pulmonary and intestinal oedema were decreased by albumin compared with crystalloid. In hypoalbuminaemia, higher doses of albumin reduced morbidity. In ascites, albumin reduced haemodynamic derangements, morbidity and length of stay and improved survival after spontaneous bacterial peritonitis. In sepsis, albumin decreased pulmonary oedema and respiratory dysfunction compared with crystalloid, while hydroxyethylstarch induced abnormalities of haemostasis. Complications were lowered by albumin compared with crystalloid in burn patients. Albumin-containing therapeutic regimens improved outcomes after brain injury.

CONCLUSIONS

Albumin can bestow benefit in diverse clinical settings. Further trials are warranted to delineate optimal fluid regimens, in particular indications.

Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Do-not-resuscitate (DNR) orders are commonly used after severe stroke. We hypothesized that there is significant variability in how these orders are applied after intracerebral hemorrhage and that this influences outcome.

METHODS

From a database of all admissions to nonfederal hospitals in California, discharge abstracts were obtained for all patients with a primary diagnosis of intracerebral hemorrhage who were admitted through the emergency department during 1999 and 2000. Characteristics included whether DNR orders were written within the first 24 hours of hospitalization. Case-mix-adjusted hospital DNR use was calculated for each hospital by comparing the actual number of DNR cases with the number predicted from a multivariable model. Outcome (in-hospital death) was evaluated in a separate multivariable model adjusted for individual and hospital characteristics.

RESULTS

A total of 8233 patients were treated in 234 hospitals. The percentage of patients with DNR orders varied from 0% to 70% across hospitals. Being treated in a hospital that used DNR orders 10% more often than another hospital with a similar case mix increased a patient's odds of dying during hospitalization by 13% (P<0.001). Patients treated in the quartile of hospitals with the highest adjusted DNR use were more likely to die, and this was not just because of individual patient DNR status.

CONCLUSIONS

In-hospital mortality after intracerebral hemorrhage is significantly influenced by the rate at which treating hospitals use DNR orders, even after adjusting for case mix. This is not due solely to individual patient DNR status, but rather some other aspect of overall care.

Intensive care decision making in the seriously ill and elderly*

OBJECTIVE

To determine the influence of self-reported preadmission quality of life, hypothetical quality of life and mortality prognosis, and length and intensity of intensive care on decision making in the seriously ill and elderly.

DESIGN

Prospective cohort study.

SETTING

Medical university.

SUBJECTS

Adult inpatients with chronic illness and an estimated 50% 6-month mortality along with patients > or =80 yrs old with an acute illness.

INTERVENTIONS

Patients were presented with two scenarios: a) mechanical ventilation for 14 days; and 2) mechanical ventilation for 1 month with tracheostomy and feeding tube placement. A modified time trade-off was used to vary survival and quality of life over plausible ranges. Patients could consent to intensive care or choose care directed at comfort measures.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were interviewed. As projected intensive care unit mortality rate or postintensive care unit quality of life decreased, patients were less likely to consent to intensive care. Postintensive care quality of life was as important to patients as intensive care survival estimates. However, prehospitalization quality of life did not significantly influence decision making regarding life-extending treatment. When progressing from the acute intensive care scenario to chronic mechanical ventilation with associated interventions, patients demanded a significant increase in survival and quality of life. Neither race nor previous intensive care unit admission was associated with consent to intensive care.

CONCLUSIONS

There is wide variation in preference for aggressive care that does not appear to be influenced by prehospitalization quality of life. However, predicted quality of life appears to be as important as estimates of intensive care unit survival in decision making. When confronted with extended mechanical ventilation and associated care, a significant proportion of patients would accept this care only for an improved prognosis. Length and intensity of intensive care should be incorporated into discussions regarding intensive care.

Long-term mortality and quality of life after prolonged mechanical ventilation

OBJECTIVE

To describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation.

DESIGN

Prospective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr.

SETTING

Intensive care units at a tertiary care university hospital.

PATIENTS

Adult patients receiving prolonged mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27).

CONCLUSIONS

Mortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

The end of the disease era

The time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and nonbiological factors, the aging population, and the interindividual variability in health priorities render medical care that is centered on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment. The numerous strategies that have evolved to address the limitations of the disease model, although laudable, are offered only to a select subset of persons and often further fragment care. Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and nonbiological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases. Anticipated arguments against a more integrated and individualized approach range from concerns about medicalization of life problems to "this is nothing new" and "resources would be better spent determining the underlying biological mechanisms." The perception that the disease model is "truth" rather than a previously useful model will be a barrier as well. Notwithstanding these barriers, medical care must evolve to meet the health care needs of patients in the 21st century.

Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: A survey of 912 healthcare professionals*

OBJECTIVE

Recently published clinical practice guidelines of the Society of Critical Care Medicine recommend monitoring for the presence of delirium in all mechanically ventilated patients because of the potential for adverse outcomes associated with this comorbidity, yet little is known about healthcare professionals' opinions regarding intensive care unit delirium or how they manage this organ dysfunction. The aim of this survey was to assess the medical community's beliefs and practices regarding delirium in the intensive care unit.

