Should we discharge comatose patients from intensive care to die in their own bed at home after withdrawal of mechanical ventilation?

Temporal trends of sepsis-related mortality in China, 2006-2020: a population-based study

BACKGROUND

The scarcity of sepsis epidemiologic data from most low- and middle-income countries (LMICs) hampered estimation of regional and global burden of the disease, and provided limited guidance for policy makers. We aimed to characterize and analyze the temporal trends of sepsis-related mortality in China, by population groups, underlying causes of death, geographic regions, and sociodemographic index (SDI) levels.

METHODS

Sepsis-related deaths were identified from the National Mortality Surveillance System (NMSS) of China from 2006 to 2020. Trends of sepsis-related mortality and years of life lost (YLLs), stratified by age, sex, underlying diseases, and regions were analyzed using the Jointpoint regression analysis. We investigated the association of SDI with trends of sepsis-related mortality.

RESULTS

In 2020, sepsis was estimated to be responsible for 986,929 deaths and 17.1 million YLLs in China. Age-standardized sepsis-related mortality significantly declined from 130.2 (95%CI, 129.4-131) per 100,000 population in 2006 to 76.6 (76.3-76.9) in 2020. Age-standardized YLLs decreased from 2172.7 (2169.4-2176) per 100,000 population in 2006 to 1271 (1269.8-1272.2) in 2020. Substantial variations of sepsis-related mortality and YLLs were observed between population groups and regions, with higher burden in males, the elderly, and western China. An inverse relation was noted between SDI and sepsis-related mortality or YLLs.

CONCLUSIONS

Despite declining trends of age-standardized mortality and YLLs of sepsis in China, significant disparities between population groups and regions highlight a need for targeted policies and measures to close the gaps and improve the outcome of sepsis.

Transferring home to die from critical care units: A scoping review of international practices

PURPOSE

To identify and characterise the international practices of transferring a dying patient home to die from critical care units.

MATERIALS AND METHODS

A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019.

RESULTS

Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes.

CONCLUSIONS

Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.

Doctors' and nurses' views and experience of transferring patients from critical care home to die: a qualitative exploratory study

BACKGROUND

Dying patients would prefer to die at home, and therefore a goal of end-of-life care is to offer choice regarding where patients die. However, whether it is feasible to offer this option to patients within critical care units and whether teams are willing to consider this option has gained limited exploration internationally.

AIM

To examine current experiences of, practices in and views towards transferring patients in critical care settings home to die.

DESIGN

Exploratory two-stage qualitative study

SETTING/PARTICIPANTS

Six focus groups were held with doctors and nurses from four intensive care units across two large hospital sites in England, general practitioners and community nurses from one community service in the south of England and members of a Patient and Public Forum. A further 15 nurses and 6 consultants from critical care units across the United Kingdom participated in follow-on telephone interviews.

FINDINGS

The practice of transferring critically ill patients home to die is a rare event in the United Kingdom, despite the positive view of health care professionals. Challenges to service provision include patient care needs, uncertain time to death and the view that transfer to community services is a complex, highly time-dependent undertaking.

CONCLUSION

There are evidenced individual and policy drivers promoting high-quality care for all adults approaching the end of life encompassing preferred place of death. While there is evidence of this choice being honoured and delivered for some of the critical care population, it remains debatable whether this will become a conventional practice in end of life in this setting.

A national survey exploring views and experience of health professionals about transferring patients from critical care home to die

BACKGROUND

Transferring critically ill patients home to die is poorly explored in the literature to date. This practice is rare, and there is a need to understand health care professionals' (HCP) experience and views.

OBJECTIVES

To examine (1) HCPs' experience of transferring patients home to die from critical care, (2) HCPs' views about transfer and (3) characteristics of patients, HCPs would hypothetically consider transferring home to die.

DESIGN

A national study developing a web-based survey, which was sent to the lead doctors and nurses in critical care units.

SETTING/PARTICIPANTS

Lead doctors and senior nurses (756 individuals) working in 409 critical care units across the United Kingdom were invited to participate in the survey.

RESULTS

In total, 180 (23.8%) completed surveys were received. A total of 65 (36.1%) respondents had been actively involved in transferring patients home to die and 28 (15.5%) had been involved in discussions that did not lead to transfer. Respondents were supportive of the idea of transfer home to die (88.8%). Patients identified by respondents as unsuitable for transfer included unstable patients (61.8%), intubated and ventilated patients (68.5%) and patients receiving inotropes (65.7%). There were statistically significant differences in views between those with and without experience and between doctors and nurses. Nurses and those with experience tended to have more positive views.

CONCLUSION

While transferring patients home to die is supported in critical care, its frequency in practice remains low. Patient stability and level of intervention are important factors in decision-making in this area. Views held about this practice are influenced by previous experience and the professional role held.

The Going Home Initiative: Getting Critical Care Patients Home With Hospice

Although considerable effort is being directed at providing patients and their families with a “good death,” most patients in intensive care units, if given the choice, would prefer to die at home. With little guidance from the literature, the palliative care committee of an intensive care unit developed guidelines to get patients home from the intensive care unit to die. In the past few years, the unit has transferred many patients home with hospice care, much to the delight of their families. Although several obstacles to achieving this goal exist, the unit has achieved success in a small-scale implementation of its Going Home Initiative.