DESIGN

Survey administration was conducted both without a delirium definition (phase 1) and then with a definition of delirium (phase 2).

SETTING

Critical care meetings and continuing medical education/board review courses from October 2001 to July 2002.

PARTICIPANTS

A convenience sample of physicians (n = 753), nurses (n = 113), pharmacists (n = 13), physician assistants (n = 12), respiratory care practitioners (n = 8), and others (n = 13).

INTERVENTIONS

Survey.

MEASUREMENTS AND MAIN RESULTS

Participants completed 912 of the surveys. The majority (68%) of respondents thought that >25% of adult mechanically ventilated patients experience delirium. Delirium was considered a significant or very serious problem in the intensive care unit by 92% of healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40% reported routinely screening for delirium, and only 16% indicated using a specific tool for delirium assessment. Delirium was considered important in the outcome of elderly and young patients by 89% and 60% of the respondents, respectively (p <.0001). The most serious complications these professionals associated with delirium were prolonged mechanical ventilation, self-injury, and respiratory difficulties. Delirium was treated with haloperidol by 66% of the respondents, with lorazepam by 12%, and with atypical antipsychotics by <5%. More than 55% administered haloperidol and lorazepam at daily doses of < or =10 mg, but some used >50 mg/day of either medication.

CONCLUSIONS

Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed. Data from this survey point to a disconnect between the perceived significance of delirium in the intensive care unit and current practices of monitoring and treatment.

Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death

OBJECTIVE

More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality.

DESIGN AND SETTING

Prospective multicenter 2-year study in six ICUs in France.

PATIENTS

The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs.

MEASUREMENTS AND RESULTS

The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887).

CONCLUSIONS

DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.

Waiting for the Platelet Count to Rise: Negotiating Care at the End of Life

Oncologists play a crucial role in enabling patients at the end of life and their families to decide whether the burden of chemotherapy is worth the benefit. Using language that displays their concern for providing ongoing care and that does not mistakenly imply withholding of effective therapies can ease the transition off chemotherapy. Providing accurate, timely prognostic information; exploring patients' hopes, goals, and values; helping them resume meaningful activities; meeting their health care proxies and discussing the advance care plan with them can all enhance the relationship with patients at the end of life and ease fears of abandonment.

Update in palliative medicine and end-of-life care

Palliative medicine includes clinical palliative care, education, and research that focus on the quality of life of patients with advanced disease and their families. The domain of palliative medicine is the relief of suffering: physical, psychological, social, and spiritual. Palliative medicine and care for patients at the end of life and their families include the following key components: compassionate communication; exploration of patient and family values and goals of care; expert attention to relief of suffering; management of pain, depression, delirium, and other symptoms; awareness of the manifestations of grief; and sensitivity to the concerns of bereaved survivors.

Preventing Delirium at the End of Life: Lessons From Recent Research

Preservation of the ability to think clearly, in comfort, is a goal of end-of-life care. Recent research on delirium at the end of life suggests clinical strategies for prevention of cognitive impairment. Clinicians should consider early warnings of mild delirium such as impairment in attention and short-term memory by following the patient's ability to remember 3 words or to attend to digit span before the patient is disoriented. If cognitive impairment is noted, clinicians should pay attention to reversible causes. This article reviews clinical concerns about opiates, benzodiazepines, steroids, hepatic encephalopathy, timely use of neuroleptic medications, and caretaking strategies at home.

Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes

OBJECTIVE

To assess the appropriateness of ICU triage decisions. DESIGN. Prospective descriptive single-center study.

SETTING

Ten-bed, medical-surgical ICU in an acute-care 460-bed, tertiary care hospital.

PATIENTS

All patients triaged for admission were entered prospectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Age, underlying diseases, admission diagnoses, Mortality Probability Model (MPM0) score, information available to ICU physicians, and mortality were recorded. Of the 334 patients (96% medical), 145 (46.4%) were refused. Reasons for refusal were being too-sick-to-benefit (48, 14%) and too-well-to-benefit (93, 28%). Factors independently associated with refusal were patient location, ICU physician seniority, bed availability, patient age, underlying diseases, and disability. Hospital mortality was 23% and 27% for patients admitted to our ICU and other ICUs, respectively, and 7.5% and 60% for patients too well and too sick to benefit, respectively. In the multivariate Cox model, McCabe = 1 [hazard ratio (HR), 0.44 (95% CI, 0.24-0.77), P=0.001], living at home without help (HR, 0.440, 95% CI, 0.28-0.68, P=0.0003), and immunosuppression (HR, 1.91, 95% CI, 1.09-3.33, P=0.02) were independent predictors of hospital death. Neither later ICU admission nor refusal was associated with cohort survival. MPM0 was not associated with hospital mortality.

CONCLUSIONS

Refusal of ICU admission was related to the ability of the triaging physician to examine the patient, ICU physician seniority, patient age, underlying diseases, self-sufficiency, and number of beds available. Specific training of junior physicians in triaging might bring further improvements. Scores that are more accurate than the MPM0 are needed.